Search

Narrative literature review.The aim of this study was to review published literature discussing sustainable healthcare and identify aspects that pertain to spine surgery.In recent years research has investigated the contribution of surgical specialties to climate change. To our knowledge no article has yet been published discussing the impact specific to spinal procedures and possible mitigation strategies.A literature search was performed for the present study on relevant terms across four electronic databases. References of included studies were also investigated.Spine surgery has a growing environmental impact. Investigations of analogous specialties find that procurement is the single largest source of emissions. Carbon-conscious procurement strategies will be needed to mitigate this fully, but clinicians can best reduce their impact by adopting a minimalist approach when using surgical items. Reduced wastage of disposable goods and increased recycling are beneficial. Technology can aid remote access to clinicians and also enable patient education.Spine-surgery-specific research is warranted to evaluate its carbon footprint. A broad range of measures are recommended from preventative medicine, to pre-, intra- and post-operative spine care.5.

A normal sagittal vertical axis (SVA) after spinal deformity correction can yield mechanical complications of up to 30%. Post-operative compensatory pelvic orientation can produce a normal SVA. We assess relative pelvic version (RPV), an individualised measure, for persistent post-operative compensatory measures.Adult spinal deformity (ASD) patients who were treated operatively, with a normal SVA ( ± 50 mm) at 6-week follow-up were included, who were then followed-up after 2 years. These only included patients with fusion of 4 vertebrae extending to L5 or below. Six-week subgroups were made regarding pelvis orientation, relative pelvic version (RPV: anteversion, aligned, moderate or severe retroversion) with analysis of patient-related outcome measures (PROMs), complications and spino-pelvic sagittal parameters.At 6 weeks, 140 patients met the inclusion criteria, 5 (3.6%) patients had anteversion, 59 (42.1%) were aligned, 60 (42.9%) had moderate retroversion and 16 (11.4%) patients had severe retroversion. Follow-up after 2 years demonstrated increased RPV in all groups except the severe RPV group who were more likely to develop SVA 50 mm. Complications occurred in all groups. Significant 2-year differences were observed between moderate and severe RPV for back pain and PROMs but not between other RPV groups.Adult spinal deformity patients with a normal SVA after spino-pelvic instrumentation carry a significant risk of retroversion progression post-operatively, followed by increased positive sagittal balance. Relative pelvic version (RPV) measurements when categorised into anteversion, aligned, moderate retroversion and severe retroversion at 6 weeks were predictive of PROMs at 2 years.

Purpose To evaluate the pain and functional effect of the COVID-19 pandemic on patients with ASD reflected by their response to SRS-22, ODI, and SF-36 questionnaires. Methods Patients who had stable pain and functional outcome scores over the preceding 2 years were enrolled in a local prospectively collected adult spinal deformity (ASD) database. A reanalysis of their SRS22, ODI and SF-36 data 14 days into confinement were compared to their last pre-confinement scores. Results 89 patients were included in this study (average age 60.7 years, 91% female) with an average time from last FU until confinement of 9.6 months. The ODI total score worsened by 5 points post-confinement with no difference seen in personal care, walking and social life. In contrast, the SRS-22 score showed small improvements in function/activity and satisfaction, but no significant differences for the other domains. Similarly, the SF-36 showed small improvements in physical function, physical and emotional role, vitality and PCS. Conclusion The global COVID-19 pandemic and ensuing confinement had variable overall effects on ASD patients, without the expected marked worsening. In addition, this study illustrates that the SRS-22 questionnaire is less influenced by environmental and psychological factors than the ODI supporting its objectivity and accuracy in the evaluation of the QoL of ASD patients.

Coronal malalignment (CM) causes pain, impairment of function and cosmetic problems for adult spinal deformity (ASD) patients in addition to sagittal malalignment. Certain types of CM are at risk of insufficient re-alignment after correction. However, CM has received minimal attention in the literature compared to sagittal malalignment. The purpose was to establish reliability for our recently published classification system of CM in ASD among spine surgeons. Fifteen readers were assigned 28 cases for classification, who represented CM with reference to their full-length standing anteroposterior and lateral radiographs. The assignment was repeated 2 weeks later, then a third assignment was done with reference to additional side bending radiographs (SBRs). Intra-, inter-rater reliability and contribution of SBRs were determined. Intra-rater reliability was calculated as 0.95, 0.86 and 0.73 for main curve types, subtypes with first modifier, and subtypes with two modifiers respectively. Inter-rater reliability averaged 0.91, 0.75 and 0.52. No differences in intra-rater reliability were shown between the four expert elaborators of the classification and other readers. SBRs helped to increase the concordance rate of second modifiers or changed to appropriate grading in cases graded type A in first modifier. Adequate intra- and inter-rater reliability was shown in the Obeid-CM classification with reference to full spine anteroposterior and lateral radiographs. While side bending radiographs did not improve the classification reliability, they contributed to a better understanding in certain cases. Surgeons should consider both the sagittal and coronal planes, and this system may allow better surgical decision making for CM.

With the identification of literature shortfalls on the techniques employed in intraoperative navigated (ION) spinal surgery, we outline a number of measures which have been synthesised into a coherent operative technique. These include positioning, dissection, management of the reference frame, the grip, the angle of attack, the drill, the template, the pedicle screw, the wire, and navigated intrathecal analgesia. Optimizing techniques to improve accuracy allow an overall reduction of the repetition of the surgical steps with its associated productivity benefits including time, cost, radiation, and safety. Cite this article: Bone Joint J 2020;102-B(3):371–375.

Aims Intraoperative 3D navigation (ION) allows high accuracy to be achieved in spinal surgery, but poor workflow has prevented its widespread uptake. The technical demands on ION when used in patients with adolescent idiopathic scoliosis (AIS) are higher than for other more established indications. Lean principles have been applied to industry and to health care with good effects. While ensuring optimal accuracy of instrumentation and safety, the implementation of ION and its associated productivity was evaluated in this study for AIS surgery in order to enhance the workflow of this technique. The aim was to optimize the use of ION by the application of lean principles in AIS surgery. Methods A total of 20 consecutive patients with AIS were treated with ION corrective spinal surgery. Both qualitative and quantitative analysis was performed with real-time modifications. Operating time, scan time, dose length product (measure of CT radiation exposure), use of fluoroscopy, the influence of the reference frame, blood loss, and neuromonitoring were assessed. Results The greatest gains in productivity were in avoiding repeat intraoperative scans (a mean of 248 minutes for patients who had two scans, and a mean 180 minutes for those who had a single scan). Optimizing accuracy was the biggest factor influencing this, which was reliant on incremental changes to the operating setup and technique. Conclusion The application of lean principles to the introduction of ION for AIS surgery helps assimilate this method into the environment of the operating theatre. Data and stakeholder analysis identified a reproducible technique for using ION for AIS surgery, reducing operating time, and radiation exposure. Cite this article: Bone Joint J. 2020;102-B(1):5–10

