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In 2017, the GAP score was proposed as a tool to reduce mechanical complications (MC) in adult spinal deformity (ASD) surgery: the reported MC rate for the GAP proportioned category was only 6%, which is clearly lower to the MC rate reported in the literature. The aim of this study is to analyse if the most recent literature confirms the promising results of the original article.Using the PRISMA flow chart, we reviewed the literature to analyse GAP score capacity in predicting MC occurrence. We included articles clearly reporting ASD surgery MC stratified by GAP categories and the score's overall capacity to predict MC using the area under the curve (AUC). The quality of the included studies was evaluated using GRADE and MINORS systems.Eleven retrospective articles (1,517 patients in total) were included. The MC distribution per GAP category was as follows: GAP-P, 32.8%; GAP-MD, 42.3%; GAP-SD, 55.4%. No statistically significant difference was observed between the different categories using the Kruskal-Wallis test (p = 0.08) and the two-by-two Pearson-Chi square test (P Vs MD, p = 0.300; P Vs SD, p = 0.275; MD Vs SD, p = 0.137). The global AUC was 0.68 ± 0.2 (moderate accuracy). The included studies were of poor quality according to the GRADE system and had a high risk of bias based on the MINORS criteria.The actual literature does not corroborate the excellent results reported by the original GAP score article. Further prospective studies, possibly stratified by type of MC and type of surgery, are necessary to validate this score.

To evaluate the feasibility and safety of percutaneous transpedicular fixation by PEEK polymer implants and cementoplasty for vertebral compression fracture (VCF). From February 2019 to December 2019, 6 consecutive patients (3 men and 3 women; mean age 55 ± 8 years; range 40–64 years) who had percutaneous transpedicular fixation with cementoplasty for the treatment of VCF (5 tumor lesions, 1 traumatic) were included. The procedure duration, length of hospital stay, and complications were reported. Visual analog scale (VAS) and the Oswestry disability index (ODI) for pain and disability were assessed before and 2 months after the procedure. The mean procedure duration was 74 ± 47 min (range 20–140 min). The median length of hospital stay was 3 days (range 2–63) after the procedure. Only minor adverse events were reported (4 asymptomatic cement leakages) but no severe complications. No cases of procedural site fracture during follow-up were noted (median 198 days; range 78–238 days). The mean VAS score decreased from 6.2 ± 1.8 mm (median 6 mm; range 4–9 mm) before the procedure to 1.7 ± 2.1 mm (median 1; range 0–5 mm) after the procedure. The ODI decreased from 36 ± 14% (range 18–54%) before the procedure to 23 ± 10% (range 11–30%) at 2-months follow-up. Percutaneous transpedicular fixation of VCF by PEEK implants with cementoplasty appears feasible and safe.

Purpose The purpose of this study was to identify sagittal spinopelvic parameters predictive of adjacent segment disease (ASD) on postoperative whole spine weight-bearing stereoradiography. Materials and methods A total of 84 patients with previous spinal fusion surgery and documented radiological follow-up with early weight-bearing postoperative whole spine stereoradiography (EOS® Imaging System) were retrospectively included. A pathological group of 42 patients (9 men, 33 women; mean age, 63.1 ± 11.5 [SD] years) who developed documented ASD (mean follow-up, 76.75 months; range: 31.5–158.5 months) was compared with a control group of 42 asymptomatic patients (7 men, 35 women; mean age, 60.9 ± 11.8 [SD] years) (mean follow-up, 115 months; range: 60–197 months) based on sagittal balance evaluation and routinely used spino-pelvic parameters. Comparisons were made using uni- and multivariate analyses. Results At univariate analysis, patients with ASD had an anteriorly displaced sagittal vertical axis (CAM plumb line) and an inadequate lumbar lordosis (LL) in reference to pelvic incidence (PI) compared to controls. They also had higher C7 slope and C2-C7 offset. At multivariate analysis, C2-C7 offset (OR = 1.152; 95% CI: 1.056–1.256; P = 0.001) and a lack of LL (OR = 5.063; 95% CI: 1.139–22.498; P = 0.033) were significantly associated with ASD. Conclusion Anterior cervical imbalance, reflected by an increase in C2-C7 offset and insufficient restoration of LL are postoperative predictive factors of ASD on stereoradiography.

To make a literature review on spinal stenosis recurrence after a first surgery and edit rules to avoid this complication. We conducted two separate PUBMED searches to evaluate the revision post-stenosis and degenerative scoliosis surgery using the terms: lumbar vertebrae/surgery, spinal stenosis, spine, scoliosis and reoperation. The resulting papers were categorized into three groups: (1) those that evaluated reoperation post-simple decompression; (2) those that evaluated spinal decompression and fusion for short (3 levels or less) or long (more than 3 levels) segment spinal fusion; and (3) those diagnosing the stenosis during the surgery. (1) We found 11 relevant papers that only looked at revision spine surgery post-laminectomy for spinal stenosis. (2) We found 20 papers looked at reoperation post-laminectomy and fusion amongst which there were two papers specifically comparing long-segment (> 3 level) and short-segment (3 or less levels) fusions. (3) In the unspecified group, we found only one article. Fifteen articles were excluded as they were not specifically looking at our objective criteria for revision surgery. In regard to revision post-adult deformity surgery, we found 18 relevant articles. After this literature review and analysis of post-operative stenosis, it seems important to provide some advice to avoid revision surgeries more or less induced by the surgery. It looks interesting when performing simple decompression without fusion in the lumbar spine to analyse the risk of instability induced by the decompression and facet resection but also by a global balance analysis. Regarding pre-operative stenosis in a previously operated area, different causes may be evocated, like screw or cage malpositionning but also insufficient decompression which is a common cause. Intraoperatively, the use of neuromonitoring and intraoperative CT scan with navigation are useful tool in complex cases to avoid persisting stenosis. Pre-op analysis and planning are key parameters to decrease post-op problems. These slides can be retrieved under Electronic Supplementary Material.

