Optimal Correction of Adult Spinal Deformities Requires Restoration of Distal Lumbar Lordosis.

PURPOSE: The aim of this study is to analyze results according to postoperative pelvic incidence-lumbar lordosis (PI-LL) mismatch in the management of adult spine deformity (ASD) patients. Recently, it has been reported that in addition to lumbar lordosis amount, lordosis repartition between its proximal and distal parts was crucial. METHODS: We enrolled 77 consecutive ASD patients who underwent posterior spinal fusion and deformity correction between 2015 and 2018. On preoperative and 1-year follow-up radiographs, we analyzed different parameters such as L1-S1 lumbar lordosis, L1-L4 proximal lordosis (PLL), L4-S1 distal lordosis (DLL), pelvic tilt (PT), sagittal vertical axis (SVA), and PI-LL mismatch. Comparisons were performed according to postoperative PI-LL mismatch (defined as "aligned" when PI-LL was <10°). The relationship between lordosis distribution and postoperative alignment status was investigated. RESULTS: On the whole series, average lumbar lordosis, SVA, and PI-LL improved (28.2° vs.43.5°, 82 vs. 51 mm, and 26°vs. 14°, all p < 0.001, respectively). On the other hand, PT remained unchanged (30° vs. 28°, p > 0.05). 35 patients were classified as "aligned" and 42 as "not aligned." Patients from the "aligned" group had a significantly lower PI than patients from the "not aligned" group (52° vs. 61°, p=0.009). Postoperative PLL was not different between groups (18° vs. 16° p > 0.05), whereas DLL was significantly higher in the "aligned" group (31° vs. 22°, p=0.003). PI-LL was significantly correlated to DLL (rho = 0.407, p < 0.001) but not with PLL (rho = 0.110, p=0.342). CONCLUSIONS: Our results revealed that in ASD patients, postoperative malalignment was associated with a lack of DLL restoration. "Not aligned" patients had also a significantly higher pelvic incidence. Specific attention must be paid to restore optimal distal lumbar lordosis in order to set the amount and the distribution of optimal postoperative lumbar lordosis.

Adult Spinal Deformities: Can Patient-Specific Rods Change the Preoperative Planning into Clinical Reality? Feasibility Study and Preliminary Results about 77 Cases.

Surgical management of adult spinal deformities remains challenging, and one of the major goals is to restore sagittal alignment. Spinal rods used for posterior fixation are usually delivered straight and bended manually during surgery. This manual bending can be responsible for undercorrection of the deformity. In the last years, prebended patient-specific rods have been developed and might be a valuable tool in order to optimize surgical results. The objective is therefore to use the time between surgical decision and operative room in order to realize a precise surgical planning and obtain patient-specific rods. We describe here the planning process and our preliminary experience with patient-specific rods in the management of adult deformity about 77 cases. On the 77 cases, PSR were used without further modifications of the shape. Based on 3-month postoperative evaluation, a significant decrease of sagittal vertical axis (-41%, p < 0.0001) and pelvic incidence-lumbar lordosis (-62%, p < 0.0001) was reported. Pelvic tilt was not significantly corrected, except in patients with Parkinson's disease. In this subgroup of patients, measurements revealed a significant correction of SVA and PI-LL (-53%, p=0.005, and -81%, p < 0.0001, respectively) but also of PT (-23%, p < 0.001). The use of PSR, in our experience, was feasible and provided satisfactory short-term results. It can be a valuable tool in the management of adult spinal deformities. Further studies will be needed in order to confirm these preliminary results.

French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury.

OBJECTIVES: To update the French guidelines on the management of trauma patients with spinal cord injury or suspected spinal cord injury. DESIGN: A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS: The committee studied twelve questions: (1) What are the indications and arrangements for spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few days in hospital? (4) What is the best way to manage these patients to improve their long-term prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® Methodology. RESULTS: The experts' work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/-) and 12 have a low level of evidence (GRADE 2+/-). For 5 recommendations, the GRADE method could not be applied, resulting in expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS: There was significant agreement among experts on strong recommendations to improve practices for the management of patients with spinal cord injury.

Minimally invasive transforaminal lumbar interbody fusion with unilateral pedicle screw fixation (UNILIF): morbidity, clinical and radiological 2-year outcomes of a 66-patient prospective series.