Wound closure after wide, local excision of an appendicular soft‐tissue sarcoma (STS) can be challenging. This study evaluates the value of magnetic resonance imaging (MRI)‐based tumour parameters in planning wound closure. A total of 71 patients with a primary limb‐based STS, excluding vascular or osseous involvement, excluding the shoulder or hand and hip or foot were included. Axial MRI images were used to measure the circumferences and cross‐sectional areas of the limb, bone, and tumour. The tumour diameter, length, and depth at the level of maximal tumour dimension were measured to identify the tumour's relative contribution to the planning of optimal wound closure management through primary closure (PC) or reconstructive surgery (RS). Eighteen patients required planned wound RS. Wound complications occurred in 14% overall. Tumours, which were closed by PC, were of significantly greater depth, shorter radial diameter, and shorter tumour circumference relative to those closed by RS. On multivariate analysis, tumour depth was the greatest contributory factor in predicting type of wound closure. A quantitative analysis of MRI‐based tumour parameters demonstrates tumour depth as the most predictive factor in planning for the type of wound closure and may prove beneficial in providing greater insight into planned wound management of sarcoma resection.

To assess pain, health-related quality of life (HRQOL) scores and sagittal parameters of adult spinal deformity (ASD)-operated patients in the context of their analgesic consumption especially opioids (narcotics) over the first year postoperative period. In total, 372 patients from a multicenter database were stratified into 3 groups at baseline: 241 patients in the minimal group (no analgesic, or NSAIDs/narcotics weekly or less), 64 in the NSAIDs every day group and 67 in the narcotics every day group. HRQOL and back and leg pain scores were evaluated at 6 months and 1 year postoperatively. Also several sagittal alignment parameters were assessed. Significant improvements in pain and HRQOL scores were observed across all 3 groups by 1 year (P

BACKGROUND: Mid-term clinical and radiological evaluation of a carbon-fiber cage in multilevel cervical spondylosis (MCS). Anterior cervical corpectomy and fusion (ACCF) using titanium mesh cages (TMC) has shown satisfactory outcomes, but with subsidence of up to 20%. Conventional long-fiber carbon fiber cages have shown a safe profile in discectomy/fusion (ACDF) but with minimal data in the setting of corpectomy. METHODS: Retrospective review of a single centre multi-surgeon cohort of MCS patients from 2007–2012. Follow-up period was a minimum of 3.5 years, mean 6 years. Outcomes included peri-operative, clinical [Nurick, European Myelopathy, Visual Analogue Scores (VAS), modified Japanese Orthopaedic Association (mJOA) scores and radiographic (C2C7, Cobb & ROM angles)]. RESULTS: A total of 102 consecutive patients were included. Mean length of stay was 5.5 (SD 3.5) days, blood loss 322 (SD 358) mL and operative time 98 (SD 31) min. Corpectomy levels included 72 single-level ACCF and 30 multiple ACCF. Fourteen had peri-operative complications. Three patients required early cage revisions. Mean pain scores improved from VAS neck 4.6 to 2.6 (P3 mm across the instrumented level were present in 5 patients, all of which displayed fusion of either grade 1 or 2. 7 had C2C7 kyphosis. Severe subsidence (>3 mm) was seen in 9 cases (13%). CONCLUSIONS: Mid-term outcomes of this carbon-fiber cage indicate that it is safe and durable for the treatment of MCS with a similar radiological profile to that of TMC.

Study Design Multicenter, prospective study of consecutive adult spinal deformity (ASD) patients. Objective To Validate Schwab's classification accuracy for surgical indication, and to evaluate a simplified sagittal modifier. Summary of Background Data The SRS-Schwab Radiologic Classification based on clinical impact parameters, offers 27 different sagittal classification possibilities regarding sagittal vertical alignment (SVA), pelvic tilt (PT), and pelvic incidence–lumbar lordosis (PI-LL). The high number of classification possibilities makes it complex to use. Methods Inclusion criteria were ASD patients, presenting at least 1 criteria: Cobb ≥ 20°, SVA ≥ 5 cm, thoracic kyphosis ≥ 60°, or PT ≥ 25°. A total of 1,004 patients (410 nonoperative and 594 operative) were classified regarding SVA, PT, and PI-LL (0, +, ++), and 27 possibilities were identified. Categories were formed by adding the number of + signs, considering PT, SVA, and PI-LL. Three specific categories were identified: Aligned: 0 +; Moderate deformity: 1 to 3+; and Severe deformity: 4 to 6+. A χ-square test was performed for surgical indication (operated or not) and an analysis of variance was performed to evaluate the relationship between categories and Oswestry Disability Index (ODI). Probability Results Significant differences for HRQoL scores and surgical indication were found in the 27 sagittal parameter possibilities. For nonoperative patients, 230 (56.1%) were classified as aligned, 145 (35.4%) as moderate, and 35 (8.5%) as severe. For operative patients, there were 200 (33.7%), 215 (36.2%), and 179 (30.1%) in each respective subgroup. For HRQoL scores and surgical indication, no significant differences were found within each category, but significant differences were found when comparing the subgroups. Conclusions Despite the correlation between SRS-Schwab classification and surgical indication, it is complex to use, with a total of 27 possibilities regarding sagittal modifiers. This simplification into three categories offers more readability, without losing any significant information, and could replace Schwab sagittal modifiers. In association with other parameters, they could be used for decision-making. Level of Evidence Level II.

Objectives in scoliosis corrective surgery include restoration of normal sagittal and coronal parameters to achieve patient satisfaction. HRQLs improvements remain limited after corrective surgery. The aim of this study was to evaluate the HRQL subclass variability specific to the sagittal and coronal correction in adult scoliosis surgery. This multi-centre prospective analysis of consecutive adult spinal deformity (ASD) patients, from five European centres, only included multilevel instrumentation for scoliosis. d-(delta) values for each parameter represented pre to post-operative changes. Parameters included demographics, baseline, 1- and 2-year. HRQL outcomes (Oswestry disability index (ODI), Scoliosis Research Society (SRS)-22 and Short Form (SF36)), sagittal correction including relative spinopelvic alignment (dRSA) and coronal correction including major Cobb (dCobb) angles. A total of 353 patients reached 1-year and 2-year follow up. All HRQL total scores significantly improved postoperatively, including ODI, SRS-22 and SF36. HRQL subclasses which displayed persistent improvements correlated to dRSA included sex-life, self-image, fatigue, vitality, social functioning. The only HRQL subclass improvement that correlated with dCobb was self-image. Adult scoliosis surgery improves overall HRQL, having a minimal effect on each variable. Importantly, greater coronal deformity correction affects only greater self-image scores, whereas with greater sagittal correction there are many greater HRQL sub-class impacts. Correction and restoration of coronal balance is one of the surgical goals in adult scoliosis but the degree to which Cobb angle is corrected, apart from self-image, does not correlate with gains in sub-classes of HRQL. These results need to be taken into account when planning surgery.

