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Introduction: Anterior approach indications in unstable thoracolumbar fractures (UTLF) are debated. The aim of this study was to evaluate the results of anterior fixation and expandable prosthetic vertebral body cage (EPVBC) implantation alone or combined with a posterior approach in the management of UTLF., Materials and Methods: Ninety-three patients underwent anterior fixation with implantation of an EPVBC for UTLF from T7 to L5. Long-term kyphosis and vertebral height loss reduction, functional outcomes including visual analogical scale and Oswestry disability index were evaluated., Results: Anterior fixation led to a significant increase of vertebral body height with a gain of 13% after a previous posterior approach, 38% after a single anterior approach and 65% after combined posterior and anterior approaches (P=0.0001). However, anterior fixation did not significantly enhance the vertebral regional kyphosis angle (P=0.08), except in cases of single anterior approach for thoracic fractures (P=0.03). No significant difference was found between early, 3 months and 1 year postoperative vertebral regional kyphosis angle and vertebral body height (P=0.6). Complete fusion was routinely observed at 1 year postoperatively. rhBMP2 implantation in selected cases appears to be a safe and reliable strategy. No infections or surgical revisions were observed after the anterior approach., Conclusion: Anterior approach and EPVBC implantation, in UTLF, is a safe and effective procedure, providing long-term vertebral body height and kyphosis correction. Adverse effects of anterior approach remain acceptable. Single anterior fixation is a reliable surgical alternative in thoracic fractures without posterior spine segment injury or spinal cord compression. These results prompted us to extend anterior approach indications in oncology and infectious diseases., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Background: Metastatic disease of the spine requires a multidisciplinary and comprehensive approach to patient care, especially, for patients in a lot of pain with neurological deficit or spinal instability requiring surgical stabilization., Objectives: The purpose of the study is to report our experience on 34 patients who underwent spinal metastasis resection. We used a single-stage posterior approach with vertebral body reconstruction by an expandable titanium cage and a posterior instrumentation. The parameters assessed were neurologic status, OMS score, angle of sagittal deformity, and morbidity., Methods: Between January 2011 and June 2014 we performed a monocentric consecutive case review of 34 patients with vertebral body tumor. All of them underwent a single-stage vertebrectomy with circumferential reconstruction and an arthrodesis by posterior approach., Results: 34 patients underwent a single stage surgery by posterior approach, including 30 thoracic lesions and 4 lumbar lesions. Pre operatively, sixteen patients presented a neurologic impairment. The mean follow-up was 13.7 months [1-32 m]. No neurologic impairment was observed in the 34 cases. At the last term of follow-up, neurologic status was improved in 23 cases. OMS score was improved in 23 cases (67.6 %), and worsened in one case. Before surgery, the average of visual analogic scale was 8.94/10 [7-10] and decreased to 2.62/10 [1-5] after surgery. Single posterior approach surgery significantly reduced the average sagittal deformity to 10.0° (0.01-19.96; P = 0.013, Mann-Whitney test)., Conclusion: Our outcomes suggest that it will be more efficient to perform an aggressive approach in spinal metastatic treatment in order to improve quality of life., (Copyright © 2015 Elsevier Inc. All rights reserved.)

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., (Copyright © 2014. Published by Elsevier Masson SAS.)

Aim: In this study, we are using a recently developed method: a minimally invasive retractor system and an operating microscope to treat far lateral lumbar herniated disc. This method decreases tissue dissection and blood loss, and improves postoperative recovery., Methods: This is a retrospective study of 46 patients, there was 25 female and 21 male. They all underwent minimal invasive surgery. The average age was 56 years old (19-83 years). Lumbar disc herniation is a common pathology. Far lateral disc herniation accounts for 2.6% to 11.2% of all lumbar disc herniation. A few surgical techniques have been describes to treat this type of disc pathology. All patients were operated under general anesthesia. The fluoroscopic guidance was absolutely necessary. A 12-15 mm skin incision was made on the side of the disc herniation (30 mm from the midline). Then, we inserted a tubular retractor system (muscle splitting approach) followed by a 14 mm diameter-working channel. Under operating microscope the pars interarticularis was dreamed to expose the nerve root and the disc. After removing the intertransverse ligament, we removed the herniated disc., Results: The average time of surgery was 55 min. The operating time decreased with the experience of the surgical team. Postoperatively the radicular pain was around 2 (using an analogical visual scale), over 7 preoperatively. The length of hospitalization was 3 days. There were no complications in our study. The average follow-up was 2 years (6-36 months). There was no complication, no postoperative infection., Conclusion: This technique combines the advantages of endoscopic surgery and microscope guided surgery (3D vision) and provides good functional results in this study.

Vertebral angioma is a common bone tumor. We report a case of L1 vertebral angioma revealed by type A3.2 traumatic pathological fracture of the same vertebra. Management comprised emergency percutaneous osteosynthesis and, after stabilization of the multiple trauma, arterial embolization and percutaneous kyphoplasty., (Copyright © 2013. Published by Elsevier Masson SAS.)