The static sagittal balance of the normal spine is a physiological alignment of the spine in the most efficient manner by the muscular forces. During gait, this balance is constantly thwarted by single-foot support. This analysis involves the study of parameters which are now well defined. The pelvic incidence is constant, and the sacral slope and the pelvic tilt are positional. The cervical parameters are the upper (O-C2) and lower cervical curvatures (C2-C7), the C7 slope, the spino-cranial angle and the vertical cervical offset. At the thoracic and lumbar level, they are, respectively, kyphosis and lordosis. The OD-HA (odontoid hip axis) angle is the most efficient parameter to analyse the global balance. The average values of these parameters are reported with the new 3D measurements by Le Huec et al. The relationship between these different parameters was analysed, and Roussouly proposed his classification of the different spine shape. Ageing makes it possible to show compensation mechanisms at three levels: spinal, pelvic and lower limbs. Understanding these different data allows for better planning of the surgical management of the patients. Global evaluation of the entire spine and the measurement of the aforementioned parameters allow to determine the extent of the correction to be performed during surgery. Taking these parameters into account also enables us to understand the complications involved in this type of surgery: transitional syndromes or junctional syndromes. Integration of these parameters into the study of gait is an area still under investigation. These slides can be retrieved under Electronic Supplementary Material .

To evaluate the feasibility and safety of percutaneous transpedicular fixation by PEEK polymer implants and cementoplasty for vertebral compression fracture (VCF).From February 2019 to December 2019, 6 consecutive patients (3 men and 3 women; mean age 55 ± 8 years; range 40-64 years) who had percutaneous transpedicular fixation with cementoplasty for the treatment of VCF (5 tumor lesions, 1 traumatic) were included. The procedure duration, length of hospital stay, and complications were reported. Visual analog scale (VAS) and the Oswestry disability index (ODI) for pain and disability were assessed before and 2 months after the procedure.The mean procedure duration was 74 ± 47 min (range 20-140 min). The median length of hospital stay was 3 days (range 2-63) after the procedure. Only minor adverse events were reported (4 asymptomatic cement leakages) but no severe complications. No cases of procedural site fracture during follow-up were noted (median 198 days; range 78-238 days). The mean VAS score decreased from 6.2 ± 1.8 mm (median 6 mm; range 4-9 mm) before the procedure to 1.7 ± 2.1 mm (median 1; range 0-5 mm) after the procedure. The ODI decreased from 36 ± 14% (range 18-54%) before the procedure to 23 ± 10% (range 11-30%) at 2-months follow-up.Percutaneous transpedicular fixation of VCF by PEEK implants with cementoplasty appears feasible and safe.

El equilibrio sagital de la columna vertebral es una situacion en la que las fuerzas involucradas son iguales. Durante la marcha, este equilibrio se ve contrarrestado de forma permanente por el apoyo unipodal. La comprension de este equilibrio requiere el analisis de fenomenos de compensacion mas o menos economicos que definen el equilibrio raquideo. El analisis del equilibrio sagital raquideo pasa por el estudio de parametros ahora bien definidos. Al nivel de la pelvis se encuentran la incidencia pelvica, la pendiente sacra y la version pelvica. Los parametros cervicales son la lordosis cervical alta y baja, la pendiente de C7, el angulo espinocraneal y el desplazamiento cervical vertical. Al nivel toracico y lumbar se trata sucesivamente de cifosis y lordosis. Es necesario referir los valores promedio de los parametros y analizar la relacion entre los diversos parametros. El estudio de los cambios en la columna vertebral durante el envejecimiento permite mostrar los mecanismos de compensacion en tres niveles: raquideo, pelvico y en los miembros inferiores. La comprension de estos datos permite planificar mejor el tratamiento quirurgico de los pacientes. Implica realizar pruebas de imagen de toda la columna vertebral y medir los parametros mencionados anteriormente para utilizar, por ejemplo, la tecnica conocida como «indice de equilibrio completo» o «integracion completa del equilibrio» (full balance index o full balance integrated [FBI]), que permite determinar, mediante la integracion de todos estos parametros, la importancia de la correccion que se realizara durante la cirugia. Tener en cuenta estos parametros tambien permite comprender las complicaciones de este tipo de cirugia: sindromes adyacentes o sindromes de la union. Tambien es posible integrar estos parametros en el estudio de la marcha, un campo en proceso de validacion.

La espondilolistesis se caracteriza por el deslizamiento de una vertebra respecto a otra situada por debajo. Puede tener un origen displasico o degenerativo y provocar dolor lumbar y/o radicular invalidante. Si fracasa el tratamiento conservador, se puede proponer un tratamiento quirurgico. Existen distintas tecnicas, que se deben dominar. La artrodesis circunferencial con instrumentacion es el tratamiento de eleccion. El analisis del equilibrio sagital es indispensable y forma parte integrante del tratamiento. Si existe un desequilibrio sagital, se debe realizar una reduccion de la cifosis lumbosacra.

An innovative low-dose X-ray biplanar imager (EOS®) allows measurement of the whole-body in standing-position which is necessary for the evaluation of spinal deformities. A total of 60 asymptomatic subjects (ages 20–81 years) were evaluated using the 3D workflow called postural assessment and 2D measures. Subjects were measured twice each by two new observers following training, including: lordosis/kyphosis, pelvic parameters, sagittal-vertical axis, and spinal-sacral angle. Intra- and inter-observer reproducibility and similarity were compared between 2D and 3D measures. The intraclass correlation coefficient (ICC) was very high for the 3D measures (>0.9) and excellent for the 2D measures (>0.75). In all cases, the overall mean absolute difference between repeated 3D measures was less than 2°, or 2 mm. For all parameters, the inter- and intra-observer reproducibility in 3D measures were significantly superior to 2D measures (p < 0.03). This study demonstrated that 3D measures have better reproducibility than 2D for sagittal balance. • Reproducibility of sagittal balance 2D/3D measurements was evaluated using EOS® full-body radiographs. • Inter- and intra-observer reproducibility were significantly superior for 3D measures vs. 2D. • 3D measures have better reproducibility than 2D for sagittal balance.

La columna vertebral toracica y la charnela cervicotoracica pueden definirse como el sector que se extiende del disco C7-T1 a T12. El conjunto de estas zonas puede verse afectado por toda la patologia vertebral: tumores, traumatismos, patologia degenerativa, deformaciones e infecciones. El tratamiento quirurgico puede estar indicado para estas distintas patologias utilizando diversas vias de acceso, que se distinguen segun su localizacion y los medios necesarios para llevarlas a cabo. En lo que respecta a la localizacion, el acceso puede ser: posterior y posterolateral en toda la region, anterolateral de T4 a T12 o anterior de C7 a T4. En lo referente a los medios, el acceso puede ser a cielo abierto o videoasistido. El conocimiento de la anatomia es una de las claves de la realizacion de estas diversas vias, lo que justifica dedicarle una resena.