Multicenter, retrospective study.The aim of this study was to examine the performance and concurrent validity of the adult spinal deformity surgical decision-making (ASD-SDM) score compared to decision-making factors in the ASD population.The ASD-SDM score, which has been recently proposed, is a scoring system to guide the selection of treatment modality for the ASD population. To secure the justification for its clinical use, it is necessary to verify its clinical performance and concurrent validity.A multicenter prospective ASD database was retrospectively reviewed. The data were analyzed separately in younger (≤40 years) and older (≥41 years) age groups. The discriminating capacity of the ASD-SDM score in cases who selected surgical and nonsurgical management was compared using area under the receiver operator characteristic curves (AUROC). Concurrent validity was examined using Spearman correlation coefficients, comparing factors that are reported to be associated with the decision-making process for ASD, including baseline symptomatology, health-related quality of life measures, and the severity of radiographic spinal deformity.There were 338 patients (mean age: 26.6 years; 80.8% female; 129 surgical and 209 nonsurgical) in the younger age group and 750 patients (mean age: 63.5 years; 84.3% female; 410 surgical and 340 nonsurgical) in the older age group. In both younger and older patients, the ASD-SDM score showed a significantly higher performance for discriminating the surgical and nonsurgical cases (AUROC: 0.767, standard error [SE]: 0.026, P 0.001, 95% confidence interval [CI]: 0.712-0.813; AUROC: 0.781, SE: 0.017, P 0.001, 95% CI: 0.747-0.812, respectively) compared to the decision-making factors analyzed. In addition, the ASD-SDM showed significant correlations with multiple decision-making factors.The ASD-SDM score alone can effectively grade the indication for surgical management whilst considering multiple decision-making factors.3.

Background: transarticular screw (TAS) fixation without a supplementary posterior construct, even in rheumatoid arthritis (RA) patients, provides sufficient stability with acceptable clinical results. Here, we present our experience with 15 RA patients who underwent atlantoaxial (AA) TAS fixation without utilizing a supplementary posterior fusion. Methods: To treat AA instability, all 15 RA patients underwent C1–C2 TAS fixation without a supplementary posterior construct. Patients were followed for at least 24 months. Pre- and postoperative sagittal measures of C1– C2, C2–C7, and C1–C7 angles, atlanto-dens interval (ADI), posterior atlanto-dens interval (PADI), and adjacent segment (i.e., C2–C3) anterior disc height (ADH) were retrospectively recorded from lateral X-ray imaging. The presence or absence of superior migration of the odontoid (SMO), cervical subaxial subluxation, C1–C2 bony fusion, screw pull-out, and screw breakage were also noted. Results: There was little difference between the pre- and postoperative studies regarding angles measured. Following TAS fixation, the mean ADI shortened, and mean PADI lengthened. There was no difference in the mean measures of C2–C3 ADH. There was no evidence of SMO pre- or postoperatively. Two patients developed anterior subluxation at C5–C6; one of the two also developed anterior subluxation at C2–C3. All patients subsequently showed C1–C2 bony fusion without screw pull-out or breakage. Conclusion: In RA patients who have undergone C1–C2 TAS fixation, eliminating a supplementary posterior fusion resulted in adequate stability.

STUDY DESIGN Retrospective, longitudinal observational study. PURPOSE To describe the natural history of anterior bone loss (ABL) in cervical disc arthroplasty (CDA) and introduce a classification system for its assessment. OVERVIEW OF LITERATURE ABL has recently been recognized as a complication of CDA, but its cause and clinical effects remain unknown. METHODS Patients with non-keeled CDA (146) were retrospectively reviewed. X-rays were examined at 6 weeks, 3, 6, 9, 12, 18, and 24 months, and annually thereafter for a minimum of 5 years. These were compared with the initial postoperative X-rays to determine the ABL. Visual Analog Scale pain scores were recorded at 3 months and 5 years. Neck Disability Index was recorded at postoperative 5 years. The natural history was determined and a classification system was introduced. RESULTS Complete radiological assessment was available for 114 patients with 156 cervical disc replacements (CDRs) and 309 endplates (average age, 45.3 years; minimum, 28 years; maximum, 65 years; 57% females). ABL occurred in 57.1% of CDRs (45.5% mild, 8.3% moderate, and 3.2% severe) and commenced within 3 months of the operation and followed a benign course, with improvement in the bone stock after initial bone resorption. There was no relationship between ABL degree and pain or functional outcome, and no implants were revised. CONCLUSIONS ABL is common (57.1%). It occurs at an early stage (within 3 months) and typically follows a non-progressive natural history with stable radiographic features after the first year. Most ABL cases are mild, but severe ABL occurs in approximately 3% of CDAs. ABL does not affect the patients' clinical outcome or the requirement for revision surgery. Surgeons should thus treat patients undergoing CDA considering ABL.

Resume Introduction L’incidence pelvienne (IP) est une reference anatomique consideree comme invariable. Les variations posturales influencent la colonne lombaire mobile, mais la lordose lombaire (LL) et le pelvis sont habituellement analyses en position debout statique. Est-ce que les autres positions de la vie courante ont une influence sur la relation IP-LL ? Hypothese Nous supposons que la lordose lombaire et la pente sacree sont correlees a l’incidence pelvienne, quelle que soit la posture. Le but de cette etude est de confirmer ou d’affirmer cette hypothese en utilisant deux positions standardisees (position couchee et position assise) differentes de la position debout habituellement utilisee. L’objectif de l’etude est d’analyser les relations entre la LL et les parametres pelviens en position debout, assise et couchee. Methode Les radiographies de 15 volontaires asymptomatiques adultes de moins de 50 ans ont ete realisees dans les 3 positions puis les parametres lombo-pelviens analyses. Les valeurs moyennes et ecarts-types etaient calcules et compares. Les correlations etaient obtenues par le test de Spearman. Resultats L’incidence pelvienne etait fixe et non modifiee par les differentes positions. La LL L1-S1 debout etait de 54,8° ± 9,8, assis : 15,9° ± 14,6 et couche : 50,2° ± 9,6. Les valeurs de version pelvienne (VP) etaient respectivement 12,1° ± 6,3° ; 37,7° ± 10,4° et 9,5° ± 5,1°. Les valeurs de pente sacree (PS) 37,1° ± 6,3°, 11,3° ± 10,8°, 41° ± 7,2°. Les correlations IP/LL (r = 0,72), LL/PS (r = 0,9) et IP/PS (r = 0,84) etaient plus fortes en position couchee. Conclusion Alors que l’IP est constante, l’orientation du sacrum et la lordose lombaire changent significativement avec les positions de la vie courante, notamment en position assise. L’ajustement de la LL avec l’IP lors des chirurgies d’arthrodeses est fondamental meme chez les patients a activite reduite. Niveau de preuve IV.

