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Purpose: To investigate the age-specific normative values of whole-body sagittal alignment (WBSA) including global balance parameters in healthy adults and to clarify the correlations among parameters based on the data from three international multicenter. Methods: Three hundred and seventeen healthy subjects (range: 20–84 y.o., mean: 43.8 ± 14.7 y.o.) were included and underwent whole-body biplanar X-ray imaging system. Spinopelvic parameters and knee flexion (KF), the center of acoustic meatus (CAM)-hip axis (HA), and C2 dentiform apophyse (OD)-HA, the cranial center (Cr)-HA were evaluated radiologically. Sub-analysis for correlation analysis between age and parameters and among parameters was performed to investigate age-specific change and compensatory mechanisms. Results: For age-related change, C2-7 angle (r = .326 for male/.355 for female), KF (r = .427/.429), and SVA (r = .234/.507) increased with age in both male and female group. For global parameters related to the center of the gravity, correlations with age were not significant (r = .120/.161 for OD-HA, r = .163/.275 for Cr-HA, r = .149/.262 for CAM-HA). Knee flexion (KF) has correlation with global parameters (i.e., SVA, OD-HA, Cr-HA, CAM-HA) and does not have correlations with local spinopelvic alignment. Conclusion: While several local alignment changes with age were found, changes in global parameters related to the center of gravity were kept relatively mild by the chain of compensation mechanisms including the lower limbs. We showed the normative values for a comprehensive WBSA in standing posture from large international healthy subjects’ database.

Purpose: Spinal osteotomies performed to treat fixed spinal deformities are technically demanding and associated with a high complications rate. The main purpose of this study was to analyze complications and their risk factors in spinal osteotomies performed for fixed sagittal imbalance from multiple etiologies. Methods: The study consisted of a blinded retrospective analysis of prospectively collected data from a large multicentre cohort of patients who underwent 3-columns (3C) spinal osteotomy, between january 2010 and january 2017. Clinical and radiological datas were compared pre and post operatively. Complications and their risks factors were analyzed.Results: Two hundred eighty-six 3C osteotomies were performed in 273 patients. At 1year follow-up, both clinical (VAS pain, ODI and SRS-22 scores) and radiological (SVA, SSA, loss of lordosis and pelvic version) parameters were significantly improved (p were assessed as risk factors for overall complication (p (p=0.02).Conclusion: Spinal 3C osteotomies were efficient to improve both clinical and radiological parameters despite high rates of complication. Efforts should be made to reduce operative time which appears to be the strongest predictive risk factor for complication.

Purpose Prospective pre-operative and post-operative comparative analysis of radiographic spino-pelvic parameters between sitting versus standing positions of patients with LS fusion, to detect adaptation mechanisms around fused spinal segments. Methods Sixteen patients aged 53.9 ± 15.9 who underwent LS fusion between L3 and S1 were extracted from the database of an ongoing prospective study. Different spino-pelvic parameters were evaluated on full spine X-rays, standing, then sitting straight. Parameters were compared pre-operative versus post-operative, and on standing versus sitting X-rays. Results Preliminary results revealed a significantly greater pre-operative pelvic tilt (PT) in sitting than standing posture, (p = 0.020) but not in post-operative (p = 0.087). After surgery, PT was lower in sitting compared to pre-operative (p = 0.034) but not in standing (p = 0.245). L4–S1 lordosis was lower in sitting than standing in pre-operative (p = 0.014) and post-operative (p = 0.021). Surgery decreased segmental lordosis above the fusion (PSL, proximal sagittal lordosis) in sitting (p = 0.039) but not in standing (p = 0.193). No significant differences in thoracic kyphosis (TK) were observed. Fusions down to L5 versus S1 showed no significant differences for PT and PSL, neither in sitting versus standing, nor pre-operative versus post-operative. Conclusion Before fusion, compared to standing, PT increases in sitting straight posture (pelvic retroversion), and the lumbar spine adapts by decreasing its lordosis, mainly at L4–S1. After fusion, the segments adjacent to the instrumented section, adapt in flexion at lumbosacral and thoracolumbar junctions, i.e. just below and above (PSL). This might have mechanical implications for the occurrence of adjacent segment disease.

The purpose of this study was to investigate the affecting factors on pelvic incidence (PI) and to test the hypothesis that PI changes even after skeletal maturity probably due to hypermobility of the sacroiliac joint using a large international multi-center database.A prospective and cross-sectional healthy adult volunteers, ages 18-80 years, across 5 countries were used. Radiographic measurements included standard whole body alignment parameters. Bivariate regression analyses between PI versus demographics and spino-pelvic anatomical parameters were performed. An effect of sex on pelvic anatomical parameters was also investigated. Multivariate logistic regression with a forward stepwise procedure was performed to identify the contributing factors to PI, and an appropriate model was obtained.PI showed a significant positive correlation with age in pooled data. Divided by sex, however, there was no correlation in men, but women showed a significant higher correlation coefficient. Pelvic thickness (PTh) had a significant negative correlation with age in pooled data. Divided by sex, no correlation was found in men, but there was a significant correlation in women with higher correlation coefficient. The stepwise multivariate analysis for the factors on PI identified four significant factors: age, sex, ethnicity, and PTh.PTh, sex, ethnicity, and age affected PI. There was a positive correlation between PI and age. The tendency was more significant in woman than in man. The results support the hypothesis that PI increases with aging, but the change seems to be small and needs to be verified in a longitudinal evaluation.

Resume Introduction La necessite d’une arthrodese associee a une decompression chez les patients ayant un canal lombaire etroit reste conversee. Le but de cette etude est de montrer qu’une decompression isolee avait un resultat equivalent a une decompression associee a une arthrodese chez un patient ayant un equilibre sagittal global conserve. Materiel et methodes Une cohorte retrospective et monocentrique de 110 patients operes d’un canal lombaire etroit sur un niveau a ete divisee en deux groupes equivalents en fonction du traitement : decompression isolee ou fusion-decompression. Les patients inclus avaient un ODHA (angle odontoide-axe des hanches et ligne verticale) normal (−5°a + 2°) et ne presentaient pas de spondylolisthesis ni de deformation frontale. Nous avons compare les scores cliniques et les parametres pelvirachidiens en preoperatoire et a un an. Nous avons evalue le MCID (Minimal Clinically Important Difference) correspondant a une difference d’ODI (Owestry disability index) de 12,8 points. Dans chaque groupe, une analyse en fonction du MCID a ete realisee. Resultats Une augmentation significative des scores cliniques dans chaque groupe a ete mise en evidence. Les 2 groupes ont 77 % de diminution de l’ODI > 12,8 points sans difference significative entre les 2 groupes. Enfin, l’analyse en fonction du MCID montre que les patients avec un mauvais resultat clinique a 1 an dans le groupe decompression isolee etaient plus lombalgiques alors qu’ils etaient plus radiculaires dans le groupe decompression-fusion. Conclusion La fusion decompression n’a pas montre de superiorite a un an sur les resultats cliniques et radiologiques en comparaison a la decompression isolee pour la prise en charge d’un canal lombaire etroit monosegmentaire chez des patients ayant un equilibre compense. L’interet de l’imagerie rachis entier en charge est de determiner l’equilibre sagittal du patient et de s’assurer de l’absence de facteurs d’instabilites radiologiques qui pourraient justifier un geste stabilisateur. Niveau de preuve IV ; etude retrospective sur une collection prospective de donnees.

Resume Dans la chirurgie rachidienne degenerative de l’adulte, la cyphose jonctionnelle pourrait etre un mecanisme de compensation d’une hyperlordose lombaire pathologique, associee a une courbure spinale disharmonieuse. Nous presentons un cas qui a beneficie d’une decompression lombaire avec fusion thoraco-lombaire et des cages par abord posterieur et lateral. La patiente a developpe une cyphose jonctionnelle proximale et malgre plusieurs reprises chirurgicales, elle a continue de presenter des complications mecaniques en raison d’un exces de lordose lombaire. Nous avons finalement effectue une osteotomie posterieure d’ouverture (OPO ou Posterior Opening Wedge Osteotomy POWO) au niveau de L3 pour corriger l’hyperlordose lombaire. A 24 mois de suivi postoperatoire, aucune autre complication mecanique n’a ete mise en evidence. A travers cet article, nous exposons le raisonnement de ce type de traitement, ainsi que la procedure chirurgicale de l’OPO. Nous analysons egalement le risque lie a une correction excessive de la lordose lombaire entrainant une modification de la courbure harmonieuse de la colonne vertebrale degenerative chez l’adulte.