Las formas de espondilolistesis que se observan con mayor frecuencia en el adulto son la forma degenerativa y la forma por lisis istmica. La espondilolistesis degenerativa se debe a la degeneracion discal, que se acompana de una perdida de altura del disco y que produce una cascada de consecuencias. La primera consecuencia es una alteracion del juego articular de las facetas cigapofisarias posteriores, que genera lesiones artrosicas mas o menos simetricas. La hipertrofia articular rechaza las facetas entre si y favorece el deslizamiento anterior (listesis) de la vertebra superior. Otros fenomenos pueden modificar este deslizamiento. Por lo tanto, es primordial comprender que la espondilolistesis es un trastorno generador de cifosis de la columna vertebral lumbosacra. El tratamiento quirurgico, cuando es necesario, debe pretender prioritariamente restablecer la lordosis lumbar y lumbosacra, y no solo reducir el deslizamiento en si mismo. Para alcanzar este objetivo, es indispensable analizar los parametros espinopelvicos que rigen el equilibrio sagital de la columna vertebral. El abanico del tratamiento quirurgico va de la fusion espinal in situ a tecnicas de reduccion de la lordosis lumbosacra mas importantes. Cada tecnica tiene indicaciones muy especificas, que se detallan en este articulo. La mayoria de las tecnicas quirurgicas que los autores de este articulo recomiendan se realizan mediante un abordaje posterior, que permite controlar mejor la reduccion de la lordosis lumbosacra. Mucho mas raramente, se opta por una via anterior.

La espondilolistesis por lisis istmica es una patologia que hay que diferenciar de la etiologia degenerativa. La espondilolistesis por lisis istmica apareceria durante la verticalizacion de la marcha y esta presente en el nino y en el adulto. Su tratamiento es complejo y requiere un estudio completo para identificar los diferentes tipos de equilibrio sagital. La estrategia terapeutica debe integrar diversos factores clinicos asi como radiologicos. Las soluciones terapeuticas pueden ser multiples, conservadoras o quirurgicas. La reduccion de la espondilolistesis no es siempre necesaria, aunque el elemento esencial es respetar un equilibrio sagital economico.

The treatment of low back pain associated to Disc Degenerative Disease (DDD) is still controversial. Segmental Fusion is the gold standard, but many studies have reported that motion-preserving devices bring substantial clinical benefits to patients. Concerns on the associated complications and on the long-term clinical effectiveness of such instrumentations are still present and have led recently to a decrease of the number of Lumbar Total Disk Replacements (TDR). The objective of this prospective study is to present the clinical and radiographic outcomes of the Maverick Lumbar disk prostheses (Medtronic, TE, Memphis, USA) at long-term follow-up. Prospective, single center study of clinical outcome of the treatment with Maverick lumbar Prosthesis of patients with low back pain from DDD resistant to conservative treatment. Patients were examined preoperatively and at 3 months, 2 and 10 years post-operatively. Patients were examined preoperatively and at 3 months, 2 and 10 years post-operatively. Visual analog scale (VAS), Oswestry disability index (ODI) and 36-Item Short Form Health Survey questionnaire were assessed to study clinical outcomes. Radiographic studies allowed measurements of range of motion, adjacent segment disease and pelvic and lumbar parameters. From an initial cohort of 87 patients who underwent TDR between 2003 and 2007 with the Maverick prosthesis, 61 were available at Final follow-up (70%). The clinical outcomes measured by VAS and ODI showed a significant improvement in all the postoperative stages of the follow-up (FU). At 10 years-FU, ODI experienced a mean decrease of 21.1 points, VAS for back pain decreased up to 3.85 and substantial clinical benefit was reached for 55.6% of the patients. Although Mobility of the prosthesis was preserved in 76.8% of the cases, TDR was not clearly protective against ALD. A significant, clinically relevant, and lasting reduction of back pain has been achieved in patients who underwent a total disk arthroplasty or a Hybrid construct with Maverik prosthesis. TDR is a safe and effective technique to decrease pain in patients with one or two levels of DDD.

Resume Introduction L’orientation tridimensionnelle (3D) de l’acetabulum natif est un sujet fondamental en chirurgie orthopedique. La tomodensitometrie (TDM) permet la realisation de mesures 3D de cette orientation acetabulaire, mais avec un surcroit d’irradiation non negligeable. En utilisant la stereoradiographie basse dose EOS, les objectifs de cette etude etait (1) de valider la reproductibilite du systeme de reconstruction sterEOS 3D pour l’acetabulum natif, (2)de donner les valeurs normales de l’orientation de l’acetabulum natif, en fonction du sexe ou du cote, (3) et de rechercher une relation entre l’anteversion acetabulaire et l’incidence pelvienne. Materiels et methodes Cent soixante-cinq patients asymptomatiques ont realise un EOS corps entier (face + profil) pour une etude prospective sur l’equilibre sagittal rachidien. Dans cette population, 102 patients avaient des images permettant l’analyse du bassin et de l’acetabulum, avec une distribution homme-femme equilibree. Les images EOS ont ete reconstruites en 3D grâce au logiciel SterEOS 3D, permettant des mesures 3D automatiques des parametres acetabulaires (anteversion et inclinaison) et des parametres pelviens (incidence pelvienne, version pelvienne et pente sacree) dans deux referentiels : le plan pelvien anterieur (PPA) qui constitue un referentiel anatomique, et le plan vertical patient qui constitue un referentiel « fonctionnel ». Resultats Les reproductibilites intra-observateur et inter-observateurs etaient bonnes avec un coefficient de correlation intra-classe superieur a 0,9 et les intervalles de Bland et Altman etaient compris dans les limites de concordances. L’Anteversion et l’Inclinaison Acetabulaires Anatomiques (AAA et IAA) etaient significativement plus elevees chez la femme que chez l’homme, mais sans difference droite/gauche (AAA droite : femme 21,3 ± 3,4° versus homme 16,1 ± 3,3° (p 62°). Conclusion–discussion Le logiciel SterEOS 3D avec module pour acetabulum natif etait un outil fiable et reproductible. Cette methode innovante a permis d’obtenir pour la premiere fois des valeurs de reference de l’orientation acetabulaire 3D en position debout dans une population asymptomatique. Nos resultats ont renforce le concept des relations hanche/rachis, grâce a une technique d’imagerie a basse irradiation. Niveau de preuve IV Etude cas temoin.