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., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

The study design includes prospective evaluation of percutaneous osteosynthesis associated with cement kyphoplasty on 18 patients. The objective of the study is to assess the efficacy of a percutaneous method of treating burst vertebral fractures in patients without neurological deficits. Even if burst fractures are frequent, no therapeutic agreement is available at the moment. We report in this study the results at 2 years with a percutaneous approach for the treatment of burst fractures. 18 patients were included in this study. All the patients had burst vertebral fractures classified type A3 on the Magerl scale, between levels T9 and L2. The patients' mean age was 53 years (range 22-78 years) and the neurological examination was normal. A percutaneous approach was systematically used and a kyphoplasty was performed via the transpedicular pathway associated with percutaneous short-segment pedicle screw osteosynthesis. The patients' follow-up included CT scan analysis, measurement of vertebral height recovery and local kyphosis, and clinical pain assessments. With this surgical approach, the mean vertebral height was improved by 25% and a mean improvement of 11.28 degrees in the local kyphotic angle was obtained. 3 months after the operation, none of the patients were taking class II analgesics. The mean duration of their hospital stay was 4.5 days (range 3-7 days) and the mean follow-up period was 26 months (range 17-30 months). No significant changes in the results obtained were observed at the end of the follow-up period. Minimally invasive methods of treating burst vertebral fractures can be performed via the percutaneous pathway. This approach gives similar vertebral height recovery and kyphosis correction rates to those obtained with open surgery. It provides a short hospital stay, however, and might therefore constitute a useful alternative to open surgical methods.

Introduction: The majority of osteoporotic, spinal cord compressive, vertebral fractures occurs at the thoracolumbar junction level. When responsible for neurological impairment, these rare lesions require a decompression procedure. We present the results of a new option to treat these lesions: an open balloon kyphoplasty associated with a short-segment posterior internal fixation., Materials and Methods: Twelve patients, aged a mean 72.3 years, were included in this prospective series; all of them presented osteoporotic burst fractures located between T11 and L2 associated with neurological impairment. The surgical procedure first consisted of a laminectomy, for decompression, followed by an open balloon kyphoplasty. A short-segment posterior internal fixation was subsequently put into place when the local kyphosis was considered severe. A CAT scan study evaluated local vertebral body's height restoration using two pre- and postoperative radiological indices., Results: All of the patients in the series were followed up for a mean 14 months. Local kyphosis improved a mean 10.8 (p<0.001). Vertebral body height was also substantially restored, with a mean gain of 26% according to the anterior height/adjacent height ratio and 28% according to the Beck Index (p<0.001). Two cases of cement leakage were recorded, with no adverse clinical side effect. Complete neurological recovery was observed in 10 patients; two retained a minimal neurological deficit but kept a walking capacity., Discussion: The results presented in this study confirm the data reported in the literature in terms of local kyphosis correction and vertebral body height restoration. The combination of this technique with laminectomy plus osteosynthesis allowed us to effectively treat burst fractures of the thoracolumbar junction and led to stable results 1 year after surgery. This can be advantageous in a population often carrying multiple co-morbidities. With a single operation, we can achieve neurological decompression and spinal column stability in a minimally invasive way; this avoids more substantial surgery in these fragile patients., Level of Evidence: Level IV. Therapeutic prospective study., (2009 Elsevier Masson SAS. All rights reserved.)

Surgically managed bacterial spondylitis is rare, and a variety of operative techniques are currently available, without any real consensus. The present study reports an original, less invasive surgical treatment for spondylitis, in two patients. An initial percutaneous posterior instrumentation fixation was followed by an anterior interbody graft performed through a retroperitoneal route. Postoperative bacterial typing was done; pain resolution was obtained in both patients. Control CT scan showed good restitution of the disk space height and a satisfactory reduction of the local kyphosis. Fusion was achieved at 6 months in both cases, with stable results at long-term follow-up. In patients presenting comorbid conditions, this technique gave interesting preliminary results, was less traumatic and shorter to perform, and finally entailed a limited operative risk.

Background: The purpose of this study was to evaluate a minimally invasive surgical technique for the treatment of lumbar far lateral disc herniation. This technique combines the tubular retractor with the operative microscope., Objective and Methods: This retrospective study analyzed the files of 26 patients: 15 men and 11 women. The average age was 56 years (range, 19-83 years). The most commonly operated level was L3-L4 (46%), then L4-L5 (30.5%) and finally L2-L3 (15.5%). All patients were operated under general anesthesia. The intraoperative radioscopic location was absolutely necessary. A 12-15 mm paramedian incision was made on the side of the herniation (30 mm from the medial line). We then inserted the tubular muscular retraction system followed by the 14 mm diameter working channel. Guided by operating microscope, the articular isthmus was reamed to expose the root and the disc. The disc herniation was then removed after opening and removing the inter-transverse ligament., Results: The average duration of the surgery was 55 min. This operating time decreased as the surgeons gained experience. The radicular pain, estimated using the analogical visual scale, varied from seven before surgery to two during the postoperative period. All the patients were standing up the day after surgery. The average duration of the postoperative stay in the hospital was three days (range, 1-5 days). We noted no complications from the surgical procedure. The average duration of the follow-up was two years (range, 6-36 months)., Conclusion: This technique combines the advantages of endoscopic surgery (less muscular and osseous damage) and microscope-guided surgery (three-dimensional vision) and provided good functional results in this series.