Study design National cross-sectional study. Background Thoracic kyphosis (TK) is related to sagittal parameters as pelvic tilt (PT), lumbar lordosis (LL) and pelvic incidence (PI). The equation TK =2 (PT+LL–PI) was validated for adolescents. Objective: to investigate if this equation correctly predicts TK regardless of age. Methods Sagittal alignment parameters were assessed on full spine radiographs of 2599 individuals without spine pathology (1488 females, 1111 males). Calculated TK (CTK) = 2 (PT+LL–PI) and measured TK (MTK) were compared by calculating the gap and using a linear regression between both parameters. Subgroup analyses were performed for gender, age, TK groups (≤20°, 21°-40°, 41°-60°, >60°), and PI groups (60°). Results Average values in the total population were: MTK 45.0°, CTK 36.9°. Average TK gap was 8.1°, 5.2° in females (intercept 11.7, slope .61) and 11.9° in males (intercept 7.1, slope .58). The mean gap was 3.6° for 15-34 years, 5.7° under 15 years and it increased progressively after 35 years with a maximum of 19.9° over 80 years. The gap also increased with the amount of MTK: -3.5° for TK60°. Differences in gaps were minor between PI groups. The intercept was smallest and slopes >.6 for PI Conclusion The formula TK=2 (PT+LL-PI) yielded moderate accuracy for adolescents and young adults, but did not fit for over 35 years and under 15. The amount and variance in TK increased in elderly subjects, which made the formula less accurate.

In a population of asymptomatic volunteers across 5 countries, we sought to: (a) establish normative values of the Odontoid-Central Sacral Vertical Line (OD-CSVL) across patient factors, and (b) assess correlations of OD-CSVL with other radiographic parameters. A prospective, cross-sectional study of asymptomatic adult volunteers, ages 18–80 years, were enrolled across 5 countries (France, Japan, Singapore, Tunisia, United States) forming the Multi-Ethnic Alignment Normative Study (MEANS) cohort. Included volunteers had no known spinal disorder(s), no significant neck/back pain (VAS ≤ 2; ODI ≤ 20), and no significant scoliosis (Cobb ≤ 20°). Radiographic measurements included commonly used coronal alignment parameters (mm) and angles (°). OD-CSVL was defined as the difference between the odontoid plumb line (line from the tip of the odontoid vertically down) and the CSVL (vertical line from the center of the sacrum). Chi-square, student’s t tests, Kruskal–Wallis, Wilcoxon rank-sum, linear regression, and Pearson’s correlation were used with significance at p

Highlight risk factors for pseudarthrosis in long-segment spinal fusions, collect the approaches carried to address this complication. Patients with ASD and fusion of ≥ 4 levels with minimum follow-up (FU) of ≥ 2 years were included. Full-body X-rays were done preoperatively

The sacroiliac joint (SIJ) is a complex anatomical structure located near the centre of gravity of the body. Micro-traumatic SIJ disorders are very difficult to diagnose and require a complete clinical and radiological examination. To diagnose micro-trauma SIJ pain it is recommended to have at least three positive provocative specific manoeuvres and then a radiologically controlled infiltration test. Conservative treatment combining physiotherapy and steroid injections is the most common therapy but has a low level of efficiency. SIJ thermolysis is the most efficient non-invasive therapy. SIJ fusion using a percutaneous technique is a solution that has yet to be confirmed on a large cohort of patients resistant to other therapies. Cite this article: EFORT Open Rev 2020;5:691-698. DOI: 10.1302/2058-5241.5.190081

The objective is to analyse peri-operative blood loss (BL) and hidden blood loss (HBL) rates in spinal deformity complex cases surgery, with a focus on the strategies to prevent major bleeding.We retrospectively analysed surgical and anaesthesiologic data of patients who had been operated for adolescent idiopathic scoliosis (AIS) or adult spinal deformities (ASD) with a minimum of five levels fused. A statistical comparison among AIS, ASD without a pedicle subtraction osteotomy (PSO) (ASD-PSO( -)) and ASD with PSO (ASD-PSO( +)) procedures was performed with a view to identifying patient- and/or surgical-related factors affecting peri-operative BL and HBL.One-hundred patients were included with a mean 9.9 ± 2.8 fused vertebrae and a mean 264.2 ± 68.3 minutes operative time (OT) (28.3 ± 9 min per level). The mean perioperative BL was 641.2 ± 313.8 ml (68.9 ± 39.5 ml per level) and the mean HBL was 556.6 ± 381.8 ml (60.6 ± 42.8 ml per level), with the latter accounting for 51.5% of the estimated blood loss (EBL). On multivariate regression analysis, a longer OT (p 0.05; OR 3.38) and performing a PSO (p 0.05; OR 3.37) were related to higher peri-operative BL, while older age (p 0.05; OR 2.48) and higher BMI (p 0.05; OR 2.15) were associated to a more significant post-operative HBL.With the correct use of modern technologies and patient management, BL in major spinal deformity surgery can be dramatically reduced. Nevertheless, it should be kept in mind that 50% of patients estimated losses are hidden and not directly controllable. Knowing the per-level BL allows anticipating global losses and, possibly, the need of allogenic transfusions.

A non-comparative multi-centre and international pilot study have been carried on Y-STRUT® (Hyprevention, France), an implantable medical device meant to reinforce the hip to reduce the risk of a contralateral hip fracture. Objectives of the study were to determine the feasibility and tolerance of the procedure. Methods Patients older than 60 years were recruited when presenting at the emergency departments with a low-energy pertrochanteric fracture on one side and with a fracture risk assessed for the contralateral side with BMD, T-Score or other bone quality evaluation tool, FRAX index, or fall risk assessment. Pain and functional ability were assessed at the different follow-up visits using VAS, WOMAC and OHS-12 scores. Results Twelve patients were included and reached a one-year follow-up. Mean age was 82 years old (65 – 91). The average hospital stay was 13 days (3 – 29). The prophylactic surgery did not delay the hospital discharge for any patient. The procedure did not lead to unresolvable serious adverse events. At 3 weeks, all patients were able to walk 6 meters, half of them in less of 30 seconds. Minimal pain was reported all along the follow-up visits, except at 3 years when one patient presented high pain in both hips. WOMAC and OHS-12 scores showed a moderate to mild hip impairment. Conclusion The good short and medium-term outcomes of this pilot study demonstrate the feasibility and the tolerability of the device. Further studies should focus on the efficacy of this immediate and lasting bone reinforcement technique.

Multicenter Cohort.Assess normative values of sagittal spinal and lower extremity alignment in asymptomatic volunteers stratified by age and gender.Our understanding of ideal sagittal alignment is still evolving. The Multiethnic Alignment Normative Study (MEANS) investigated skeletal alignment of the largest multiethnic cohort of asymptomatic adult volunteers. We aim to assess normative values of sagittal spinal and lower extremity alignment in asymptomatic volunteers stratified by age and gender.Asymptomatic volunteers between the ages of 18-80 years were enrolled prospectively and then analyzed retrospectively from six different centers. Volunteers included reported no significant neck or back pain, nor any known spinal disorder(s). All volunteers underwent a standing full-body or full-spine low-dose stereoradiograph.MEANS consisted of 468 volunteers with a mean age of 40.4±14.8 years. Thoracic kyphosis (TK) from T4 to T12 showed a mean of 37.4±10.9°. The average L1-S1 lumbar lordosis (LL) was -57.4±11.3°. LL did not show significant differences across the five age groups. TK showed a significant difference based on age ( P0.0001). Sagittal vertical axis increased across age groups from -14.2 mm in young adults to 17.0 mm in patients64. Similar trend was seen for T1 pelvic angle with a mean of 5.0° in young adults and 13.7° in those older than age 64. Knee flexion increased across age groups without a significant change in odontoid-knee distance which is a surrogate for the center of the head aligned over the knees.In asymptomatic volunteers, sagittal alignment parameters showed a slow and steady change across age groups exemplified by an increase in TK. However, LL did not show a significant decrease across age groups. Volunteers used compensatory mechanisms such as slight pelvis retroversion, knee flexion, and neck extension to maintain an aligned sagittal posture with their head centered over their knees (odontoid-knee).3.