Background Pelvic incidence (PI) is an anatomical parameter that is considered invariable in a given individual. Although changes in posture influence the mobile lumbar spine, lumbar lordosis (LL) and the pelvis are typically evaluated only in the standing position. Thus, whether other positions commonly used during daily activities influence the relationship between LL and PI is unknown. The objective of this study was to determine whether LL and sacral slope (SS) correlated with PI, using two standardised positions, seated and supine, different from the standing position that is generally used. Hypothesis We are supposing that lumbar lordosis and sacral sloop are correlated to pelvic incidence whatever the posture. The goal of this study was to confirm or deny this hypothesis, using two standardize positions (sitting and lying) different that the usual standing position. LL and SS correlate with PI in the standing, seated, and supine positions. Method Lumbar and pelvic parameters were measured on radiographs obtained in the standing, seated, and supine positions in 15 asymptomatic adult volunteers younger than 50 years of age. Mean values with their standard deviations were computed and compared across the three positions using ANOVA. Spearman's test was applied to assess correlations. Results PI had the same value in all three positions. The L1-S1 LL angle was 54.8 ± 9.8° in the standing position, 15.9 ± 14.6° in the seated position, and 50.2 ± 9.6° in the supine position. Pelvic tilt (PT) in the same three positions was 12.1 ± 6.3°, 37.7 ± 10.4°, and 9.5 ± 5.1°, respectively; and SS was 37.1 ± 6.3°, 11.3 ± 10.8°, and 41 ± 7.2°, respectively. Correlations were strongest in the supine position between PI and LL (r = 0.72), LL and SS (r = 0.9), and PI and SS (r = 0.84). Conclusion Whereas PI remains unchanged in a given individual, lumbar lordosis and sacral orientation show significant changes across positions used in daily life, with the greatest changes seen in the seated position. During spinal fusion surgery, adjusting LL based on IP is crucial even in patients who have limited physical activity. Level of evidence IV.

We aimed to elucidate the factors for the decision-making process in the treatment of adult spinal deformity (ASD), including sagittal parameters, that impact health-related quality of life (HRQOL). A multicenter prospective ASD database was retrospectively reviewed. The demographic data, HRQOL, and radiographic measures were analyzed using multivariate analyses in younger (≤ 50 years) and older (> 50 years) age groups. This study included 414 patients (134 surgical and 280 nonsurgical; mean age 30.7 years) in the younger age group and 575 patients (323 surgical and 252 nonsurgical; mean age 65.8 years) in the older age group. Worse HRQOL measures drove surgical treatment, both in younger and older patients. The SRS-22 self-image score was the most differentiating domain, both in the younger and older age groups, and an additional significant factor in the older age group was pain and disability. Coronal deformity drove surgical treatment for the younger age group; however, older surgical patients were less likely to have coronal malalignment. Sagittal parameters were associated with the decision-making process. Greater pelvic incidence minus lumbar lordosis mismatch in the younger age group and smaller lumbar lordosis index in the older age group were most correlated with the decision to undergo surgery. Aside from the HRQOL measures and coronal deformity, sagittal parameters were identified as significant factors for the decision-making process in the ASD population, and the lack of lumbar lordosis in relation to pelvic incidence was a strong driver to pursue surgical treatment. These slides can be retrieved under Electronic Supplementary Material.

Pedicle Subtraction Osteotomy (PSO) is an effective surgical technique for the correction of fixed sagittal malalignment of the spine. It is a demanding technique that requires a long learning curve. The aim of this study is to analyze a surgeon’s learning curve for lumbar PSO in relation to the preoperative, perioperative, and postoperative management, with assessment of the global outcome. 102 patients operated over an 8-year period were included, distributed in 3 groups over the time, and retrospectively analyzed. The following data were collected: demographic characteristics, preoperative and postoperative radiological parameters, operative technical details, and complications. Multiple regression analysis was performed, and while the number of cases was the predictor, other variables such as demographic, radiographical, and surgical variables were considered as a covariate in the final model. When comparing the first group and the last group of patients, the mean surgical time had decreased by 50 min, the estimated blood loss was decreased by 655 ml, and a significant decrease in dural tear occurrence was noticed. In addition, we found a significant decrease in the hospital stay length. Multivariate linear regression analysis showed that when the surgeon’s experience doubles, the operative time decreases by 29 min, the blood loss by 281 ml, and the odds of hospital stay ≥ 21 days decrease by 0.66 times. PSO technique has a relatively long learning curve. This study showed that accumulating the experience over the years, while performing cases on a regular basis, is definitely the key in mastering this complex and risky technique, with significant improvements in the perioperative parameters that directly impact the recovery and global outcome. These slides can be retrieved under Electronic Supplementary Material.

To assess the efficacy of bisphosphonate therapy in the management of spinal aneurysmal bone cysts (ABCs). A prospective study of six consecutive patients aged between 7 and 22 years with spinal ABCs treated with pamidronate (1 mg/kg) or zoledronate (4 mg). A visual analogue scale (VAS) for pain and radiological (contrast-enhanced MRI and CT scan at 3 and 6 months, then yearly X-rays) follow-up was continued for a minimum of 6 years. One patient with an unstable C2/3 failed to respond to a single dose of bisphosphonate and required surgical resection and stabilisation with autologous bone grafting. Another, with a thoraco-lumbar ABC, experienced progression of neurological dysfunction after one cycle of bisphosphonate and, therefore, required surgical resection and stabilisation. In all other patients pain progressively improved and was resolved after two to four cycles (VAS 7.3–0). These patients all showed reduction in peri-lesional oedema and increased ossification by 3 months. No patients have had a recurrence within the timeframe of this study. Bisphosphonate therapy can be used as the definitive treatment of spinal ABCs, except in patients with instability or progressive neurology, where surgical intervention is required. Clinicians should expect a patients symptoms to rapidly improve, their bone oedema to resolve by 3 months and their lesion to partially or completely ossify by 6–12 months.