BackgroundStaphylococcus aureus surgical-site infections (SSIs) are a major cause of poor health outcomes, including mortality, across surgical specialties. Despite current advances as a result of preventive interventions, the disease burden of S. aureus SSI remains high, and increasing antibiotic resistance continues to be a concern. Prophylactic S. aureus vaccines may represent an opportunity to prevent SSI.MethodsA review of SSI pathophysiology was undertaken in the context of evaluating new approaches to developing a prophylactic vaccine to prevent S. aureus SSI.ResultsA prophylactic vaccine ideally would provide protective immunity at the time of the surgical incision to prevent initiation and progression of infection. Although the pathogenicity of S. aureus is attributed to many virulence factors, previous attempts to develop S. aureus vaccines targeted only a single virulence mechanism. The field has now moved towards multiple-antigen vaccine strategies, and promising results have been observed in early-phase clinical studies that supported the recent initiation of an efficacy trial to prevent SSI.ConclusionThere is an unmet medical need for novel S. aureus SSI prevention measures. Advances in understanding of S. aureus SSI pathophysiology could lead to the development of effective and safe prophylactic multiple-antigen vaccines to prevent S. aureus SSI.

Recruitment in preventive vaccine trials (PVT) is challenging due to common barriers to clinical research and lack of vaccine confidence. Identifying determinants of participation can help to improve recruitment. A prospective survey was conducted in 5 French clinical investigational sites. People asked to participate in a PVT were given a questionnaire whether they decided to participate or not in the trial. A total of 341 people answered the survey: 210 accepting and 131 declining to participate in a PVT. Acceptors were significantly younger (38.5 vs 54.9 years old), more likely to be involved in early phase trials, had a higher level of education (p 0.005) and a significantly better general opinion concerning vaccines (92.3% versus 72.3%, p 0.005) compared with those who declined. Factors associated with acceptance or refusal were evaluated in 224 people in the 4 sites where both groups were included. In a multivariate analysis, three factors: older age, having heard about PVT through multiple sources and financial incentives were significantly associated with refusal to participate in the PVT. A generally favourable opinion of vaccines was associated with acceptance. The main motivation for participation was altruism (93.2%) whereas fear of side effects was at the forefront of the barriers (36.6%). Information given by the physician was a key point for decision-making in 70.2% of those who accepted. In brief, vaccine hesitancy may decrease recruitment in PVTs; reinforcing altruism and quality of information given are key points in acceptance of participation in PVT.

Normal spino-pelvic values for patients with lumbarization of S1 have not been described in the literature. Presented are the normal values for this population group, the prevalence of S1 lumbarization, and the correlation between pelvic incidence (PI) and lumbar lordosis (LL) in this group. Two databases of asymptomatic patients were combined to identify 11 patients with the lumbarization of S1. The whole spine images were used to measure the true prevalence rate. Lumbar 3D EOS models were built to measure spino-pelvic parameters for the lumbarization group compared to the asymptomatic population. Seven patients appeared at first to have six lumbar vertebrae, but counting caudally from C2 showed this was not the case. 11/268 patients demonstrated the lumbarization of S1 to give a true prevalence rate of 4.1 %. The lumbarization group demonstrated a statistically significant difference with regard to PI, PT, and SS, and total lordosis measured from superior endplate of L1 to the superior endplate of the first fixed sacral segment. L6I was not significantly correlated to lordosis; however, PI did have a significant correlation with lordosis. Lordosis could be estimated in this group by the equation: $$ {\text{LL }} = 1.16 \times {\text{PI}} - 19.39 $$ . Incomplete imaging of the spine may lead to false estimation of the prevalence of lumbarization. Patients with lumbarization have higher lordosis values and lordosis can now be estimated during pre-operative planning for this group.

La charnela toracolumbar es una region compleja de transicion tanto morfologica como dinamica. Permite el paso de la columna vertebral toracica a la columna vertebral lumbar, pero tambien de la cavidad toracica a la cavidad abdominal. Desempena varias funciones: proteger el sistema nervioso, pero tambien permitir el paso de elementos anatomicos importantes, como los vasos (aorta y vena cava), el tubo digestivo, el sistema vegetativo, etcetera. Las dos cavidades estan separadas por el diafragma, que se comporta como una autentica barrera anatomica. Se trata de un musculo en forma de cupula, con inserciones perifericas en las costillas y el esternon, asi como inserciones vertebrales de T11 a L3. El acceso quirurgico de la charnela toracolumbar requiere unos conocimientos anatomicos precisos de estas inserciones, pero tambien de las relaciones con los elementos anatomicos principales. Es frecuente realizar una desinsercion, que debe dominarse para minimizar los riesgos quirurgicos. Las vias de acceso anterolaterales permiten realizar procedimientos de descompresion y de estabilizacion de la columna que no son posibles con la via posterior. Por tanto, la primera parte de este articulo se dedica a una resena anatomica precisa de las inserciones y de las relaciones de los distintos elementos presentes. En la segunda parte, se presentan las distintas vias, con una descripcion inicial de las vias clasicas seguida por la de las vias minimamente invasivas. La evolucion de las tecnicas y la utilizacion de endoscopios han permitido la reduccion de las incisiones y el desarrollo de accesos poco agresivos que permiten una recuperacion precoz de los pacientes.

Degenerative de novo scoliosis is commonly present in older adult patients. The degenerative process including disc bulging, facet arthritis, and ligamentum flavum hypertrophy contributes to the appearance of symptoms of spinal stenosis. Idiopathic scoliosis has also degenerative changes that can lead to spinal stenosis. The aetiology, prevalence, biomechanics, classification, symptomatology, and treatment of idiopathic and degenerative lumbar scoliosis in association with spinal stenosis are reviewed. Review study is based on a review of pertinent but non-exhaustive literature of the last 20 years in PubMed in English language. Retrospective analysis of studies focused on all parameters concerning scoliosis associated with stenosis. Very few publications have focused specifically on idiopathic scoliosis and stenosis, and this was before the advent of modern segmental instrumentation. On the other hand, many papers were found for degenerative scoliosis and stenosis with treatment methods based on aetiology of spinal canal stenosis and analysis of global sagittal and frontal parameters. Satisfactory clinical results after operative treatment range from 83 to 96 % but with increased percentage of complications. Recent literature analysed the importance of stabilizing or not the spine after decompression in such situation knowing the increasing risk of instability after facet resection. No prospective randomized studies were found to support short instrumentation. Long instrumentation and fusion to prevent distabilization after decompression were always associated with higher complication rates. Imbalance patients with unsatisfactory compensation capacities were at risk of complications. Operative treatment using newly proposed classification system of lumbar scoliosis with associated canal stenosis is useful. Sagittal balance and rotatory dislocation are the main parameters to analyse to determine the length of fusion.