This is a cross-sectional cohort.The aim was to describe sagittal plane alignment and balance in a multinational cohort of nondegenerated, asymptomatic adults.Current sagittal alignment targets were developed using correlations between radiographic and quality-of-life measures in spinal deformity patients, rather than disease-free samples leading to relatively poor accounting for variance within a population.Sagittal balance was defined using vertebral body tilt and spinopelvic alignment was defined as the vertebral pelvic angles from C2 to L5 (vertebral pelvic angle=vertebral tilt+pelvic tilt). Associations with pelvic incidence (PI) were assessed using linear regression. Multivariable linear regression was used to estimate a normal L1-S1 lordosis, adjusting for PI and the L1 pelvic angle (L1PA). Correlation between the L1 and T4 pelvic angles was assessed to define a normal thoracic alignment conditioned on lumbar alignment.Among 320 volunteers from 4 continents, median age was 37% and 60% were female. C2 tilt was independent of PI with minimal variation. PI was inadequate for estimating a normal lumbar lordosis (L1-S1, r2 =0.3), but was strongly associated with the lumbar pelvic angles (L1PA, r2 =0.58). Defining lumbar lordosis as a function of PI and L1PA resulted in high explained variance ( R2 =0.74) and the T4 pelvic angle had near perfect correlation with the L1PA ( r =0.9).We defined normal sagittal balance and spinopelvic alignment in a disease-free international volunteer cohort. Four parameters are either fixed or directly modifiable in surgery and can define a normal thoracic and lumbar alignment: the L1-S1 lordosis defined as a function of PI and the L1PA; and the T4 pelvic angle is nearly equivalent to the L1PA, aligning the T4-L1-hip axis.

Sagittal balance (SB) plays an important role in the surgical treatment of spinal disorders. The aim of this research study is to provide a detailed evaluation of a new, fully automated algorithm based on artificial intelligence (AI) for the determination of SB parameters on a large number of patients with and without instrumentation.Pre- and postoperative sagittal full body radiographs of 170 patients were measured by two human raters, twice by one rater and by the AI algorithm which determined: pelvic incidence, pelvic tilt, sacral slope, L1-S1 lordosis, T4-T12 thoracic kyphosis (TK) and the spino-sacral angle (SSA). To evaluate the agreement between human raters and AI, the mean error (95% confidence interval (CI)), standard deviation and an intra- and inter-rater reliability was conducted using intra-class correlation (ICC) coefficients.ICC values for the assessment of the intra- (range: 0.88-0.97) and inter-rater (0.86-0.97) reliability of human raters are excellent. The algorithm is able to determine all parameters in 95% of all pre- and in 91% of all postoperative images with excellent ICC values (PreOP-range: 0.83-0.91, PostOP: 0.72-0.89). Mean errors are smallest for the SSA (PreOP: -0.1° (95%-CI: -0.9°-0.6°); PostOP: -0.5° (-1.4°-0.4°)) and largest for TK (7.0° (6.1°-7.8°); 7.1° (6.1°-8.1°)).A new, fully automated algorithm that determines SB parameters has excellent reliability and agreement with human raters, particularly on preoperative full spine images. The presented solution will relieve physicians from time-consuming routine work of measuring SB parameters and allow the analysis of large databases efficiently.

Background Spinal surgery performed entirely with minimally invasive surgery is referred to as circumferential MIS (cMIS). However, cMIS still has a limited sagittal correction capability for adult spinal deformity (ASD) with a marked sagittal deformity. We investigated the effectiveness of cMIS using oblique lateral interbody fusion (OLIF) and percutaneous posterior spine fixation in correcting marked sagittal deformity. Methods This study retrospectively evaluated 23 patients with ASD with marked sagittal deformity who underwent cMIS using OLIF without osteotomy and were followed-up for at least 24 months (whole group). The whole group was divided into the following two groups according to the type of interbody fusion at L5–S1: the OLIF51 group (n = 13) underwent OLIF at L1–L5 and L5–S1 and the TLIF51 group (n = 10) underwent OLIF at L1–L5 and transforaminal lumbar interbody fusion (TLIF) at L5–S1. Results Sagittal vertebral axis (SVA; 125.7 vs. 29.5 mm, p p p p p Conclusion Successful sagittal correction in ASD patients with marked sagittal deformity was achieved with cMIS using OLIF. OLIF at L5–S1 showed a synergistic effect in sagittal deformity correction by cMIS.

Unfortunately, the affiliation of the second author (Jean Charles Le Huec) was incorrectly published in the original publication.

Previous studies on adults with degenerative scoliosis (ADS) have been fixed the threshold of PI-LL mismatch less than 10° for achieving good clinical outcomes. Recent studies discussed that PI-LL mismatch should consider individual pelvic incidence (PI) and should be set first in a normal population. The purpose of this study is to assess the variability of PI-LL mismatch according to PI in an asymptomatic population.Full-body low dose stereoradiographic evaluation was done in a multi-ethnic cohort of 468 asymptomatic adult volunteers. Patients were clustered in three groups depending on individual PI values: PI 45°, 45° PI 60° and PI 60°. 3D measurements were performed using a commercially available 2D/3D modeling software to establish a correlation of PI with other spinopelvic parameters. ANOVA and Tukey's HSD for post-hoc analysis were used to determine the differences between the three groups.In our asymptomatic population, the mean value of PI-LL mismatch is - 5.4° ± 10.7°. Clusterization of the population reveals significant differences in the distribution of L1S1 lordosis, pelvic tilt and PI-LL with positive linear correlation according to PI values. As an interestingly result, PI-LL mismatch is equal to 0° when PI is around 64°.The present study demonstrated that PI-LL mismatch is negative in an asymptomatic population (- 5.4° ± 10.7°) and the value should be customized to each patient to be able to restore the appropriate lordosis in ADS. The PI-LL mismatch is given by the formula PI-LL = - 28.5 + 0.44 × PI.

Spinal alignment can have a significant impact on a patient's overall quality of life. Predicting the ideal sagittal spinal alignment of a specific individual is still a difficult task. The Multi-Ethnic Alignment Normative Study (MEANS) investigated skeletal alignment, including the spine and lower extremities, of the largest multi-ethnic cohort of asymptomatic adult volunteers. In this analysis, the authors aim to assess normative values of spinopelvic parameters and the regional cervical, thoracic, and lumbar spinal alignment in asymptomatic volunteers stratified by age and sex.Asymptomatic volunteers between ages 18 and 80 years were enrolled prospectively from centers in France, Japan, Singapore, Tunisia, and the United States. Volunteers included reported no significant neck or back pain (Visual Analog Scale ≤2), nor any known spinal disorder(s). All volunteers underwent a standing full-body or full-spine low-dose stereoradiograph.MEANS consisted of 468 volunteers with a mean age of 40.4±14.8 years. Mean cervical lordosis from C2 to C7 was -0.4±12.7°. The T1-slope averaged 23.0±7.9° and showed strong correlation ( r =0.87) with the C7-slope mean of 19.8±8.6°. Thoracic kyphosis (TK) from T4 to T12 showed a mean of 37.4±10.9°. Average L1-S1 lumbar lordosis (LL) was -57.4±11.3°. The mean pelvic incidence (PI) measured 52.0±10.7° and pelvic tilt was 12.5±7.3°. Sacral slope averaged 39.5±8.2°. The average PI-LL was -5.4±10.7°. Approximately 60% of volunteers met the PI-LL criteria within ±10°, 8.3% were ≥10°, while 32.1% were ≤-10°. LL showed moderate correlation with PI ( r =0.53) and TK ( r =0.50), while there was no correlation between TK and PI. Multiple linear regression including PI, TK, and age resulted in the following equation LL=14.6+0.57 (PI)+0.57 (TK)-0.2 (age) ( r =0.75).LL did not change with increasing age in asymptomatic volunteers. However, TK did increase with age leading to an increase in T1-slope and a compensatory increase in cervical lordosis. TK did not correlate with PI and was an independent variable in the prediction of LL.Level II-prospective cohort study.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience\ud and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.\ud PURPOSE: This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an\ud ERAS program.\ud STUDY DESIGN: This is a review article.\ud METHODS: Under the impetus of the ERAS� society, a multidisciplinary guideline development\ud group was constituted by bringing together international experts involved in the practice of ERAS\ud and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in\ud the English language was performed in MEDLINE, Embase, and Cochrane Central Register of\ud Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were\ud included, and the evidence was graded according to the Grading of Recommendations, Assessment,\ud Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the\ud group after a critical appraisal of the literature.\ud RESULTS: Two hundred fifty-six articles were included to develop the consensus statements for\ud 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to\ud very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS\ud items, 28 recommendations were included. All recommendations on ERAS protocol items are\ud based on the best available evidence. These included nine preoperative, eleven intraoperative, and\ud six postoperative recommendations. They span topics from preoperative patient education and\ud nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.\ud CONCLUSION: Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS� Society presents this comprehensive consensus\ud review for perioperative care in lumbar fusion.