The CTDR is a technique that treats cervical disc degenerative disease. Initial shorter-term studies showed good clinical and radiological results. To assess the clinical and radiological results of Bryan cervical disc replacement (Medtronic Sofamor Danek Inc., Memphis, TN) at 15-year follow-up. This prospective study included 20 patients who underwent 22 CTDR, comprising a single-level procedure in 14 patients and two-level procedures in six patients. The mean follow-up period was 15.5 years. The mean age at the intervention was 46.2 years (range: 26–65 years). Two patients needed re-operation for recurrence of symptoms. According to Odom’s criteria, 80.0% (16 of 20 patients) had excellent outcomes, VAS for neck pain was 2.6 (0–10), for shoulder/arm pain it was 1.8 (0–7), and NDI at the final follow up was 14.9. The SF-12 PCS was 46.1, and SF-12 MCS was 51.9. Mobility was maintained in 15 of the 22 (68.2%) operated segments, range of motion (ROM) of prostheses were 9° ± 3.9° (range 4–15°). The prostheses were positioned in kyphosis in 14 of 22 levels (63.6%). There was a positive correlation between the kyphosis of the prosthesis and the occurrence of heterotopic ossification (HO), and their grade (ρ = 0.36, CI 95%[−0.68; 0.07]). HO had developed at 12 of the 22 levels (54.5%) and upper adjacent segment degeneration in 11 of 18 of patients (64.7%). All these results were not significantly different to outcomes at 8 years follow-up. In a cohort of 20 patients with 15-year clinical and radiological follow-up, the Bryan CTDR has demonstrated a sustained clinical improvement and implant mobility over time, despite a moderate progression of degenerative processes at the prosthetic and adjacent levels.

Background: Identifying the gluteal vessels during a posterior sacrectomy can be challenging. This study defines anatomical landmarks that can be used to approximate the location of the superior and inferior gluteal arteries (SGA and IGA) during a posterior sacrectomy. Methods: Cadaveric dissection of six fresh adult pelvises to determine the location of the SGA and IGA in relation to the posterior-inferior aspect of the sacroiliac joint (PISIJ), lateral sacral margin and sacrococcygeal joint (SCJ). Results: The anatomical landmarks are easily palpable. The position of the SGA to the PISIJ is relatively constant as it is tethered by a posterior branch of the artery, which runs inferior to the PISIJ. The IGA position is also relatively constant below the mid-point of the PISIJ and SCJ. The vessels are separated from the sacrospinous/sacrotuberous ligament complex (SSTL) in the perisacral region and as a result an anatomical plane exists anterior to the SSTL, which affords protection of the vessels during SSTL transection. The distance between the vessels and the SSTL increases the more medial the dissection. Conclusions: The described anatomical landmarks can be used to predict the location of the SGA and IGA during posterior sacrectomy. An anatomical plane exists anterior to the SSTL, which provides protection to the vessels during SSTL transection. Furthermore, the distance between the vessels and the SSTL increases the more medial the dissection, thus, resection of the SSTL as close to the lateral sacral margin as the pathology permits, is advocated.

To evaluate the radiographic, functional outcomes, complications and surgical specificities of L5 pedicle subtraction osteotomy for fixed sagittal and coronal malalignment. A retrospective cohort of consecutive patients with prospectively collected data. Ten patients who underwent PSO at L5 were eligible for a 2-year minimum follow-up (average, 4.0 years). Patients were evaluated by standardized upright radiographs. Preoperative and postoperative radiographies, surgical data and complications were collected. All surgeries were revision surgeries. The mean lumbar lordosis before surgery was − 22.5° (range, 8° to − 33°) and improved to − 58.5° (range, − 40° to − 79°). The sagittal vertical axis demonstrated a preoperative mean sagittal malalignment of 13.7 cm (range 3.5 to 20 cm), with correction to 4.6 cm postoperatively. Three patients required additional surgery at the latest follow-up for rod breakage. PSO of L5 can be a safe and effective technique to treat and correct fixed sagittal imbalance and provide biomechanical stability. The high complication rate mandates a careful assessment of the risk/benefit ratio of such a major surgery. Most patients are satisfied, particularly when sagittal balance is achieved.

Firstly, to describe two cases of cerebral ischaemia complicating anterior upper thoracic spinal surgery and define the likely cause of this complication. Secondly, to describe preventative measures and the effect these have had in reducing this complication within our institution. Firstly, a review of two cases of cerebral ischaemia complicating anterior upper thoracic spinal surgery utilizing a partial manubrial resection. Secondly, cadaveric dissections of the carotid arteries to determine the effect of neck positioning and aortic arch retraction during a simulated procedure. Thirdly, a retrospective review of 65 consecutive cases undergoing this procedure and assessment of the rate of this complication before and after the adoption of preventative measures. Two cases of carotid artery territory cerebral ischaemia, without radiographic evidence of carotid or cardiac pathology were identified in 50 consecutive cases prior to the implementation of preventative measures. These patients revealed fluctuating hemodynamic instability after placement of the inferior retractor. Cadaveric dissection reveals significant carotid artery traction particularly with neck extension. Since the adoption of preventative measures, no cases of cerebral ischaemia have been encountered. Cerebral ischaemia is a potential complication of anterior upper thoracic spinal surgery requiring retraction of the aortic arch. This most likely occurs from carotid stenosis due to aortic retraction and therefore, may be reduced by positioning the patient with neck flexion. Continuous non-invasive monitoring of cerebral saturation, as well as actively monitoring for hemodynamic instability and reduced carotid pulsation after retractor placement, allows for early detection of this complication. If detected, perfusion can be easily restored by reducing the retraction of aortic arch.

The incidence of pneumocephalus and pneumorrhachis after spinal surgery is unknown, with a paucity of literature on this complication. We present the first published case of delayed onset tension pneumocephalus and pneumorrhachis associated with spinal surgery. This complication occurred from a cerebro-spinal fluid (CSF) leak after posterior instrumentation removal and was successfully treated with emergent wound debridement and the formation of a CSF fistula. This case illustrates that delayed post-operative tension pneumocephalus and pneumorrhachis can occur after spinal surgery in a patient with a CSF leak. It also illustrates that pneumocephalus and pneumorrhachis can be easily diagnosed with cross-sectional CT imaging. Furthermore, in a patient with rapid deterioration emergent surgical debridement may be necessary. Lastly, if the dural tear cannot be identified intra-operatively, the formalization of a CSF fistula should be considered.