Pedicle subtraction osteotomy (PSO) is one of the surgical options for treating alignment disorders of the fused spine (due to post-surgical fusion or related to arthritis). It enables satisfactory sagittal realignment and improved function due to economic sagittal balance. The aim of this study was to analyze clinical and radiological results of PSO after a minimum follow-up of 2 years and demonstrate the benefit of sub-group analysis as a function of pelvic incidence (PI).A descriptive prospective single center study of 63 patients presenting with spinal global malalignment who underwent correction by PSO. Function was assessed by the Oswestry disability index (ODI), a visual analog scale of lumbar pain (VAS) and a SF-36 questionnaire. Radiographic analyses of pre- and post-operative pelvic-spinal parameters were performed on X-rays obtained by EOS(®) imaging after 3D modeling. Global analysis and analysis of sub-groups as a function of pelvic incidence were performed and the full balance integrated index (FBI) was calculated.this series showed a marked clinical improvement and significant progress of functional scores. Global post-operative radiological analysis showed a significant improvement in all pelvic and spinal parameters. The mean correction obtained after PSO was 31.7° ± 8.4°, hence global improvement of lumbar lordosis of 22°. The sagittal vertical angle (SVA) decreased from +9 cm before surgery to +4.3 cm after surgery. Sub-group analysis demonstrated greater improvement in pelvic tilt, sacral slope and spinal parameters of patients with a small or moderate pelvic incidence; all had an FBI index 10°. Most of the pelvic and spinal parameters of patients with a large pelvic incidence were insufficiently corrected and they had an FBI index 10°PSO is a surgical procedure enabling correction of multiplane rigid spinal deformities that require major sagittal correction. It was seen to be highly effective in patients with a small or moderate pelvic incidence (PI 60°) but was sometimes less effective in patients with large pelvic incidence due to insufficient lordosis correction. Clinical results were highly correlated with the value of the FBI index.

Pedicle subtraction osteotomies (PSO) enable correction of spinal deformities but remain difficult and are associated with high complication rates. This study aimed to prospectively review different post-operative complications and mechanical problems in patients who underwent PSO as treatment for sagittal imbalance as sequelae of degenerative disc disease or previous spinal fusion. This was a descriptive prospective single center study of 63 patients who underwent sagittal imbalance correction by PSO. Radiographic analysis of pre- and post-operative pelvic and spinal parameters was completed based on EOS images following 3D modeling. Global and sub-group analyses were completed based on the Roussouly classification. A systematic analysis of post-operative complications was conducted during hospital stay and at follow-up visits. Complications included 15 cases (20.2 %) of bilateral leg pain, with transient neurological deficit in 6 cases (9.5 %), and 9 cases (12.5 %) of early surgical site infections. Intra-operative complications included five tears of the dura mater and two cases of excessive blood loss (>5,000 mL). Two mortalities occurred from major intracerebral bleeds in the early post-operative period. Mechanical complications were principally non-union (9 cases) and junctional kyphosis (3 cases). All 19 post-operative complications (28.1 %) were revised at an average of 2 years following surgery. All mechanical complications were found in the patients who had insufficient imbalance correction and this was mainly associated with high PI (>60°) or a moderate PI (45–60o) combined with excess FBI pre-operatively that remained >10° post-operatively. Infection and neurologic complications following PSO are relatively common, and frequently reported in the literature. The principal cause of mechanical complications, such as non-union or junctional kyphosis, was insufficient sagittal correction, characterized by post-operative FBI >10°. The risks of insufficient correction are greater in patients with higher pelvic incidence and those patients who required very high correction.

To define reference parameters for analyzing sagittal balance of the cervical spine in asymptomatic volunteers. Prospective study after Bioethics Committee approval. Imaging performed using a low-dose radiographic system (EOS Imaging, Paris, France). The absence of pain was assessed using the Oswestry Questionnaire and VAS. 106 subjects were included of whom 55.66 % were men. The parameters measured were: pelvic incidence, pelvic tilt, sacral slope, thoracic and lumbar curvature, C7 plumb line position and the spino-sacral angle. The C7 slope and new parameters were measured: cranial incidence, defined in relation to the McGregor line and the sella turcica allowing to define cranial slope and tilt, and the spino-cranial angle (SCA). This study demonstrated a close correlation between the C7 slope and the cranio-cervical system. Economic sagittal balance in the asymptomatic population was defined by a constant SCA angle of 83° ± 9°. To maintain this balance, a spine with a marked C7 slope will present lordosis and vice versa. Cranial incidence is an anatomical parameter characteristic of the cranio-cervical system which makes it possible to analyze the spatial positioning of the head and to predict the desired value of cervical lordosis which is closely correlated to cranial slope. The C7 slope has a predictive value of the shape of the cervical spine in the sagittal plane. One-third of the asymptomatic population had cervical kyphosis. Our results could be used to study sagittal balance before and after arthrodesis, or cervical prosthesis.

Gorham-Stout syndrome is an aggressive, non-heritable skeletal disease characterized by osteolysis following minor trauma. The primary involvement of the spine is less common (10 %) and has been described in only about 20 cases; there is no consensus about the best way to treat this condition.To report a case of Gorham-Stout syndrome involving the thoracic spine and to review the literature to suggest a post-operative treatment to prevent osteolysis.A thirty-year-old female patient was admitted to the unit in March 2013 for a pathologic T4 fracture. X-rays and CT scan revealed the onset of T4 osteolysis and an increase in thoracic kyphosis (the local kyphosis was up to 100°). We performed surgery by posterior approach, combining posterior fixation with screws and rods from T3 to T9, decompression and vertebral osteotomy of 65°. The immediate outcome of surgery was good and the patient returned home after 24 days. At 6 and 12 months of follow-up, the patient was walking normally with no neurological sequelae.We report a case of Gorham-Stout syndrome involving the thoracic spine that was successfully treated by interpedicular osteotomy associated with a 6 month follow-up. We suggest that this strategy can provide good results, because after fusion, the disease process remains stable. Because of the lack of cases reported, surgeons must be careful when using multiple treatments, because these treatments have many side effects.Level IV case report.

The Fig. 20 is not from the study by Shiba et al., but is a courtesy from Dr. Stephane Armand, Laboratory of Kinesiology, Geneva University Hospitals, Geneva, Switzerland.