Background In patients with osteoarthritis (OA) and an intact rotator cuff, hemi-shoulder arthroplasty (HSA) can be a viable option as it offers the advantage of keeping the native glenoid intact. However, glenoid erosion has frequently been reported. The aim of this study was to report preliminary clinical results of HSA with a new pyrolytic carbon (pyrocarbon) humeral head. Methods This prospective multicenter study included a continuous series of 65 patients who underwent pyrocarbon HSA in 5 centers. Results At the time of analysis, 1 patient was lost to follow-up, 3 patients underwent revision, and 61 patients were evaluated at a mean follow-up of 25.9 ± 3.3 months. The mean age at index surgery was 57.9 ± 13.3 years. The indications were primary glenohumeral OA in 37 patients, osteonecrosis in 11, secondary OA in 11, and rheumatoid arthritis in 2. The mean Constant score increased from 31.0 ± 15.8 points at baseline to 74.6 ± 17 points at last follow-up. Radiographic analyses showed that 86% of glenoids remained unchanged whereas 14% evolved slightly. Conclusions Pyrocarbon HSA grants improvement in pain and function in patients with primary OA or secondary OA after instability but at a lower level in patients with post-traumatic sequelae (secondary OA or osteonecrosis). These preliminary clinical and radiologic results are encouraging, although they need to be confirmed by longer-term follow-up observations.

Study Design Electronic survey administered to Scoliosis Research Society members. Objective To determine the prevalence of minimally invasive surgery (MIS) techniques for the treatment of adult spinal deformity. Summary of Background Data There is a paucity of data available on the practice pattern, prevalence of minimally invasive spine surgery, and the preferred minimally invasive techniques in the treatment of adult spine deformity. Methods An electronic nine-question survey regarding individual usage pattern of minimally invasive spine surgery techniques was administered in 2016 to the members of the Scoliosis Research Society. Determinants included complexity in condition of patient population, prevalence of use of minimally invasive techniques in the surgeon's practice, prevalence of use of a particular MIS technique, strategy elected during surgery, adoption of staging of procedures and timing between staging of procedures. Results A total of 357 surgeons responded (61.3% response rate), and 154 (43.1%) of the respondents said that they use MIS as a part of their surgical treatment of adult spinal deformity. However, of these 154 respondents, 67 (43.5%) said that their MIS usage in deformity practice was between 1% and 20%. Only 11 (7.2%) said that they used MIS 81% to 100% of the time. The top MIS approaches that surgeons chose were MIS lateral lumbar interbody fusion 109 (70.59%) and MIS percutaneous screws 91 (58.8%). Conclusions The low rate of adoption of these techniques among the SRS members may be due to the false perception that there is not enough data to support that MIS techniques are better. This and the fact that a practitioner needs to be facile at different MIS techniques may be the true impediment to the adoption of MIS techniques in the treatment of ASD. Level of Evidence Level IV.

To develop and assess the reliability of new nomenclature system that systematically organizes osteotomy techniques and briefly describes the surgical approach, the surgical sequence, and the fixation technique for cervical spine deformity (CSD). We developed a new classification system (SOF system) for CSD surgery that describes the sequence of surgical approach (S), the grade of osteotomy (O), and the information of fixation (F) using alphanumeric codes. Twenty CSD osteotomies (8 anterior osteotomies, 12 posterior osteotomies) were included in this study to evaluate the inter- and intra-observer agreement based on operation records. Six observers performed independent evaluations of the operation records in random order. Each observer described 20 CSD surgeries using the SOF system twice (> 30 days between assessments) based on operation records to validate SOF system. Overall agreement (among all six observers at the initial assessment) on the anterior and posterior osteotomy was ICC = 0.96 and ICC = 0.91, respectively. Overall agreement (repeat observations after at least 30 days) on the anterior and posterior osteotomy was ICC = 0.96 and ICC = 0.91, respectively. This data showed that both inter- and intra-observer agreement revealed ‘excellent’. This study introduces the SOF system of the CSD surgery to understand the surgical sequence, the type of osteotomy and the fixation techniques. The investigation of the inter- and intra-observer agreement revealed ‘excellent agreement’ for both anterior and posterior osteotomies. Thus, SOF system can provide a consistent description of the various CSD surgeries and its use will provide a common frame for CSD surgery and help communicate between surgeons.

Introduction The need to combine fusion with decompression in patients with lumbar canal stenosis is still controversial. The aim of this study was to show that isolated decompression leads to the same outcomes as decompression plus fusion in patients who have preserved global sagittal balance. Materials and Methods A single-center retrospective cohort of 110 patients who were operated for a single-level lumbar stenosis was divided into two groups based on the treatment: isolated decompression or fusion-decompression. These patients had a normal odontoid-hip axis angle (ODHA) (−5° to +2°) and had no spondylolisthesis or frontal deformity. We compared the clinical outcome scores and spinal-pelvic parameters preoperatively and at 1 year of follow-up. We evaluated the minimal clinically important difference (MCID) corresponding to a 12.8-point difference in the Owestry Disability Index (ODI). The analysis in each group was based on the MCID. Results The clinical outcome scores improved significantly in both groups. There was a 77% decrease in the ODI > 12.8 points with no significant difference between groups. The analysis based on the MCID showed that patients with a poor clinical result at 1 year in the isolated decompression group were more likely to have lumbar pain, while the ones in the fusion-decompression group were more likely to have radicular pain. Conclusion The clinical and radiological results of fusion-decompression are not superior at 1 year relative to isolated decompression for treating single-level lumbar canal stenosis in patients with compensated sagittal balance. Full-spine weight bearing radiographs are key to determining the patient's sagittal balance and to ensuring there are no radiological instability factors that may require a stabilizing procedure. Level of evidence IV Retrospective study of data collected prospectively.

This prospective study compared the outcomes after 3 different treatments for large and massive rotator cuff tears.Patients with a diagnosis of large-to-massive rotator cuff tears were prospectively included. Patients were allocated in 3 groups: (1) arthroscopic complete repair (repair group), (2) open repair and xenograft patch augmentation (patch group), and (3) arthroscopic débridement and tenotomy of the long head of the biceps (débridement group). Patients were evaluated preoperatively and postoperatively at 3, 6, 12 and 24 months. The primary outcome measure was the Constant-Murley score.The study included 32 consecutive patients. The mean improvement in the Constant-Murley score was +29.1 for the repair group (P .01), +32.2 for the patch group (P .01), and +20.1 for the débridement group (P .01) at the final follow-up examination. No differences were found between the repair and patch groups, but the difference became significant between the débridement group and the patch group (P .001) and also between the débridement group and the repair group (P .002) at 12 months and the final follow-up. Moreover, 5 complications occurred in 11 patients in the patch group, whereas there was only 1 complication in the repair group and no complications in the débridement group.The use of porcine dermis patches to augment repairs of massive and irreparable rotator cuff tears is not recommended because there is no benefit compared with repair without augmentation and patches result in more complications.