BACKGROUND: Thoracic hyperkyphosis can display pathological deterioration, resulting in either hyperlordotic cervical compensation or sagittal malalignment. Various techniques have been described to treat fixed malalignment. Pedicle subtraction osteotomy (PSO) is commonly used in the lumbar spine and frequently limited to the distal thoracic spine. This series focuses on the surgical specificities of proximal thoracic PSO, with clinical and radiological outcomes. OBJECTIVE: To report the surgical specificities and assess the clinical and radiological outcomes of proximal thoracic osteotomies for correction of rigid kyphotic deformities. METHODS: This is a retrospective review of 10 consecutive patients who underwent single level proximal thoracic PSO (T2-T5). Preoperative and postoperative full-body EOS(TM) radiographs, perioperative data, and complications were recorded. The surgical technique and its nuances were described in detail. RESULTS: Patients had mean age of 41.8 yr and 50% were female. The technique provided correction of segmental and global kyphosis, 26.6° and 29.5°, respectively. Patients reported reciprocal reduction in C2-C7 cervical lordosis (37.6°-18.6°, P < .001), significantly correlating with the reduction of thoracic hyperkyphosis (R = 0.840, P = .002). Mean operative time was 291 min, blood loss 1650 mL, and mean hospital stay was 13.8 d. Three patients reported complications that were resolved, including 1 patient who was revised because of a painful cross link. There were no neurological complications, pseudarthroses, instrumentation breakage, or wound infections at a minimum of 2-yr follow-up. CONCLUSION: Proximal thoracic PSO can be a safe and effective technique to treat fixed proximal thoracic hyperkyphosis leading to kyphosis reduction and craniocervical relaxation.

BACKGROUND: Both adult spinal deformity (ASD) and obesity are growing concerns internationally. This study therefore aims to determine the effect of increasing body mass index (BMI) on the pain and function of patients with ASD. METHODS: A retrospective review of prospectively collected data from a multicentre European database was undertaken. Initially a univariate analysis was performed on the effect of BMI on the initial presentation of functional scores in patients with ASD. The functional scores included the Numerical Rating Scale (NRS) back and leg score, Core Outcome Measures Index (COMI) back score, SRS22 total score, Short Form 36 (SF-36) [general health, physical component score (PCS) and mental component score (MCS)] and Oswestry Disability Index (ODI) score (including all domains). Subsequently a multivariate analysis controlling for age, sex, comorbidities, employment status, smoking status and radiological parameters [coronal cobb, coronal balance, sagittal balance, global tilt, and pelvic incidence minus lumbar lordosis (PI − LL) mismatch] was performed. RESULTS: A total of 1,004 patients were included in this study (166 male, 838 female). On univariate analysis a statistically significant (P0.05). CONCLUSIONS: Increasing BMI has a significant adverse effect on the pain and functioning of patients with ASD. Clinicians should recognise this association and treat patients accordingly.

This chapter describes details of the craniovertebral junction that pertain to alignment of the spine. Foremost in our understanding is the discovery of how and why Hominidae came to this evolutionary point. The relationship of the craniovertebral junction to the subaxial spine is dynamic and displays a “fine tuning” contribution to sagittal balance of both the neck and the overall spine. Degenerative conditions of the cervical spine affect this as will instability, malformations, and trauma. Finally, cognizance of alignment contributions from the craniovertebral junction are particularly relevant when operating on the CVJ.

We aimed to develop and internally validate a scoring system, the adult spinal deformity surgical decision-making (ASD-SDM) score, to guide the decision-making process for ASD patients aged above 40 years. A multicentre prospective ASD database was retrospectively reviewed. The scoring system was developed using data from a derivation set and was internally validated in a validation set. The performance of the ASD-SDM score for predicting surgical management was assessed using the area under the receiver operating characteristic curve (AUC). A total of 702 patients were included for analysis in the present study. The scoring system developed based on 562 patients, ranging from 0 to 12 points, included five parameters: leg pain scored by the numerical rating scale; pain and self-image domains in the Scoliosis Research Society-22 score; coronal Cobb angle; and relative spinopelvic alignment. Surgical indication was graded as low (score 0 to 4), moderate (score 5 to 7), and high (score 8 to 12) groups. In the validation set of 140 patients, the AUC for predicting surgical management according to the ASD-SDM score was 0.797 (standard error = 0.037, P

Background: Anterior bone loss (ABL) has recently been described in cervical disc arthroplasty (CDA). Its cause remains unknown but because it has not been described in anterior cervical disectomy and fusion (ACDF) researchers believe the cause relates to wear debris. Therefore, this study aims to describe ABL in ACDF and therefore support alternative causes for this phenomenon. Methods: Two case reports of ABL after ACDF are presented. Results: Both cases developed early ABL (within 3 months) that was static by one year. Neither patient developed neck pain (VAS 0/10). The functional outcomes of the first case were excellent and no further treatment was required. The second patient developed adjacent segment disease and worsened myelopathy necessitating further surgery. Conclusion: ABL occurs in ACDF, supporting the hypothesis that ABL is a surgical technique rather than implant specific phenomenon. Clinical relevance: ABL is not specific to CDA and therefore not likely to be caused by wear debris, but rather surgical technique or stress shielding.

We aimed to develop and internally validate a simple scoring system: the adult spinal deformity (ASD) surgical decision-making (ASD-SDM) score, which is specific to the decision-making process for ASD patients aged below 40 years. A multicentre prospective ASD database was retrospectively reviewed. The scoring system was developed using data from a derivation cohort and was internally validated in a validation cohort. The accuracy of the ASD-SDM score was assessed using the area under the receiver operating characteristic curve (AUC). A total of 316 patients were randomly divided into derivation (253 patients, 80%) and validation (63 patients, 20%) cohorts. A 10-point scoring system was created from four variables: self-image score in the Scoliosis Research Society-22 score, coronal Cobb angle, pelvic incidence minus lumbar lordosis mismatch, and relative spinopelvic alignment, and the surgical indication was graded into low (score 0–4), moderate (score 5–7), and high (score 8–10) surgical indication groups. In the validation cohort, the AUC for selecting surgical management according to the ASD-SDM score was 0.789 (SE 0.057, P

Discuss the relevant literature on surgical and nonsurgical treatments for multiple myeloma (MM) and their complementary effects on overall treatment. Existing surgical algorithms designed for neoplasia of the spine may not suit the management of spinal myeloma. Less than a fifth of metastatic, including myelomatous lesions, occur in the cervical spine but have a poorer prognosis and surgery in this area carries a higher morbidity. With the advances of chemotherapy, early access to radiotherapy, early orthosis management, and high definition imaging, including CT and MRI, surgical indications in MM have changed. Medical decompression (or oncolysis), including in the presence of neurological deficit and orthotic stabilization, are proving viable nonsurgical options to manage MM. A key to decision making is the assessment and monitoring of biomechanical spinal stability as part of a multidisciplinary approach.