PURPOSE: To assess clinical and radiological outcomes at 2-year follow-up of one-level minimally invasive transforaminal interbody fusion with unilateral pedicle screw fixation (UNILIF) in the treatment of stable lumbar degenerative diseases. METHODS: From January 1, 2012 to January 31, 2013, we prospectively collected clinical and radiological data on patients with stable degenerative lumbar disease managed by UNILIF in a single institution. Preoperatively and at 2 years, we recorded ODI, SF-12, Quebec and VAS. Interbody fusion was analyzed on radiography and on a CT scan, and sagittal balance was tested on full spine radiography. RESULTS: Mean operation time was 74.5 min ± 16.8, mean blood loss was 130.8 ml ± 210.9. At 2 years, ODI, SF-12, Quebec and VAS were significantly improved (p > 0.005).The fusion rate was 96.8% on radiographic analysis and was 87.9% on CT scan analysis. CONCLUSIONS: One-level UNILIF constitutes an effective alternative for management of stable lumbar degenerative diseases. These slides can be retrieved under Electronic Supplementary Material.

Is anatomic acetabular orientation related to pelvic morphology? CT analysis of 150 healthy pelvises.

BACKGROUND: Links between sagittal spinal alignment and acetabular orientation attract considerable research attention with the goal of optimising prosthetic cup position. However, whether pelvic incidence (PI) is related to anatomic acetabular orientation remains unknown. We therefore conducted a radiological study with the following objectives: to look for correlations between PI and anatomic acetabular parameters; to describe the sacro-pubic angle (SPA), defined by fixed bony pelvic landmarks, and its relations with acetabular anteversion; and to determine whether anatomical parameters (PI and SPA) correlate with demographic characteristics. HYPOTHESIS: PI correlates with anatomical acetabular parameters. MATERIALS AND METHODS: We conducted a computed tomography (CT) study of the pelvises of 150 patients free of degenerative disease. Three parameters were measured: anatomic acetabular orientation in the Lewinnek reference plane, PI, and the SPA subtended by the line connecting the midpoint of the sacral endplate to the pubic symphysis and the anterior pelvic plane. Statistical tests were performed to look for correlations among these parameters. RESULTS: Intra-observer and inter-observer reproducibility was considered highly satisfactory (inter-class correlation coefficient, >86% and >82%, respectively). Mean PI was 58.6°±10.2° (range, 32.8°-97.6°), with no significant differences between genders or across age groups. Mean SPA was 34.7°±5.5° (range, 18.3°-49.8°). Mean anatomic acetabular anteversion (AAA) was greater in females (23.4°; range, 11.5°-34.5°) than in males (20°; range, 7.5°-34.5°) (P<0.001). PI did not correlate with any of the acetabular parameters (PI/AAA, r=0.8 and P=0.33; PI/acetabular inclination on the horizontal, r=-0.96 and P=0.24). SPA correlated significantly with both PI (r=0.33 and P<0.001) and AAA (r=0.33 and P<0.001). DISCUSSION: This CT study of normal pelvises showed that AAA was significantly greater in females and that SPA correlated significantly with both PI and acetabular anteversion. SPA could serve to define the "theoretical" AAA of each individual patient and could thus be incorporated into surgical planning protocols or intra-operative guidance methods for hip replacement surgery. LEVEL OF EVIDENCE: IV, retrospective study with no control group.

Percutaneous surgery for thoraco-lumbar fractures in ankylosing spondylitis: Study of 31 patients.

BACKGROUND: The risk of vertebral fracture is increased 4-fold in patients with ankylosing spondylitis (AS). Diagnostic challenges and the vulnerability associated with AS combine to generate high morbidity and mortality rates. The objective of this study was to assess the outcome of percutaneous thoraco-lumbar fracture surgery in patients with AS, in terms of quality of life, fracture healing, and complications. HYPOTHESIS: Percutaneous surgery used to treat thoraco-lumbar fractures in patients with AS reliably provides fracture healing, preserves self-sufficiency, and minimises post-operative complications. METHODS: Two centres included 31 patients with AS who were managed by percutaneous surgery for thoraco-lumbar fractures in 2013-2015. The data were reviewed retrospectively, although admission data were collected prospectively. Clinical outcomes were assessed by comparing the values at baseline and last follow-up of three variables: the Parker score, the visual analogue scale (VAS) pain score, and the EuroQol five dimensions (EQ-5D) quality-of-life score. Computed tomography was performed 1 year after surgery to evaluate bone healing, screw position, and implant loosening. Intra- and post-operative complications were recorded. RESULTS: The 31 patients had a mean age at surgery of 75.1 years, a mean follow-up of 35.6 months, and a minimum follow-up of 12 months. Three patients died during follow-up. Mean hospital stay duration was 6 days. Cemented screw fixation was used in 18 patients. At last follow-up, all patients had recovered their self-sufficiency; the mean Parker score was 7.14, compared to 6.73 at baseline, the mean VAS pain score was 1.8, and the mean EQ-5D score decrease versus baseline was 0.07 (P=0.02). Bone healing was consistently achieved. Loosening of an uncemented pedicle screw was noted in 1 patient. Of the 228 screws implanted, 6 (2.6%) were improperly positioned, including 1 within the spinal canal in a patient free of neurological manifestations. Asymptomatic cement leakage was noted in 2 patients. DISCUSSION: Percutaneous fixation of thoraco-lumbar fractures in patients with AS is a reliable method that produces a high healing rate and allows prompt patient mobilisation with preservation of self-sufficiency. The post-operative complication rate is low. LEVEL OF EVIDENCE: IV, retrospective observational study.