Sacral fractures are uncommon injuries that are often diagnosed late, the transverse fracture dislocation of the sacrum at the S1-S2 level associated with a L5 Chance fracture has never been reported. The purpose of this report is to describe operative treatment of transverse fracture dislocation of the sacrum at the S1-S2 level associated with a L5 Chance fracture. A 17-year-old woman sustained multiple injuries in a road accident and presented with hypovolumic shock. Radiological assessment demonstrated transverse fracture dislocation of the sacrum at the S1-S2 level associated with a L5 Chance-fracture. Neurologic examination demonstrated L5 root deficit and perineal hypoesthesia. Operative treatment was undertaken. The procedure consisted of laminectomy of L5, S1, and S2 and osteosynthesis of L3-L4 - S3-S4 (in sacral alae). Attempts to reduce dislocation failed. Postoperative recovery was uneventful. One year after operative treatment the patient presented no neurologic deficit and had resumed normal activity. Follow-up radiological imaging demonstrated consolidation of fracture zones. Management for uncommon lumbrosacral junction injuries must take into account various parameters including hemodynamic condition, neurologic status, and stability of the spinal lesions. Decompression of neural impingement and stabilization of fractures by osteosynthesis appear to be a useful alternative that allows patients to stand again and begin rehabilitation quickly.

Background: Synovial cysts represent an uncommon and probably underestimated pathological entity of the degenerative lumbar spine. The authors report a retrospective analysis of the clinical presentation, radiological studies and operative findings in 77 patients surgically treated for symptomatic lumbar synovial cysts at their institution., Materials and Method: Between January 1992 and June 1998, a total of 77 patients presenting with symptomatic lumbar synovial cysts were operated on in the author's department. Operative procedure, complications, results and pathological findings were correlated with preoperative assessment. There were 41 men and 36 women with an average age of 63 years (range 44-90 years)., Results: On the basis of their symptom complex on presentation, two populations were identified: patients who presented with a single radicular pain (group I = 51 patients), and patients who presented with bilateral neurogenic claudication (group II = 26 patients). Neurological examination on presentation demonstrated motor deficit (12%), sensory loss (26%) and reflex changes (35%). Degenerative disc disease and facet joint osteoarthritis was a frequent finding in patients with pre-operative MRI. Facet joint orientation was >45 degrees in 76.6% of patients. Preoperative spondylolisthesis was found in 48% on radiological studies. All the patients were treated surgically with resection of the cyst. No fusion was performed as a first line procedure. However subsequent fusion was necessary in one patient who developed symptomatic spondylolisthesis. Mean follow-up period was of 45 months ranging from 18 to 105 months. Only one recurrence occurred during the follow-up period. An excellent or good functional outcome was seen in 97.4% of cases, and 89% of the patients with motor deficit recovered., Conclusions: Surgical resection of lumbar synovial cysts is an effective treatment associated with very low morbidity. Synovial cysts are associated with increased grade and frequency of facet joint asteoarthritis but not with increased grade or frequency of degenerative disc disease compared with patients without cysts. In the author's opinion, at the present time, there is no reliable criterion which allows the development of a symptomatic spinal instability to be predicted in patients with a preoperative spondylolisthesis and therefore fusion as a first line procedure is still debatable.

We report a retrospective analysis of a series of 32 cases of lumbar synovial cysts. Clinically, two populations were identified: patients who presented radicular pain mimicking the clinical diagnosis of disk herniation (group I) and patients who presented neurogenic claudication consistent with a diagnosis of lumbar spinal stenosis (group II). The radiological work-up consisted in standard X-rays and CT-scan for all patients. MRI (magnetic resonance imaging) was performed in 14 patients. All the patients were operated on. The surgical technique consisted in foraminotomy for patients in group I and more or less extensive laminectomy for patients in group II. Functional outcome was marked by a significant improvement in 96.9% of the patients and those who presented a motor deficit recovered in 83% of the cases. Based on the findings in this series, we discuss the clinical aspects and the therapeutic management of this pathological entity.

Background: Anterior lumbosacral dislocation is a rare traumatic anterior spondylolisthesis., Methods: We report a new case surgically treated and review the eight cases previously reported., Results: The mechanism of injury is hyperflexion-distraction. Neurological signs are inconsistent. Indirect radiological signs such as bilateral multiple transverse process fractures are strongly suggestive of the diagnosis. This complete soft tissue injury induces a definitive instability and requires an open reduction with posterior fixation., Conclusions: Suspicion of lumbosacral dislocation requires a computed tomography scan exploration with multiplanar reconstructions. Early reduction is associated with neurologic recovery. However, prognosis is correlated with the initial neurologic status and the severity of other associated injuries.

The authors describe a rare late complication of lumbar arthrodesis, a synovial cyst occurring in association with overuse of the underlying facet joint. [ABSTRACT FROM AUTHOR]