STUDY DESIGN Multicenter, prospective study of consecutive adult spinal deformity (ASD) patients. OBJECTIVE To evaluate back and leg pain as a combined score in ASD and compare their relative and cumulative correlations with health-related quality of life (HRQOL) and sagittal parameters. SUMMARY OF BACKGROUND DATA Pain and disability are commonly reported in patients with ASD. This can affect their back, their legs or both. ASD-associated pain has been correlated with numerous HRQOL scores and radiological parameters. METHODS Preoperative pain intensity was assessed with a Numerical Rating Scale (NRS) for individual back and leg pain as well as a combined score, NRS20 (0-20, back plus leg pain).This yielded a range of static measures in all patients with ASD with differing burdens of disease. Linear regression analysis was performed to calculate the correlation between pain and HRQOL scores (Scoliosis Research Society 22, 36-Item Short Form Health Survey Physical Component Summary, 36-Item Short Form Health Survey Mental Component Summary, Core Outcome Measures Index, and Oswestry Disability Index), and radiological spinopelvic parameters (sagittal and coronal planes). RESULTS A total of 1309 patients were included in this study. A combined score (NRS20) was better correlated with HRQOL (P

Background context Correction of scoliotic deformity in Duchenne muscular dystrophy (DMD) is performed to maintain adequate seating posture and facilitate comfort. Delaying surgery can predispose to greater morbidity as DMD exhibits progressive cardiorespiratory compromise. Early limited instrumentation may provide a solution to optimize patients with this condition. Purpose The aim was to assess outcomes for a cohort of DMD patients who had posterior single-rod instrumentation and bilateral spinal fusion of their neuromuscular scoliotic deformity. Study design This was a retrospective cohort study. Patient sample Forty-one consecutive patients were included. Outcome measures Perioperative morbidity, seating outcomes, pulmonary function, deformity correction, and instrumentation integrity were assessed. Methods Clinical and radiographic review was performed. Results No perioperative mortality or neurologic deterioration was encountered. Total surgical time was 96 minutes, mean total blood loss was 2.3l, mean intensive care unit stay was 41 hours, and overall length of stay was 11 days. Mean Cobb angle improved from 24.3° to 15.6°, pelvic obliquity improved from 7° preoperatively to 5° postoperatively. Three patients had failure of fixation at a mean of 3.5 years. Forced vital capacity was 60% preoperatively and 56% at 1 year, forced expiratory volume/1 second was 67% and 62% at 1 year postoperatively. Seating and posture was satisfactory in all these patients. Conclusions The authors advocate early operative intervention using a limited instrumentation technique in patients with DMD to maintain seating balance and minimize perioperative morbidity.

Background & aim Intraoperative epidural corticosteroids have been used to decrease post-operative pain post-discectomy. The objective of this study is to assess the efficacy of epidural corticosteroids on post-operative pain and length of post-operative hospital stay in patients undergoing unilateral lumbar microdiscectomy. Methods 150 consecutively treated, comparable patients with unilateral lumbar disc herniation were prospectively allocated randomly to receive either a sponge soaked in epidural corticosteroids or saline at the end of the operative procedure. The intensity of spontaneous pain was quantified by using the Oswestry low back pain index pre-operatively, at discharge, at week 1 follow-up and at 1st month of follow up. At the same intervals, each patient underwent the passive straight leg-raising test (PSLRT) and Visual Analogue Scale (VAS) testing. The duration of hospital stay, time taken to return to daily life activities and quantity of analgesia consumed post-operatively were also recorded. Results The mean hospital stay was 1.3 ± 0.9 days in the corticosteroids group (group 1) compared to 3.2 ± 1.2 in the control group (group 2). The mean interval until return to daily life activities was 6.7 ± 2.1 days in group 1 versus 9.6 ± 4.1 days in group 2. No statistically significant difference was measured between the steroid-treated and control groups when the data were stratified for sex, age, and site of disc herniation. Differences in the OLBI scores were statistically significant at all post-operative intervals. At baseline (preoperatively), group 1 (DepoMedrol™ group) had an average score of 72.3% (±2.6%) compared to 74.6% (±3.1%) in group 2 (Control group) ( P = 0.45). At discharge, OLBI scores declined to 49.7% (±4.5%) in group 1 compared to 63.5% (±3.9%) in group 2 ( P = 0.034). At week 1 follow-up, OLBI scores further declined to 41.3% (±2.9%) in group 1 versus 54.2% (±5.3%) in group 2 ( P = 0.014). After one month of follow-up, OLBI scores were 34.1% (±6.7%) in group 1 and 42.6% (±4.1%) in group 2 ( P = 0.004). Results of VAS and PSLRT are also documented in the manuscript. The mean postoperative analgesic medications consumed was 15.6 ± 1.9 mg of morphine equivalent in the corticosteroid group versus 10.3 ± 1.8 mg of morphine equivalent in the control group. No complications of treatment occurred in either groups. Conclusion Intraoperative application of epidural corticosteroids, Depomedrol, significantly reduces post-operative pain, length of post-operative stay and duration to return to daily living activities following lumbar discectomy.

Objectives Hip arthroplasty registries, encompassing all-cause end-stage hip degeneration, have shown that slightly more right hip replacements are performed than left. Given that greater than 85% of individuals are right-handed, we sought to investigate the association between side of hand dominance and side of hip osteoarthritis. Methods This Level III observational study evaluated exclusively end-stage osteoarthritis of the hip, using 3 independent centres totalling 386 consecutive arthroplasty patients. Logistic regression was used as a statistical model. Results In total, 322 patients with hip osteoarthritis were included in the final analysis, including 146 (45.5%) women and 176 (54.5%) men, with a mean age of 68.1 years (SD = 9.5 years). There were 133 (41.2%) right, 73 (22.6%) left, and 116 (35.9%) bilateral hips where the contralateral side had been previously replaced. The proportion of individuals requiring unilateral hip arthroplasty on their dominant side was 67.4%. Conclusions In the development of hip osteoarthritis, one is significantly more likely to require hip arthroplasty on their dominant side than in the contralateral hip. Assessment of hand dominance identifies cerebral laterality as a contributing factor in predisposing one’s dominant side to hip osteoarthritis.

Unfortunately, two author names were missed out in author group of the original publication.