La escoliosis idiopatica (o primaria) aparece en la infancia y continua su evolucion en la edad adulta, no solo en el aspecto angular sino, ademas, con la aparicion de rigidez y de lesiones degenerativas, sobre todo en las zonas de transicion. El envejecimiento muscular, oseo y neurologico contribuye a agravar la deformacion en los planos del espacio. El equilibrio sagital es un factor fundamental para la comprension de los sindromes raquideos dolorosos y las indicaciones quirurgicas. Desde un punto de vista clinico, las raquialgias y el perjuicio estetico son las quejas mas corrientes de los pacientes. Tambien se observan trastornos neurologicos (radiculalgias, etc.), sobre todo en caso de lesion degenerativa y de luxacion rotatoria. En el adulto, las complicaciones respiratorias derivadas de las grandes deformaciones toracicas son cada vez mas infrecuentes debido a la deteccion y al tratamiento precoz durante el crecimiento. Las radiografias digitales y los programas informaticos especificos permiten identificar las referencias anatomicas de manera muy precisa, lo que facilita el analisis optimo de los parametros raquideos y pelvicos. En el aspecto terapeutico, el tratamiento medico inespecifico y de rehabilitacion se destina a los pacientes que presentan una deformacion estable sin repercusion funcional. El objetivo de la cirugia, que en todos los casos debe estar precedida por una valoracion completa, es enderezar la curvatura o curvaturas escolioticas y obtener la fusion osea. Despues de los 70 anos, el tratamiento quirurgico puede limitarse a una liberacion neurologica localizada en caso de radiculalgias invalidantes. La posible correccion de una curvatura se basa esencialmente en la restitucion de un equilibrio sagital satisfactorio.

Three-dimensional (3D) acetabular orientation is a fundamental topic in orthopedic surgery. Computed tomography (CT) allows 3D measurement of native acetabular orientation, but with a substantial radiation dose. The EOS imaging system was developed to perform this kind of evaluation, but has not been validated in this indication with specific attention to the acetabulum. We therefore performed a prospective study using EOS to assess: (1) the reproducibility of the 3D acetabulum orientation measures; (2) normative asymptomatic acetabular morphology in standing position, according to side and gender; and (3) the relationship between acetabular anteversion and pelvic incidence.The low-dose EOS imaging system is a reproducible method for measuring 3D acetabular orientation in standing position.In a previous prospective study of spine sagittal balance, 165 asymptomatic volunteers were examined on whole-body EOS biplanar X-ray; 102 had appropriate images for pelvic and acetabular analysis, with an equal sex-ratio (53 female, 49 male). These EOS images were reviewed using sterEOS 3D software, allowing automatic measurement of acetabular parameters (anteversion and inclination) and pelvic parameters (pelvic incidence, pelvic tilt and sacral slope) in an anatomical (anterior pelvic plane: APP) and a functional reference plane (patient vertical plane: PVP).Both intra- and inter-observer analysis showed good agreement (ICC0.90); Bland-Altman plot distributions were good. Acetabular anatomical anteversion and inclination relative to APP (AAAPP and AIAPP, respectively) were significantly greater in women than in men, with no effect of side (right AAA: women 21.3°±3.4° vs. men 16.1°±3.3° (P0001); right AIAPP: women 55.3°±3.7° vs. men 52.5°±3.0° (P0001); left AAAPP: women 20.9°±3.5° vs. men 15.6°±4.0° (P0001); left AIAPP: women 54.6°±3.5° vs. men 52.7°±2.8° (P=0003)). The same differences between men and women were observed when measurements were related to PVP. Pelvic incidence subgroup (44°; 44-62°;62°) correlated significantly with functional acetabular orientation in standing position: PVP functional anteversion decreased by 5° relative to APP anteversion with incidence44°, was equal to APP with incidence 44-62°, and or was greater by 4° relative to APP with incidence62°.The use of a 3D sterEOS software prototype version for 3D reconstruction of the native acetabulum from standard EOS X-ray was shown to be a reliable and reproducible method. This innovative method enabled the reference values of 3D acetabular orientation in standing position to be measured for the first time. The results reinforced the concept of hip-spine relationships, and involved very low radiation dose.IV prospective study without control group.

Chronic low back pain is a significant public health issue. Both its direct and indirect cost represents tens of billions of US dollars. Although chronic low back pain can be the result of many factors, the predominant cause is disc degeneration. Recent studies have shown genetic involvement in up to 74% of cases. This study aimed to evaluate genetic risk factors of disc degeneration by performing a systematic analysis of association studies. The objective is to provide a guide for practice by assessing the clinical relevance of current information. We performed a meta-analysis of 3122 items collected from 6 databases. 74 articles were selected according to our inclusion criteria. 18 (24%) could be grouped into 16 meta-analyses of 16 mutations in 12 genes. The statistics of the meta-analysis were conducted through Revman 5.1 software. The items included are 10,250 cases and 14,136 controls. The GOLD range from 3.42 to 0.38. Two alleles were significantly associated with disc degeneration: IL-6 rs1800797 and MMP-9 rs17576 and one proved to be protective: IL-6 rs1800795. 13 meta-analyses did not yield significant results and methodological heterogeneity. The results highlight the lack of methodological rigor in most of the studies. The absence of international clinical and radiological classification of early disc degeneration, limits the homogeneity of studies. Understanding which populations are predisposed to this significant public health problem may change our approach to diagnostic and therapeutic methods. This work opens up enormous opportunities to provide a genetic solution and consider new diagnostic and therapeutic means to this public health problem.

Pelvic incidence angle is not always measurable due to lumbosacral transitional vertebrae (LSV). The fifth lumbar vertebra (L5) is rarely abnormal. The purpose of this study was to quantify from full-body standing X-rays, the L5 incidence angle (L5I) in a normal asymptomatic population and to correlate it with standard spino-pelvic parameters taking the sacrum (S1) as a reference. One hundred and forty seven asymptomatic volunteers were enrolled. The ethics committee approved the study protocol. Subjects underwent a low-dose full spine X-ray. 3D reconstructions were obtained and L5I was measured using the upper L5 endplate as the reference instead of the S1 endplate. A group of subjects with LSV was identified and subdivided in two subgroups. Standard spino-pelvic parameters and normative values for the L5 parameters were obtained. Statistical correlations were calculated between the standard and L5 parameters as well as L5I with L1–L5 lordosis in both subgroups. Twenty two (14.96 %) subjects with LSV were found. Ten of these had an unidentifiable S1 endplate due to a sacralisation of L5. Mean values for the L5I, L5 tilt, L5 slope and L1–L5 lordosis were, respectively, 22.43, 4.65, 17.73, and 45.51 for normal subjects (N = 137) and 32.75, 6.63, 26.38, and 55.02 for sacralisation of L5 subjects (N = 10). Mathematical relationship found: L5I = 0.7641 * PI − 17.725 (R = 0.83) and L1–L5 = 0.67 * L5I + 30.7 (R = 0.64). This prospective study is first to provide normative spino-pelvic values at the L5 level in an asymptomatic population, particularly in case of (LSV) sacralisation of L5 (N = 10) where L5I and L1–L5 lordosis appears to be 10° more important than in normal population. We propose L5I as a new spino-pelvic parameter to restore in case of L5-S1 disk disease. These normative values will help to control peri-operatively the adequate lordosis restoration, in the presence of LSV.