Cervical spine is part of the spine with the most mobility in the sagittal plane. It is important for surgeons to have reliable, simple and reproducible parameters to analyse the cervical. This study is a systematic review and a critique of current parameters to help improve the study of cervical spinal balance. We conducted a systematic search of PUBMED/MEDLINE for literature published since January 2014. Only studies written in English and containing abstracts were considered for inclusion. The search performed was: «C7 slope» OR «T1 slope» OR «C2C7 offset» OR «C2C7 lordosis» OR «cervical SVA (sagittal vertical axis)» OR «TIA (thoracic inlet angle)» (Lee et al., J Spinal Disord Tech 25(2):E41–E47, 2012) OR «SCA (spino-cranial angle)». Exclusion criteria were purely post-operative and cadaveric analysis, studies performed with CT scan or MRI, studies on adolescent idiopathic scoliosis, traumatology studies and no standing analysis of the cervical spine. Relevance was confirmed by investigators if cervical parameters was a major criteria of the study. 138 articles were found by the electronic search. After complete evaluation 20 articles were selected. The large majority of papers used the same parameters C2_C7 lordosis, C2–C7 SVA, T1 slope or C7 slope and T1 slope/cervical lordosis mismatch. Janusz reported a new parameter using a retrospective cohort of patient with cervical radiculopathy: the TIA (thoracic inlet angle). Le Huec reported an other new parameter based on a prospective study of asymptomatic volunteer: the spino-cranial angle (SCA). This parameter is highly correlated with the C7 slope and the cervical lordosis. Other studies reported parameters that are more global balance analysis including the cervical spine than cervical spine balance itself. The most important parameters to analyse the cervical sagittal balance according to the literature available today for good clinical outcomes are the following: C7 or T1 slope, average value 20°, must not be higher than 40°. cSVA must not be less than 40°C (mean value 20 mm). SCA (spine cranial angle) must stay in a norm (83° ± 9°). Future studies should focus on those three parameters to analyse and compare pre and post op data and to correlate the results with the quality of life improvement.

To identify risk factors, in 12 patients with junctional breakdown (JBD) after thoraco-sacral fusions and to test a software locating maximal bending moment on full spine EOS images. Twelve patients underwent long fusions for lumbar degenerative pathologies. Preop EOS images were compared to first postop EOS showing JBD. Parameters analyzed were: spinopelvic parameters [pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), sagittal vertical axis (SVA), spinosacral angle (SSA), lordosis, and kyphosis], proximal junctional angle (PJA), odontoid-hip axis angle (ODHA), and CIA. A new software estimated the location of maximum bending moment (M max) before and after JBD. All patients except one had a JBD located between T10 and L1, diagnosed at average follow-up of 18.58 months. JBD was a fracture in six patients, severe adjacent disc degeneration in the remaining. Average PI was 52°. PT increased, SS decreased after JBD versus preop (p > 0.05). Average PJA was 34.5°. Global lordosis (GLL), upper lordosis (ULL), L4–S1 lordosis, and thoracic kyphosis (TK) were increased (p 0.05). CIA average value decreased by 7.5% after JBD. T1–T5 alignment was correlated to C7 slope before (R 2 = 0.77075) and after JBD (R 2 = 0.85409). ODHA decreased after JBD (p > 0.05). Most JBD occurred at or one level away from preoperative M max location. This study confirms the importance of harmonious distribution of lumbar (GLL, ULL, and ILL) and thoracic curves (TK, T1–T5 segment) in thoraco-sacral fusions. All patients showed an exaggerated ULL, resulting in a posterior shift and increased lever arm at the thoraco-lumbar junction, leading to JBD.

We report a rare and aggressive case of malignant triton tumor (MTT) at the thoracolumbar junction with foraminal extension mistreated as schwannoma. A 70-year-old man with a 2-year history of lower back pain and left L4 radiculopathy with no history of neurofibromatosis. Pre-operative MRI suggested a typical schwannoma. Upon complete marginal resection, histological findings revealed a MTT. The patient presented with a local and regional recurrence and died 10 months after surgery. MTTs are a subgroup of malignant peripheral nerve sheath tumors, which develop from Schwann cells of peripheral nerves or within existing neurofibromas, and display rhabdomyoblastic differentiation. Based on the Grand Round case and relevant literature, we present a case of a highly aggressive and fast-growing tumor with a very high local and distant recurrence. There is no consensus treatment plan available and patients usually die shortly after diagnosis.

BACKGROUND CONTEXT Spinal procedures often require the removal of bony tissues to prevent nerve compression and reduce pain. In order to reach difficult-access spinal regions such as the foramen, the surgeon is often required to drill (or otherwise remove) through healthy supporting bone structures, therefore increasing the risk of spinal instability. PURPOSE This study describes the authors' experience with a recently developed, FDA-approved, curved-at-the-tip drill-like device, designed to provide efficient bone removal from difficult-access areas. The device is shielded on one side of the tip in order to improve safety and reduce the risk of complications. STUDY DESIGN/SETTING Multi-center retrospective study and surgeon questionnaire analysis. PATIENT SAMPLE Device-use patterns were extracted from 103 lumbar foraminotomies, 53 cervical osteophyte removals and 143 transforaminal lumbar interbody fusion (TLIF) procedures conducted using the device and 66 comparable control TLIF procedures conducted by the same surgeon group used as a control group. OUTCOME MEASURES Device-related dural tear rate, surgeon assessment of the procedure, duration of device use. For the TLIF procedures, OR time and length of stay were also compared with the control group. METHODS The rate of device-related dural tears was calculated from 1,116 safety records of procedures conducted using the device and compared with literature rates of traditional-tools device-related tears. Surgeon assessment was obtained using questionnaires at the end of each procedure. The duration of device-use, length of procedure and other operative and postoperative parameters were extracted from procedure records and reviewed where available. RESULTS The device-related dural tear rate was 0.3% (three tears in 1,116 procedures). This rate is significantly lower than the device-related tear rate of 2.9% associated with the Kerrison rongeur and high-speed drill published in a prior literature review. Surgeon satisfaction rate was 94% and sufficient bone volume reduction was reported in 95% of the procedures. Surgery time reduction was the most common comment in surgeon questionnaires. In some cases, of multi-level complicated fusions, the time reduction was estimated as several hours. Lumbar foraminotomy using the device required, on average, 2 minutes/foramen. In some of the cases, the device enabled the surgeon to avoid a spinal fusion as the improved access eliminated the need for excessive bone removal. Cervical osteophyte removal required, on average, three minutes, and in the majority of the cases enabled the surgeons to avoid additional level discectomy or corpectomy. TLIF procedures required on average 10 minutes less than control procedures with a 0.5 days reduction in length-of-stay. The device was successfully used in both open and minimal invasive settings without a significant difference between settings. CONCLUSIONS The device is safe and effective for performing spinal surgery in multiple indications. Procedure time reduction was noted as the most significant advantage by the surgeons. FDA DEVICE/DRUG STATUS Dreal (Carevature Medical Ltd.) (Approved for this indication)

Purpose: There is insufficient information regarding axial plane characteristics of scoliosis despite its 3D nature. The posterior–anterior vertebral vector (VV) has been proposed to characterize the axial plane appearances of the thoracic scoliosis. This study aimed to highlight the importance of knowledge of axial plane features when determining fusion levels and correction techniques of thoracic curves. Methods: Altogether, 233 thoracic curves were analyzed using the VV after proving its usability instead of 3D angles to determine axial plane parameters such as apical vertebral (APV) axial rotations, APV lateral displacement, and intervertebral rotations (IVR). K-means clustering and regression analysis were used to identify axial plane curve patterns and determine the relationship between the coronal angles and axial plane characteristics, respectively. Results: A close correlation was found between 3D angles and VV projected angles. Eight axial plane clusters were distinct, exhibiting different lateral APV displacement toward the interacetabular axis with relatively small axial rotations and a simultaneous decrease in sagittal curves. The regression analysis showed that the correlation of coronal curve magnitude was significantly stronger (r = 0.78) with APV lateral translation than with APV axial rotation (r = 0.65). Conclusion: Based on these findings, the primary goal of scoliosis correction should focus on minimizing lateral translation rather than eliminating axial rotation. Knowing the IVR in the axial plane helps accurately determine the limits of the structural curves. VV-based axial views can facilitate the accurate determination of the end vertebrae and selection of the appropriate correction technique of the curve. Graphic abstract: These slides can be retrieved under Electronic Supplementary Material. [Figure not available: see fulltext.]