Trends in the surgical management of odontoid fractures in patients above 75 years of age: Retrospective study of 70 cases.

BACKGROUND: Odontoid fractures are the most common upper cervical spine fracture in adults over 70 years of age. Hence, treatment of these fractures has public health implications. OBJECTIVES: Evaluate the early complications, bone healing and mortality in patients above 75 years of age who undergo surgical treatment of an odontoid fracture. Compare the results between patients operated with the Harms technique or anterior screw fixation. METHODS: This was a retrospective study of 70 patients with an odontoid fracture who were treated surgically between 2000 and 2015 at the Hôpital de la Timone in France. The age at the time of diagnosis, comorbidities, ASA score and autonomy were evaluated. Bone healing was determined using computed tomography. RESULTS: In the cohort, 22 patients underwent anterior screw fixation, 38 were treated using the Harms technique and 10 with other procedures. The average age was 85.1 years. Fifty-four percent of patients had an ASA score above 3. The average follow-up was 23.4 months. An Anderson type II fracture was present in 80.6% of patients. In the anterior screw fixation group, the operative time was significantly shorter than in the Harms group and no blood transfusions were needed. However, 13.6% of these patients had to be re-operated because the initial construct was unstable; no patients in the Harms group underwent revision surgery. There were more complications in the anterior screw fixation group than in the Harms group: 41% versus 13.2% (P<0.02). The fractures had healed in all patients reviewed after 1 year. The 3-month survival in the anterior screw fixation group was 64.7% and it was 81.3% in the Harms group. These rates were stable at 1 year with no statistical differences between groups. CONCLUSION: Surgical treatment of odontoid fractures in the elderly results in an excellent union rate. The mortality rate is stable after 3 months. In our experience, the Harms technique has a lower risk of complications and better mechanical stability than anterior screw fixation. Despite the steep learning curve, we believe the Harms technique is probably the best choice for treating odontoid fractures in the elderly. LEVEL OF EVIDENCE: IV.

Surgical techniques for lumbo-sacral fusion.

Lumbo-sacral (L5-S1) fusion is a widely performed procedure that has become the reference standard treatment for refractory low back pain. L5-S1 is a complex transition zone between the mobile lordotic distal lumbar spine and the fixed sacral region. The goal is to immobilise the lumbo-sacral junction in order to relieve pain originating from this site. Apart from achieving inter-vertebral fusion, the main challenge lies in the preoperative determination of the fixed L5-S1 position that will be optimal for the patient. Many lumbo-sacral fusion techniques are available. Stabilisation can be achieved using various methods. An anterior, posterior, or combined approach may be used. Recently developed minimally invasive techniques are gaining in popularity based on their good clinical outcomes and high fusion rates. The objective of this conference is to resolve the main issues faced by spinal surgeons in their everyday practice.

Surgical management of post-traumatic atlantoaxial rotatory fixation due to C2 facet fracture: 5 clinical cases.

PURPOSE: Report the results of surgical treatment of post-traumatic atlantoaxial rotatory fixation (AARF) due to C2 articular facet fracture in adults. MATERIAL AND METHODS: The records of five patients treated since 2009 for AARF due to a C2 articular facet fracture were analyzed retrospectively. Three women and two men with an average age of 60 years (27-82) were included, one of whom initially had neurological deficits. In all cases, the surgical strategy consisted of posterior fixation: Harms-type in four cases and trans-articular with hooks in one case. RESULTS: Dislocations due to fracture of the C2 articular facet are rare in adults; various treatment strategies have been described. In our experience, posterior screw fixation leads to satisfactory clinical and radiological outcomes. Fusion is not necessary in these cases because the dislocation is related to an asymmetric fracture without ligament damage. CONCLUSION: Posterior fixation provides satisfactory reduction of these injuries and leads to satisfactory bone union. This surgical treatment can be performed early on after the trauma and is an interesting alternative to conservative treatment.