Due to the lack of macroporosity in current available Calcium Phosphate cement used in osteoarticular surgery, Micro and Macroporous Biphasic CaP Cement (MCPC™) was developed. The MCPC™ concept was the association of a settable and a fast resorbable matrix and a sieved fraction of microporous biphasic calcium phosphate (BCP) granules, recognized for the high osteoconductive and osteogenic properties. During the resorption of the matrix, a porous structure is created and the osteoconductive effect of the granules promotes the bone ingrowth. A goat preclinical study was realized to evaluate the efficacy of MCPC™ for C3 and C4 vertebral body filling defects during 6 months. Bone remodelling was evidenced demonstrating bone ingrowth at the expense of the cement and surrounding the residual BCP granules. Bone trabeculae were observed coming from the spongious bone to the implant site. Human vertebral body filling cases demonstrated the biocompatibility and the safety of MCPC™ for bone reconstruction. Results of this study demonstrated the importance of special combination of calcium phosphate granules in the MCPC™ to provide macroporosity and scaffolding for newly formed bone.

The main objective of all the sagittal compensating mechanisms is to allow a subject to stand and keep an erect position.The cascade of compensating mechanisms appears progressively with the increasing amount of imbalance of the spine until compensation is no longer possible. The loss of lumbar lordosis can be considered as the initiating event of sagittal imbalance. This loss of the normal lordosis pushes the C7 plumb line forward.The assessment of sagittal balance has to include to be complete: a parameter measuring the global balance of the trunk, either C7 plumb line and sacral plateau, the position of the pelvis rotation by the pelvic tilt, and a description of the position of the lower limbs. Those three parameters have been taken into account by the newly described method called full balance integrated (FBI). This evaluation is easily done on a sagittal full spine standing X-ray from C2 to the pelvis, including the first 10 cm of the femur.Three questions to answer: What is the value of the pelvis incidence? Is the patient balanced? Are there compensatory mechanisms?

The aim of this prospective study was to assess the sagittal alignment of the spine and pelvis before and after surgical treatment of isthmic spondylolisthesis with flat sacrum. At the same time, the functional outcome was analyzed and correlation examined.This study comprises analysis of 30 subjects (mean age 43 years) with isthmic spondylolisthesis and an average follow-up of 2.5 years after posterior spinal fusion. Radiological spinopelvic parameters were measured and functional evaluation was made using the Oswestry Disability Index.Significant improvement toward more normal values for PT and SS in relation to PI was observed after surgery. Pelvic incidence was unaffected by surgery. Correction of the spinosacral angle shows that the anterior tilt with anterior sagittal imbalance due to spondylolisthesis may be corrected by reduction and fusion of the slipped level. Functional outcome was satisfactory with a statistically significant difference between preoperative values and final follow-up values. The sub-group of patients with insufficient restoration of sagittal balance parameters had less good outcomes than the others.Surgical management of low- and mid-grade isthmic spondylolisthesis showed good clinical outcome with restoration of correct values for the pelvic position-dependent parameters, i.e., pelvis tilt, sacral slope, C7 plumb line position and SSA.

Total disc arthroplasty for lumbar spine is a new solution for low back pain treatment after adequate patient selection. The surgical technique starts with a morphological and anatomical analysis to eliminate surgical exposure problems. The surgical approach is retroperitoneal from the left or the right side after horizontal skin incision. Video-assistance improves vision and allows minimal invasive exposure. At level L5-S1, the exposure is performed in the vessels bifurcation (aorta and vena cava), at level L4–L5 the ligature of the lumbar ascending vein is the key point to allow appropriate retraction of the vessels. In some difficult cases the use of dedicated implants allows prosthesis insertion without extensive exposure by the use of an oblique implant. The disc preparation is crucial with a good posterior release. Insertion of the prosthesis is guided with instruments according to the type of fixation (keel or pikes). To optimise the implant positioning, navigation guidance is a useful tool as any offset of the prosthesis can induce a bad mechanical load transmission. Patient selection remains the key for good clinical outcomes.

Resume Le but de cette etude prospective etait d’evaluer les resultats cliniques et radiologiques d’une serie de patients lombalgiques operes d’une arthrodese L5-S1 par voie anterieure retroperitoneale. La greffe corticospongieuse etait placee dans une cage Union en carbone composite et la synthese effectuee a l’aide d’une plaque Pyramid anterieure triangulaire vissee (Medtronic Sofamor Danek, Memphis, Etats-Unis). Quarante patients resistant au traitement medical depuis plus de six mois ont pu beneficier de cette technique. Le suivi clinique pre- et postoperatoire a ete effectue par le score d’Oswestry et le score evaluation visuelle analogique (EVA). Tous les patients ont eu un bilan radiologique lombaire et une IRM en preoperatoire. Le suivi a ete fait par controle radiologique standard et IRM en cas de complication. Trente patients presentant une discopathie evoluee de niveau L5-S1 (primitive ou postdiscectomie) et dix patients porteurs de spondylolysthesis par lyse isthmique bilaterale de L5 (trois grade 0 et sept grade 1 de Meyerding) ont ete operes. Selon la classification de Modic, nous avions a l’IRM 23 type 1, 13 type 2 et quatre type 0. Le recul minimal a ete de 12 mois, le recul moyen de 18 mois. Le score d’Oswestry etait passe de 52 a 16 % et le score EVA de 7,82 a 1,83 au recul des 18 mois. Aucune complication peroperatoire n’a ete deploree. En postoperatoire, une stenose ureterale secondaire resolutive a ete notee Trois patients sont restes lombalgiques, cinq patients ont presente des syndromes facettaires et deux patients ont souffert de radiculalgies. Deux patients ont presente une pseudarthrose confirmee a l’IRM. Il s’agissait d’un spondylolysthesis de grade 0 chez un patient hyperactif et d’un spondylolysthesis de grade 1 discarthrosique reopere a huit mois avec un bon resultat final.