Proximal junctional kyphosis (PJK) is a compensatory phenomenon in reaction to pathologic lumbar hyperlordosis. Inappropriate spinal curve harmony incurs risk of PJK. Postoperative failure of posterior instrumentation, with kyphosis resistant to revision surgery at the proximal junction, may be caused by excessive iatrogenic lumbar lordosis. The surgical attitude should be to decrease lumbar lordosis by posterior opening wedge osteotomy (POWO). We describe the rationale for POWO and surgical techniques at L3. The technique is illustrated by a case report at 24 months' follow-up. Based on rational analysis of the distribution of lordosis along the lumbar spine and of adaptation of the sitting position, POWO may be indicated to avoid PJK after revision surgery in adult spinal Deformation revision surgery.

Background The objectives of this study were to define the role for surgery in the treatment of chronic low back pain (cLBP) and to develop a new classification of cLBP based on the pattern of injury. Hypothesis Surgery may benefit patients with cLBP, and a new classification based on the injury pattern may be of interest. Method A systematic literature review was performed by searching Medline, the Cochrane Library, the French public health database (Banque de Donnees en Sante Publique), Science Direct, and the National Guideline Clearinghouse. The main search terms were “back pain” OR “lumbar” OR “intervertebral disc replacement” OR “vertebrae” OR “spinal” AND “surgery” OR “surgical” OR “fusion” OR “laminectomy” OR “discectomy”. Results Surgical techniques available for treating cLBP consist of fusion, disc replacement, dynamic stabilisation, and inter-spinous posterior devices. Compared to non-operative management including intensive rehabilitation therapy and cognitive behavioural therapy, fusion is not better in terms of either function (evaluated using the Oswestry Disability Index [ODI]) or pain (level 2). Fusion is better than non-operative management without intensive rehabilitation therapy (level 2). There is no evidence to date that one fusion technique is superior over the others regarding the clinical outcomes (assessed using the ODI). Compared to fusion or multidisciplinary rehabilitation therapy, disc replacement can produce better function and less pain, although the differences are not clinically significant (level 2). The available evidence does not support the use of dynamic stabilisation or interspinous posterior devices to treat cLBP due to degenerative disease (professional consensus within the French Society for Spinal Surgery). The following recommendations can be made: non-operative treatment must be provided for at least 1 year before considering surgery in patients with cLBP due to degenerative disease; patients must be fully informed about alternative treatment options and the risks associated with surgery; standing radiographs must be obtained to assess sagittal spinal alignment and a magnetic resonance imaging scan to determine the mechanism of injury; and, if fusion is performed, the lumbar lordotic curvature must be restored. Discussion This work establishes the need for a new classification of cLBP based on the presumptive mechanism responsible for the pain. Three categories should be distinguished: non-degenerative cLBP (previously known as symptomatic cLBP), in which the cause of pain is a trauma, spondylolysis, a tumour, an infection, or an inflammatory process; degenerative cLBP (previously known as non-specific cLBP) characterised by variable combinations of degenerative alterations in one or more discs, facet joints, and/or ligaments, with or without regional and/or global alterations in spinal alignment (which must be assessed using specific parameters); and cLBP of unknown mechanism, in which the pain seems to bear no relation to the anatomical abnormalities (and the Fear-Avoidance Beliefs Questionnaire and Hospital Anxiety and Depression Scale may be helpful in this situation). This classification should prove useful in the future for constituting well-defined patient groups, thereby improving the assessment of treatment options. Level of evidence II, systematic review of level II studies.

Resume Objectif Le but de ce travail a ete de preciser la place de la chirurgie dans la lombalgie chronique puis de proposer une nouvelle classification basee sur le mecanisme lesionnel. Methode Une revue systematique de la litterature a ete realisee en utilisant les bases de donnees suivantes : Medline, The Cochrane Library, Banque de Donnees en Sante Publique, Science direct, National Guideline Clearinghouse. Les principaux mots cles utilises ont ete : back pain or lumbar or intervertebral disc replacement or vertebrae or spinal and surgery or surgical or fusion or laminectomy or discectomy. Resultats Les techniques chirurgicales de la lombalgie chronique sont representees par : les techniques de fusion, la prothese discale, les systemes de stabilisation dynamique et les dispositifs inter epineux. La fusion n’est pas superieure au traitement conservateur incluant une reeducation intensive et une prise en charge cognitive sur la fonction (evaluee par l’ODI) et la douleur (niveau 2). Les resultats de la fusion sont superieurs au traitement non chirurgical n’incluant pas de reeducation intensive (niveau 2). Les donnees de la litterature ne permettent pas de conclure quant a la superiorite d’une technique de fusion comparee a une autre en termes de resultat clinique (evalue avec l’ODI). La prothese discale, par comparaison a la fusion ou a la reeducation multidisciplinaire, peut ameliorer la fonction et la douleur sans que cette amelioration ait une signification clinique (niveau 2). En l’etat actuel des connaissances, les systemes de stabilisation dynamique et les dispositifs inter epineux ne sont pas recommandes dans le cadre de la lombalgie chronique d’origine degenerative (accord professionnel SFCR). Il est par ailleurs recommande : une prise en charge non chirurgicale d’au moins un an avant d’envisager une chirurgie chez un patient ayant une lombalgie chronique d’origine degenerative ; une information du patient sur les alternatives therapeutiques disponibles ainsi que sur les risques de la chirurgie ; une evaluation radiographique de l’equilibre sagittal du patient en charge et une IRM pour determiner le mecanisme lesionnel de la lombalgie ; une restauration de la lordose lombaire lorsqu’une arthrodese est envisagee. Conclusions Ce travail a mis en lumiere la necessite d’une nouvelle classification de la lombalgie chronique, basee sur le mecanisme lesionnel presume de la douleur, en distinguant 3 categories : lombalgie d’origine non degenerative (anciennement dite symptomatique) secondaire a une cause traumatique, tumorale, infectieuse ou inflammatoire ; lombalgie d’origine degenerative (anciennement dite commune) secondaire a une pathologie discale, facettaire, ligamentaire, mixte, associee ou non a un trouble regional et/ou global de la statique rachidienne (impliquant la mesure des parametres d’equilibre) ; lombalgie d’origine indeterminee sans relation retrouvee avec des lesions anatomiques (utilite des scores HAD et FABQ). Cette classification et ces sous-groupes permettront a l’avenir de comparer des groupes de patients bien identifies pour mieux juger les solutions therapeutiques.

The sacro-iliac joint (SIJ) located at the transition between the spine and the lower limbs is subjected to major shear forces. Mobility at the SIJ is very limited but increases during pregnancy and the post-partum period. Familiarity with the anatomy and physiology of the SIJ is important. The SIJ is a diarthrodial joint that connects two variably undulating cartilage surfaces, contains synovial fluid, and is enclosed within a capsule strengthened by several ligaments. This lecture does not discuss rheumatic or inflammatory diseases of the SIJ, whose diagnosis relies on imaging studies and blood tests. Instead, it focuses on micro-traumatic lesions. Micro-trauma causes chronic SIJ pain, which must be differentiated from hip pain and spinal pain. The diagnosis rests on specific clinical provocation tests combined with a local injection of anaesthetic. Findings are normal from radiographs and magnetic resonance imaging. Non-operative treatment with exercise therapy and stretching aims primarily to strengthen the latissimus dorsi, gluteus, and hamstring muscles to increase SIJ coaptation. Other physical treatments have not been proven effective. Radiofrequency denervation of the dorsal sensory rami has shown some measure of efficacy, although the effects tend to wane over time. Patients with refractory pain may benefit from minimally invasive SIJ fusion by trans-articular implantation of screws or plugs, which has provided good success rates.