[Use of pedicle percutaneous cemented screws in the management of patients with poor bone stock]. / Utilisation de vis cimentées percutanées dans la prise en charge rachidienne des patients à faible capacité osseuse.

INTRODUCTION: Management of patients with poor bone stock remains difficult due to the risks of mechanical complications such as screws pullouts. At the same time, development of minimal invasive spinal techniques using a percutaneous approach is greatly adapted to these fragile patients with a reduction in operative time and complications. The aim of this study was to report our experience with cemented percutaneous screws in the management of patients with a poor bone stock. METHODS: Thirty-five patients were included in this retrospective study. In each case, a percutaneous osteosynthesis using cemented screws was performed. Indications were osteoporotic fractures, metastasis or fractures on ankylosing spine. Depending on radiologic findings, short or long constructs (2 levels above and below) were performed and an anterior column support (kyphoplasty or anterior approach) was added. Evaluation of patients was based on pre and postoperative CT-scans associated with clinical follow-up with a minimum of 6 months. RESULTS: Eleven men and 24 women with a mean age of 73 years [60-87] were included in the study. Surgical indication was related to an osteoporotic fracture in 20 cases, a metastasis in 13 cases and a fracture on ankylosing spine in the last 2 cases. Most of the fractures were located between T10 and L2 and a long construct was performed in 22 cases. Percutaneous kyphoplasty was added in 24 cases and a complementary anterior approach in 3 cases. Average operative time was 86minutes [61-110] and blood loss was estimated as minor in all the cases. In the entire series, average volume of cement injected was 1.8 cc/screw. One patient underwent a major complication with a vascular leakage responsible for a cement pulmonary embolism. With a 9 months average follow-up [6-20], no cases of infection or mechanical complication was reported. CONCLUSION: Minimal invasive spinal techniques are greatly adapted to the management of fragile patients. The use of percutaneous cemented screws is, in our experience, a valuable alternative for spinal fixation in patients with poor bone stock. This technique allows a good bony fixation with a low rate of complications. However, rigorous preoperative planning is necessary in order to avoid complications.

Quantitative MRI water content mapping of porcine intervertebral disc during uniaxial compression.

BACKGROUND: Intervertebral disc (IVD) diseases are major public health problem in industrialized countries where they affect a large proportion of the population. In particular, IVD degeneration is considered to be one of the leading causes of pain consultation and sick leave. The aim of this study was to develop a new method for assessing the functionality of IVD in order to diagnose IVD degeneration. METHODS: For this purpose, we have designed a specific device that enables to mechanically load porcine IVD ex vivo in the 4.7-Tesla horizontal superconducting magnet of a magnetic resonance (MR) scanner. Proton density weighted imaging (ρH-MRI) of the samples was acquired. FINDINGS: The post-processing on MR images allowed (1) to reconstruct the 3D deformation under a known mechanical load and (2) to infer the IVD porosity assuming an incompressible poroelastic model. INTERPRETATION: This study demonstrates the ability to follow the change in morphology and hydration of an IVD using MR measurements, thereby providing valued information for a better understanding of IVD function.

Minimally invasive posterior transforaminal lumbar interbody fusion: One-year postoperative morbidity, clinical and radiological results of a prospective multicenter study of 182 cases.

INTRODUCTION: Interbody fusion is the gold standard treatment for the management of numerous diseases of the spine. Minimally invasive techniques may be more beneficial than conventional techniques. The main goal of this study was to report the one-year postoperative results of a series of posterior lumbar interbody fusions by a minimally invasive technique in relation to improvement in functional outcome, interbody fusion and morbidity. MATERIALS AND METHODS: Between January 2012 and May 2013, 182 patients treated by minimally invasive posterior transforaminal lumbar interbody fusion (TLIF) were included in this prospective multicenter study. Clinical assessment was based on a comparison of the preoperative and one-year postoperative Oswestry (ODI), SF-12 and Quebec Scores and the Visual Analog Scale (VAS). Surgical and postoperative follow-up data were evaluated. Radiological assessment was based preoperative and one-year postoperative full spine teleradiographs. Interbody fusion at one-year was systematically evaluated by CT scan. RESULTS: One hundred and eighty-two patients were included, mean age 58.9 years old. Surgery lasted a mean 101 minutes, mean preoperative bleeding was 143 mL, and mean radiation exposure was 247.4 cGy/cm(2). The rate of postoperative complications was 7.7%. The ODI, the Quebec Score, the SF-12 and the VAS were all significantly improved at one-year (P<0.0001). The rate of fusion was 72.6% at the final follow-up. There was no significant difference in functional outcome between patients with and without fusion. DISCUSSION: The one-year postoperative radiological results and functional outcome of minimally invasive posterior lumbar fusion are satisfactory. The benefits of this minimally invasive approach are mainly found in the first 6 postoperative months. Successful radiological interbody fusion was not correlated to functional outcome at the final follow-up.