To understand whether a spondylolisthesis in the sub-axial spine cranial to a cervical disc arthroplasty (CDA) construes a risk of adjacent level disease (ALD). A retrospective review of 164 patients with a minimum 5-year follow-up of a cervical disc arthroplasty was performed. Multi-level surgeries, including hybrid procedures, were included. Multiple implant types were included. The two inter-vertebral discs (IVD) cranial of the CDA were monitored for evidence of radiologic degeneration using the Kettler criteria. The rate of ALD in CDA found in this series was 17.8%, with most affecting the immediately adjacent IVD (27.4 and 7.6%, respectively p = 0.000). Pre-operative mild spondylolisthesis adjacent to a planned CDA was not found to be a risk factor for ALD within 5 years. Those with a degenerative spondylolisthesis are at higher risk of ALD (33%) than those with a non-degenerative cause for their spondylolisthesis (11%). Post-operative CDA alignment, ROM or induced spondylolisthesis do not affect the rate of ALD in those with an adjacent spondylolisthesis. Patients with ALD experience significantly worse 5-year pain and functional outcomes than those unaffected by ALD. A pre-operatively identified mild spondylolisthesis in the sub-axial spine cranially adjacent to a planned CDA is not a risk factor for ALD within 5 years. These slides can be retrieved under Electronic Supplementary Material.

The stress distribution and plastic deformation of peri-prosthetic trabecular bone during press-fit tibial component implantation in total knee arthroplasty is investigated using experimental and finite element techniques. It is revealed that the computed stress distribution, implantation force and plastic deformation in the trabecular bone is highly dependent on the plasticity formulation implemented. By incorporating pressure dependent yielding using a crushable foam plasticity formulation to simulate the trabecular bone during implantation, highly localised stress concentrations and plastic deformation are computed at the bone-implant interface. If the pressure dependent yield is neglected using a traditional von Mises plasticity formulation, a significantly different stress distribution and implantation force is computed in the peri-prosthetic trabecular bone. The results of the study highlight the importance of: (i) simulating the insertion process of press-fit stem implantation; (ii) implementing a pressure dependent plasticity formulation, such as the crushable foam plasticity formulation, for the trabecular bone; (iii) incorporating friction at the implant-bone interface during stem insertion. Simulation of the press-fit implantation process with an appropriate pressure dependent plasticity formulation should be implemented in the design and assessment of arthroplasty prostheses. peer-reviewed

The optimum cementing technique for the tibial component in cemented primary total knee replacement (TKR) remains controversial. The technique of cementing, the volume of cement and the penetration are largely dependent on the operator, and hence large variations can occur. Clinical, experimental and computational studies have been performed, with conflicting results. Early implant migration is an indication of loosening. Aseptic loosening is the most common cause of failure in primary TKR and is the product of several factors. Sufficient penetration of cement has been shown to increase implant stability.This review discusses the relevant literature regarding all aspects of the cementing of the tibial component at primary TKR.Cite this article: Bone Joint J 2013;95-B:295–300.

Background Standard positioning for percutaneous balloon kyphoplasty requires placing a patient prone with supports under the iliac crests and upper thorax. The authors believe that hip hyperextension maximises pelvic anteversion creating anterior longitudinal ligamentotaxis, thus facilitating restoration of vertebral height. Methods Radiographic imaging including pre-operative, post-positioning, post balloon tamp inflation and post-operative lateral radiographs were analysed for anterior and posterior column height, wedge angle of the affected vertebra and 3-level Cobb angle in patients with recent fractures of T11-L1. Fracture dimensions of the index vertebra were expressed as percentage of the analogous dimension of the referent vertebra. Results From a total of 149 patients, a full imaging sequence was available on 21 cases of vertebral compression fractures. The described positioning technique created a mean anterior column height increase from 68.3% to 75.3% with positioning (p = 0.15), increasing to 82.3% post balloon inflation. Average Cobb and wedge angle improvement of 4.7 degrees (p= 0.004) and 3.6 degrees (p= 0.002) from positioning along were also recorded. Conclusion The Reverse Thomas Position is a safe and effective technique for augmenting thoracolumbar fracture height restoration in percutaneous balloon kyphoplasty.

Introduction L’Echelle d’Evaluation Numerique (EEN) lombaire et radiculaire est effectuee en routine clinique. L’evolution des symptomes, notamment apres une chirurgie de deformation rachidienne, peut rendre difficile l’interpretation des resultats cliniques et de l’impact reel d’une chirurgie rachidienne. L’objectif de cette etude est d’evaluer l’EEN global correspondant a la somme de l’EEN lombaire et radiculaire. L’hypothese est que ce parametre simple est correle aux scores de qualites de vie et aux parametres radiologiques sagittaux. Materiel et methodes Il s’agit d’une etude retrospective de patient inclus de maniere prospective et consecutive. Au total, 1526 patients suivi pour une deformation rachidienne de l’adulte ont ete inclus. Au moment de l’inclusion, les patients ont ete stratifies en 3 categories de douleur pour l’EEN lombaire et radiculaire (douleur legere : 0–4, douleur moderee : 5–7, douleur severe : 8–10) et en 4 categories pour l’EEN global (douleur tres legere : 0–5, douleur legere : 11–15, douleur moderee : 11–15, douleur severe : 16–20). Une regression lineaire a ete realisee pour evaluer la correlation entre la douleur, les parametres radiologiques sagittaux (Global Tilt, VP, SVA) et les scores de qualite de vie (SRS-22, SF-36, COMI, ODI). Resultats L’EEN globale est plus correlee que l’EEN lombaire ou radiculaire aux parametres radiologiques et aux scores de qualite de vie. (Pearson 0,6 vs. 0,56 ou 0,46, 0,3 vs. 0,23 or 0,27 respectivement). L’EEN lombaire est plus correlee avec les scores de qualite de vie alors que l’EEN radiculaire est plus correle avec les parametres radiologiques sagittaux. Pour une valeur d’EEN Discussion L’EEN globale est plus correlee aux scores de qualites de vie et aux parametres radiologiques sagittaux que l’EEN lombaire ou que l’EEN radiculaire. Il est interessant de noter que les douleurs au niveau des membres inferieurs sont quasi nulles pour un score EEN global Conclusion L’EEN globale est un parametre interessant pour evaluer l’intensite des douleurs chez des patients atteints de deformations rachidiennes.

Cementless hemiarthroplasty in hip fracture surgery has been associated with poorer outcomes and more pain than cemented hemiarthroplasty. The aim was to investigate clinical and radiographic outcomes for a cementless tapered titanium fully hydroyxapatite-coated (Corail® System) stem in this consecutive cohort of hip fracture patients. We retrospectively evaluated the results of 68 consecutive elderly patients with displaced intracapsular hip fractures, treated with this implant. Mean clinical follow-up was 4.3 years (2–6 years). One-year mortality was 24%. 95% of patients had no/occasional/mild mid-thigh pain, with moderate pain in 5%. 39% achieved independent or walking-stick mobility. 36 patients had follow-up radiography. Osseointegration was noted in 34, with a mixed bony/fibrous in-growth in 2. One patient had revision for subsidence of an undersized implant, with no conversions to total hip arthroplasty. The Corail® stem can be used effectively for the treatment of femoral neck fractures in the elderly.