Background This is a Phase IV, national, multicentre, retrospective study to observe the real-world use of rhBMP-2 in France. Hypothesis There was no statistical hypothesis, the statistical analyses were descriptive in nature. Patients and methods Data was collected from patient medical files in 10 French spinal centres. Primary objectives were to understand which patients were treated with rhBMP-2, commercialised in Europe as InductOs™ and how rhBMP-2 was used during spinal fusion surgery in France between 2011 and 2012. Results Four hundred patients (634 levels) treated with rhBMP-2 were included in the analysis. The most frequent primary diagnostic indication for rhBMP-2 use was degenerative disc disease (DDD; 129/400; 32.3% of patients) followed by spondylolisthesis (119/400; 29.8%), deformity (59/400; 14.8%) and pseudoarthrosis (29/400; 7.3%). The most frequently treated level was L4–L5 (33.8% of levels in 53.5% of patients); followed by L5–S1 (29.8%, 47.3%), L3–L4 (16.7%, 26.5%), and L2–L3 (7.3%, 11.5%), all other levels (less than 5% of patients). No interbody fusion device was used in 42.7% of levels. Wetted matrix of rhBMP-2 was placed in the interbody space in 58.4% of levels (370/634). The most common procedure for rhBMP-2 treatment was posterior lumbar fusion (PLF) (221/634; 34.9% of levels), followed by anterior lumbar interbody fusion (ALIF) (188/634; 29.7%), posterior lumbar interbody fusion (PLIF) (111/634; 17.5%), lateral lumbar interbody fusion (LLIF) (106/634; 16.7%), transforaminal lumbar interbody fusion (TLIF) (4/634; 0.6%) and ‘other’ (4/634; 0.6%). Thirty-one adverse events of Interest (AEI) were recorded in 27 patients. One AEI was considered related to rhBMP-2. Unplanned secondary spine interventions at index level treated with rhBMP-2 were required in 4 patients. Discussion In years 2011 and 2012 when the surgeries captured in this retrospective study were done, rhBMP-2 was indicated for single level (L4–S1) anterior lumbar spine fusion as a substitute for autogenous bone graft in adults with DDD. The most common procedure for the treatment with rhBMP-2 was PLF (off-label use), followed by ALIF (on-label use). The safety findings confirm a predictable and manageable safety profile. Level of evidence IV.

Sagittal balance analysis has gained importance and the measure of the radiographic spinopelvic parameters is now a routine part of many interventions of spine surgery. Indeed, surgical correction of lumbar lordosis must be proportional to the pelvic incidence (PI). The compensatory mechanisms [pelvic retroversion with increased pelvic tilt (PT) and decreased thoracic kyphosis] spontaneously reverse after successful surgery. This study is the first to provide 3D standing spinopelvic reference values from a large database of Caucasian (n = 137) and Japanese (n = 131) asymptomatic subjects. The key spinopelvic parameters [e.g., PI, PT, sacral slope (SS)] were comparable in Japanese and Caucasian populations. Three equations, namely lumbar lordosis based on PI, PT based on PI and SS based on PI, were calculated after linear regression modeling and were comparable in both populations: lumbar lordosis (L1–S1) = 0.54*PI + 27.6, PT = 0.44*PI − 11.4 and SS = 0.54*PI + 11.90. We showed that the key spinopelvic parameters obtained from a large database of healthy subjects were comparable for Causasian and Japanese populations. The normative values provided in this study and the equations obtained after linear regression modeling could help to estimate pre-operatively the lumbar lordosis restoration and could be also used as guidelines for spinopelvic sagittal balance.

The modern literature is producing a rapidly growing number of articles which highlight the relationship between infection and lumbar disc degeneration. However, the means by which samples are collected is questionable. Posterior approach surgery is not free from skin contamination. The possibility of intraoperative contamination of disc biopsies cannot be excluded.The objective of this study was to determine if an association existed between lumbar disc degeneration and chronic infection of the intervertebral disc.313 patients (186/127, F/M) with chronic low back pain secondary to degenerative disc disease which was resistant to medical treatment were included in a single-centre prospective study. All underwent a lumbar anterior video-assisted minimally invasive fusion or disc prosthesis in L4-L5 and/or L5-S1 via an anterior retroperitoneal approach. The patients MRI scans demonstrated in Pfirrmann's classification grade IV or V disc degeneration; 385 disc drives were taken. In terms of Modic changes, 303 Modic 1, 58 Modic II and 24 absence of Modic change, respectively. All underwent intraoperative biopsy, performed according to a strict aseptic protocol. The biopsies were then cultured for 4 weeks with specialised enrichment cultures and subjected to histopathological analysis.The mean age was 47 ± 8.6 years sterile cultures were obtained in 379 samples (98.4%) and 6 were positive (1.6%). The cultured bacteria were: Propionibacterium acnes (n:2), Staphylococcus epidermidis (n:2), Citrobacter freundii (n:1), and Saccharopolyspora hirsuta (n:1). Histopathological analysis did not demonstrate any evidence of a neutrophilia. There were no delayed or secondary infections.Unlike the posterior approach where contamination is common, the anterior video-assisted approach allows a biopsy without skin contact. This approach to the spine is the most effective way to eliminate the risk of contamination. Our results confirm the absence of any relationship between infection and disc degeneration. We suggest that the 6 positive samples in our study may be related to contamination. The absence of infection at 1-year followup is an additional argument in favour of our results. In conclusion, our study shows no association between infection and disc degeneration. The pathophysiology of disc degeneration is complex, but the current literature opens new perspectives.

To evaluate postoperative changes within the cervical alignment following surgical lumbar correction by pedicle subtraction osteotomy (PSO) in patients affected with sagittal global malalignment disease. This was a monocentric, radiographic, and prospective study. 79 patients, who underwent sagittal correction by PSO, performed an EOS imaging pre- and postoperatively between January 2008 and December 2013 at the University Hospital of Bordeaux. Inclusion criteria were a performed pre- and postoperative EOS imaging and a preoperative C7SVA > 5 cm. Were excluded patients who did not allow EOS with a viewable cervical spine due to hyperkyphosis. The study involved the analysis of pelvic, lumbar, thoracic, cervical, and cranial parameters before and after the surgery. 59 patients met the criteria. Mean follow-up was 38 months. The lumbar PSO significantly improved sagittal alignment including L1S1 lordosis, T1T12 kyphosis, and C7SVA (p

Pedicle subtraction osteotomy is a well-described surgical technique for treatment of kyphotic deformity in the spine. It is not widely used for treatment of thoracic kyphosis. We present the first documented series of 28 patients who underwent this procedure in 3 international centers. These patients presented with severe deformity with a wide range of aetiologies. Kyphosis larger than 70 degrees, which is demonstrably rigid based on dynamic imaging. 28 patients underwent surgery following pre-op neurological and radiographic assessment to fully assess the deformity. A triangular osteotomy was carried out using intraoperative navigation techniques. The patients were assessed post-operatively again with clinical and radiographic parameters at regular follow-up. The mean ODI score after surgery was 24.7 (16–42) while the pre-op was 53.4 (38–76). Mean thoracic kyphosis was improved from 64.2° (±20.1°) to 41.1° (±17.4°) resulting in a mean sagittal correction of 23.1°. Mean segmental correction at the PSO for all 28 cases was 17.8° (±8.1°). Stratified by region we found different values for the PSO correction: between T1 and T5 (6 cases) it was 17.5° (±5.4°) and between T6 and T9 (4 cases) 18.2° (±4.7°) and between T10 and L1 (18 cases) 26.2° (±5.2°). FBI index was 22.3° pre-op and improved to 7.8° post-op. Calculations were performed with Microsoft excel (2011 Microsoft, Redmond, WA). Global sagittal balance was statistically improved in this series as demonstrated by FBI and C7 SVA correction.