Delayed hypersensitivity reaction after cervical disc replacement: a case report.

We report a case of allergic reaction after total cervical disc arthroplasty. A 52-year old woman was operated on for right C6 cervicobrachial neuralgia secondary to C5-C6 disc disease with foraminal stenosis. A cobalt-chromium-molybdenum total disc prosthesis had been implanted two years earlier. The patient was referred to our institution for recurrence of axial neck pain associated with abdominal patches of erythematous itching rash and swallowing disorder. Allergy tests confirmed type-4 allergic reaction to chromium. Symptoms decreased after removal of the prosthesis with secondary fusion. Delayed allergic reaction is uncommon in spine surgery, but should be considered in case of recurrence of initial symptomatology associated with non-spinal signs.

Early percutaneous fixation of spinal thoracolumbar fractures in polytrauma patients.

INTRODUCTION: Care of polytrauma patients is complex and requires that a particular treatment sequence be followed during what is typically a short period of time. Early, temporary stabilization of injuries (damage control orthopedics [DCO]) is a validated strategy for the care of polytrauma patients. Application of this concept to spinal fractures has also led to good outcomes for patients. The recent development of percutaneous thoracolumbar fixation could improve the initial care of these vulnerable patients even more. The purpose of this study was to evaluate preliminary results in a series of polytrauma patients presenting with thoracolumbar fractures without neurological deficits who were treated according to DCO principles using early percutaneous fixation. MATERIALS AND METHODS: All severe polytrauma patients admitted with a thoracic and/or lumbar spine fracture without neurological deficit were included in this prospective study. The care was standardized according to the degree of urgency of the initial injuries, with percutaneous spinal fixation being performed as early as feasible. The outcomes were evaluated using clinical parameters (duration of stay in intensive care unit, surgical data, blood loss) and radiographic parameters measured during a systematic postoperative CT scan (traumatic deformity, placement of pedicle screws, fusion rate). If needed, an anterior intervertebral graft was performed during a secondary procedure. RESULTS: In all, 10 patients (average age of 40 years) were included, corresponding to 18 vertebral fractures. During the initial assessment, at least one peripheral bone fracture was found in 90% of cases and at least one organ was injured in all patients (thoracic in 80% of cases, cerebral in 50%, facial area in 40% and abdominal-pelvis in 30%). The average time elapsed between admission and spine surgery was 4 days (80% of cases before day 7). There were no cases of deep infection in any of the patients. An additional anterior procedure was needed in three patients within 1 month of the initial surgery. DISCUSSION: The strategy for treating thoracolumbar fractures in polytrauma patients is still not widely accepted. The presence of associated lesions could make it difficult to perform conventional spine surgery early on. Development of percutaneous techniques that reduce perioperative morbidity seems to be an alternative approach well-suited to DCO, as long as there are no neurological deficits. However, a secondary evaluation of the anterior spine is essential to determining if an anterior graft remains needed. LEVEL OF EVIDENCE: Level IV.

[Biometric and biomechanic analysis of lumbar posterior facets based on a CT-scan database]. / Analyse biométrique et biomécanique des articulaires lombaires postérieures au sein d'une base de données scanographique.

AIM OF THE STUDY: Our knowledge on anatomy of lumbar spine is based on few cadaver's study with old and few subjects. CT-scan is very precise for lumbar facet's morphology. We have analysed 400 subjects. The aim of this study is to measure different distances, angles and circles to better understand the mechanical function of the lumbar facets. PATIENTS AND METHODS: We have analysed 720 CT-scan. We had 217 men and 183 women with 59 years of mean age. We used native slices of 1.25 mm thick from L1 to S1. We created transversal plan and we put different mark point. We took their coordinates and we have calculated different distances, angles and mechanical circles. We have compared different axis of rotation of the facets. RESULTS: From L1 to S1, the facets goes near to the posterior wall and far from themselves. Moreover, the posterior angle between both facets increase down to the sacrum. The radius of the left side circle and the right one are very closed in 50% of the cases but the three radius are close only in 10% of cases. CONCLUSION: This study based on 400 subjects shows that there is not a unique axis of rotation for both lumbar posterior facets. We have had only 50% of symmetry between both sides whatever the level studied.

Minimally invasive management of thoraco-lumbar fractures: combined percutaneous fixation and balloon kyphoplasty.

STUDY DESIGN: Retrospective review of prospectively collected data. BACKGROUND: There is no consensus regarding the ideal treatment of thoraco-lumbar spine fractures without neurological compromise. Many surgical techniques have been described but none has proved its definite superiority. The main drawback of these procedures is directly related to the morbidity of the approach. As minimally invasive fixation combined with balloon kyphoplasty for treatment of thoraco-lumbar fractures is gaining popularity, its efficacy has yet to be established. PURPOSE: The purpose of this study is to report operative data, clinical and radiological outcomes of patients undergoing minimally invasive management of thoraco-lumbar fracture at our institutions. METHODS: Forty-one patients underwent percutaneous kyphoplasty and stabilization for treatment of single-level fracture of the thoracic or lumbar spine. All patients were neurologically intact. There were 20 males and 21 females with an average age of 50 years. RESULTS: The mean follow-up was 15 months (3-90 months). The mean operative time was 102 minutes (range 35-240 minutes) and the mean blood loss was <100mL. VAS was significantly improved from 6.7 to 0.7 at last follow-up. Vertebral kyphosis decreased by 16° to 7.8° postoperatively (P<0.001). Local kyphosis and percentage of collapse were also significantly improved from 8° to 5.6° and from 35% to 16% at last follow-up. Fifteen leaks have been identified, three of which were posterior; all remained asymptomatic. No patient worsened his or her neurological condition postoperatively. CONCLUSION: Percutaneous stabilization plus balloon kyphoplasty seems to be a safe and effective technique to manage thoraco-lumbar fractures without neurological impairment.

Sagittal spine posture assessment: feasibility of a protocol based on intersegmental moments.

Evaluation of spinal posture has recently benefited from the contribution of three-dimensional reconstruction technologies that have helped improve our understanding of this dynamic balance. The aim of this study was to present the preliminary results of a three-dimensional protocol to analyze postural balance. This analytical method is not limited by certain constraints of the radiological approach and evaluates postural balance using a new approach taking into account the net efforts of different intersegmental centers. These preliminary results show the technical feasibility of the protocol. Its future development and clinical use could provide a better understanding of postural balance disorders, and help evaluate the impact of surgical correction on spinal balance.

Percutaneous management of thoracolumbar burst fractures: Evolution of techniques and strategy.

INTRODUCTION: A number of techniques have been described in the management of thoracolumbar spinal fractures, testimony to the absence of consensus on their treatment. For the past few years, minimally invasive techniques have been developed to limit surgery-related iatrogenic injury. The objective of this study was to report the results of percutaneous management of these lesions and the technical progress made based on our experience. PATIENTS AND METHODS: Twenty-nine patients presenting an A3 fracture, with a mean age of 51 years, were included in this study. All had a balloon kyphoplasty and percutaneous osteosynthesis. Of the first 22 cases, kyphoplasty was the initial procedure performed associated with reduction maneuvers using distraction. Assessment was clinical (neurological status and pain intensity) and radiological (implant positioning, cement leakage, restoration of local kyphosis and any loss of correction). RESULTS: In the overall series, the mean local kyphosis correction was 11° with a 2° angle loss at the last follow-up. Pain assessment showed significant improvement, decreasing from 6/10 to 1/10 on discharge. The mean hospital stay lasted 4 days. On the follow-up radiological exams, no cases of extrapedicular screw migration were noted; in two cases, lateral cement leakage was found. The results were equivalent in terms of correction no matter which procedure was performed first, although for the second part of the series the technology was available to bend the spinal fixation rod to the desired curve. DISCUSSION: The results of this study support the growing interest in minimally invasive techniques in the management of spinal injuries with no neurological deficit. In addition, the evolving material makes it possible to come close to conventional techniques, including reduction maneuvers, while limiting muscle injury by using a purely percutaneous approach. Rigorous patient selection is necessary and the time to learn the procedure must be taken into account. Studies with a longer follow-up are required to confirm the stability of the correction over time. LEVEL OF EVIDENCE: Level IV. Retrospective observational study.