EOS imaging system is accessible to clinicians since 2007, allowing 3D spinal reconstructions in a functional standing position with reduced radiation. However, numerous ongoing research protocols continuously help implementing the dedicated software. The main principle and applications of the EOS device are discussed here, with an emphasis on future projects. In particular, the authors studied the postoperative modification of the rib cage and spinal morphology after posteromedial correction, in a consecutive series of adolescent idiopathic scoliosis (AIS) patients.49 thoracic AIS patients underwent low-dose stereoradiography preoperatively, postoperatively and at latest examination, with a minimum 2-year follow-up. Spinal and rib cages 3D reconstructions were obtained using dedicated software, and the postoperative modification of thoracic parameters was reported.All parameters were significantly improved after surgery. Mean thoracic volume increase was 8.4% (±8), influenced by the postoperative derotation of the apical vertebra. No difference was found in thoracic volume increase in patients who gained more than 10° of thoracic kyphosis. A significant correlation was found between spinal penetration index at the apex and thoracic sagittal alignment (p = 0.02).EOS imaging device now reliably provides a global 3D quantitative analysis of scoliotic deformities in a context of routine clinical use. This innovative tool will help in the future to better understand scoliosis physiopathology and to evaluate treatment strategies.

Study design Narrative review. Objective To provide a comprehensive narrative review of cervical alignment parameters, the methods for quantifying cervical alignment, normal cervical alignment values, and how alignment is associated with cervical deformity and myelopathy with discussions of health-related quality of life. Summary of background data Indications for surgery to correct cervical alignment are not well-defined and there is no set standard to address the amount of correction to be achieved. In addition, classifications of cervical deformity have yet to be fully established and treatment options defined and clarified. Methods A survey of the cervical spine literature was conducted. Results New normative cervical alignment values from an asymptomatic volunteer population are introduced, updated methods for quantifying cervical alignment are discussed, and describing the relationship between cervical alignment, disability, and myelopathy are outlined. Specifically, methods used to quantify cervical alignment include cervical lordosis, cervical sagittal vertical axis, and horizontal gaze with the chin-brow vertical angle. Updated methods include T1 slope. Evidence from a few recent studies suggests correlations between radiographical parameters in the cervical spine and health-related quality of life. Analysis of the cervical regional alignment with respect to overall spinal pelvic alignment is emerging and critical. Cervical myelopathy and sagittal alignment of the cervical spine are closely related as cervical deformity can lead to spinal cord compression and tension. Conclusion Cervical deformity correction should take on a comprehensive approach in assessing global cervical-pelvic relationships and the radiographical parameters that effect health-related quality of life scores are not well-defined. Cervical alignment may be important in assessment and treatment of cervical myelopathy. Future work should concentrate on correlation of cervical alignment parameters to disability scores and myelopathy outcomes. SUMMARY STATEMENTS: STATEMENT 1: Cervical sagittal alignment (cervical SVA and kyphosis) is related to thoracolumbar spinal pelvic alignment and to T1 slope. STATEMENT 2: When significant deformity is clinically or radiographically suspected, regional cervical and relative global spinal alignment should be evaluated preoperatively via standing 3-foot scoliosis X-rays for appropriate operative planning. STATEMENT 3: Cervical sagittal alignment (C2-C7 SVA) is correlated to regional disability, general health scores and to myelopathy severity. STATEMENT 4: When performing decompressive surgery for CSM, consideration should be given to correction of cervical kyphosis and cervical sagittal imbalance (C2-C7 SVA) when present.

Background We studied Y-STRUT® (Hyprevention, France), a new percutaneous internal fixation device, in combination with bone cementoplasty to prevent hip fracture. Methods Between February 2013 and February 2015, a total of 16 femoral necks in 4 osteoporotic and 12 oncologic patients have been considered for prophylactic consolidation in this prospective multicentre pilot study involving 4 different hospitals. These consolidations were performed percutaneously under fluoroscopic guidance using Y-STRUT®, a dedicated internal fixation device. For osteoporotic patients, orthopaedic surgeons performed the prophylactic consolidations immediately after surgical treatment of a hip fracture (same anaesthesia) in the opposite side. For oncologic patients, without current hip fracture but considered at risk (Mirels score ≥8), interventional radiologists performed the procedures. We report the preliminary results of feasibility, safety and tolerance of these preventive consolidations using Y-STRUT®. Results Four patients (mean 83 years old) had prophylactic consolidation because of a severe osteoporosis (mean T-score −3.30) resulting in first hip fractures. Ten patients (mean 61 years old) were treated because of impending pathological fractures (mean Mirels score 9) related to femoral neck osteolytic metastases. All the procedures were performed with success. Wound healing was achieved in all cases with no access site complication. Radiographic exams performed at 3 months follow-up revealed that Y-STRUT® was well integrated in the bone. For the osteoporotic cohort, mean pain was 0.9 ± 0.7 at 3 weeks. For the oncologic cohort, it decreases from 3.6 ± 2.9 at baseline to 2.4 ± 0.9 at 2 months. Conclusions Preliminary results demonstrate the feasibility and safety of Y-STRUT® implantation as well as the tolerance of the device.

The purpose of the study is to describe the biomechanical theory explaining junctional breakdowns in thoraco-lumbar fusions, by taking the example of vertebral compression fractures. Also, a new angle, the cervical inclination angle (CIA), describing the relative position of the head at each vertebral level, is presented. For the CIA, the data were collected from 137 asymptomatic subjects of a prospective database, containing clinical and radiologic informations. All the 137 subjects have an Oswestry score less than 15% and a pain score less than 2/10 and were part of a previously published study describing the Odontoid-hip axis angle (ODHA). For each vertebral level from T1 to T12, the CIA as well as the vertical and horizontal distances was measured in reference to the sella turcica (ST), and a vertical line drawn from the ST. Average values and correlation coefficients were calculated. The CIA is an angle whose average value varies very little between T1 and T5 (74.9°–76.85°), and then increases progressively from T6 to T12. T1–T5 vertebra are always in line within the thoracic spine for each subject and can be considered as a straight T1–T5 segment. In addition, it was found that the vertical inclination of T1–T5 segment is correlated with the C7 slope (R 2 = 0.6383). The T1–T5 segment inclination is correlated with the C7 slope, and because the latter defines the cervical curve as previously shown, the T1–T5 segment can be considered as the base from which the cervical spine originates. Its role is, thus, similar to the pelvis and its sacral slope, which is the base from which the lumbar spine originates. The CIA along with the ODHA, which describes the adequacy of the global balance in young and elderly asymptomatic populations, are two important parameters that could help us to better understand junctional breakdowns in thoraco-lumbar fusion surgeries.

Purpose The aim was to quantify the postural alignment of asymptomatic elderly, in comparison to a reference population, searching for possible invariants and compensatory mechanisms. Methods 41 volunteers (49–76 years old) underwent bi-planar X-rays with 3D reconstructions of the spine and pelvis. Alignment parameters were compared with those of a reference group of asymptomatic subjects younger than 40 years old, with a particular focus on center of acoustic meati (CAM) and odontoid (OD) with regard to hip axis (HA). Possible markers of compensation were also investigated. Results No significant difference among groups appeared for CAM-HA and OD-HA parameters. Twenty four percent of elders had an abnormally high SVA value and twenty seven percent had an abnormal global spine inclination. Increased pelvic tilt and cervical lordosis allowed maintaining the head above the pelvis. Conclusions CAM-HA and OD-HA appeared quasi-invariant even in asymptomatic elderly. Some subjects exhibited alteration of spine alignment, compensated at the pelvis and cervical regions. The authors are grateful to the Banque Public d’Investissement for financial support through the dexEOS project part of the French FUI14 program. Authors thank the ParisTech BiomecAM chair program on subject-specific musculoskeletal modeling, and in particular COVEA and Société Générale. The authors thank EOS Imaging for their help in the data collection.