Since their discovery 40 years ago by Urist M., several studies have been done on the bone morphogenetic proteins (BMP). They belong to the superfamily of TGF β (Transforming Growth Factor) and are the only osteo-inductive growth factors known until now. They are nowadays up to 20. After the fixation of these molecules on their receptors, intracellular cell reactions occur, inducing bone formation by the activation of genes responsible for cartilaginous formation and osteogenesis. In experimental studies on animal species, BMP showed their efficiency on the recovery of bone defects, on the acceleration of fractures consolidation or spine arthrodesis fusion or on pseudarthrodesis treatment. To be efficient, BMP must be used at the proper dose and delivered locally for a sufficient period by a biocompatible and biodegradable matrix, whose tridimensional structure allows its invasion by new bone and vascular cells. According to these data, clinical trials have been conducted on the human. Only rhBMP-2 and rhBMP-7 uses are validated for definite clinical applications (vertebral fusion, tibial pseudarthrosis and open leg fracture) by the results of randomized multicentric studies. Other clinical applications have been reported in the literature but large-scale studies are still necessary to confirm their results. Even if the clinical results are sometimes spectacular, and if the use of BMP, currently reserved because of their cost, in difficult situations give rise to big hopes, many questions remain unsolved. These questions will probably be dealt with in the future: stability of the new bone formation, eventual long-term adverse effects.

This in vivo biomechanical study was undertaken to analyze the consequences for sagittal balance and lumbar spine movement in three different lumbar disc prostheses. A total of 105 patients underwent total disc replacement in three different centers. The Maverick prosthesis was used in 46 patients, the SB Charité device was used in 49 patients and the Prodisc device was utilized in 10 patients. The analysis was computer assisted, using Spineview and Matlab softwares. The intra and inter-observer reliability and measurement uncertainty was performed. The analysis of lateral X-ray films in flexion-extension allowed to measure the prosthesis positioning, the range of motion (ROM), the localization of the mean center of rotation (MCR), the vertebral translation and the disc height, for each prosthesis device. The sagittal balance was analyzed on a full spine film. The parameters studied were described by Duval-Beaupère. The results were compared to the data found in literature, and compared to 18 asymptomatic volunteers, and 61 asymptomatic subjects, concerning the sagittal balance. The prostheses allowed an improvement of the ROM of less than 2 degrees. The ROM of L5-S1 prostheses ranged from 11.6 to 15.6% of the total lumbar motion during flexion-extension. At L4-L5 level, the ROM decreased when there was an arthrodesis associated at the L5-S1 level. There was no difference of ROM between the three prostheses devices. The MCR was linked to the ROM, but did not depend on the prosthesis offcentering. The disc height improved for any prosthesis, and decreased in flexion or in extension, when the prosthesis was offcentered. An increase of translation indicated a minor increase of the ROM at L4-L5 level after Maverick or SB Charité implantation. The L5-S1 arthrodesis was linked with an increase of the pelvic tilt. The lumbar lordosis curvature increased between L4 and S1, even more when a prosthesis was placed at the L3-L4 level. Total disc arthroplasty is useful in the surgical management of discogenic spinal pathology. The three prostheses studied allowed to retorate the disc height, the ROM, without disrupting the sagittal balance, but induced modification of the lumbar curvature.

Resume L’abord anterieur mini-invasif retroperitoneal du rachis lombaire est une technique reconnue pour l’excision discale et la mise en place d’une prothese discale. La fenetre operatoire exigee est importante. L’une des complications les plus graves est la survenue d’une plaie veineuse. Nous avons analyse l’angle et la position de la bifurcation ilio-cave sur une angio-IRM preoperatoire et nous avons correle ces donnees aux constatations peroperatoires. Le but de cette etude etait de savoir si l’angio-IRM preoperatoire donne des indications quant a la difficulte peroperatoire et la strategie a adopter pour la mise en place d’une prothese. Cette etude prospective et continue a inclus 35 patients, chez qui a ete mis en place une prothese discale type Maverick®. L’âge moyen est de 46,7 ans, l’indication operatoire etait une discopathie degenerative isolee avec lombalgie chronique invaidante sans atteinte des masses musculaires ou des articulaires posterieures. Une angio-IRM preoperatoire a ete realisee avec des sequences spin echo T1 en coupes coronales et des coupes axiales T2 passant par l’extremite superieure du disque L5-S1. Nous avons correle les IRM et les comptes rendus operatoires. Les elements etudies ont ete ceux de la classification de Capellades: la hauteur de la bifurcation ilio-cave (haute, tres haute, basse, tres basse), la position de la veine iliaque commune (laterale, intermediaire, mediale), l’angle forme par les deux veines iliaques communes. La position haute et laterale est la plus frequente (31,5 %). La moyenne de l’angle de bifurcation des veines iliaques est de 65°. Dans un seul cas, il n’a pas ete possible de « passer » sous la bifurcation ilio-cave, il s’agissait d’une situation tres basse et mediale associee a un angle aigu des veines iliaques (45°). Notre serie comprend un groupe homogene comparable a ceux de la litterature. L’angle de bifurcation des situations tres basses mediales a une importance considerable car pour un angle superieur a 60°, il est toujours possible de mettre en place l’implant en L5-S1 en passant sous la bifurcation ilio-cave. La situation de la bifurcation ilio-cave et l’angle de cette derniere ont une importance considerable pour la mise en place d’une prothese discale en L5-S1. L’angio-IRM preoperatoire a donc un interet double: connaitre en preoperatoire les eventuelles difficultes que l’on va rencontrer pendant l’intervention, et prevenir le patient qu’il ne sera peut-etre pas possible de mettre en place l’implant et, dans ce cas, proposer une autre therapeutique.

Resume Les possibilites de traitement des fractures de la charniere thoraco-lombaire sont multiples (abords anterieurs classiques, posterieurs, voies combinees). L’avenement des techniques mini-invasives video assistees permet de minimiser les complications. Le but de ce travail etait d’analyser le resultat clinique et radiologique de 20 patients operes par cette technique exclusivement et ce de maniere prospective. Il s’agit d’une etude prospective de 20 patients d’âge moyen 43,3 ans, au recul minimum de 1 an. Tous les patients avaient un examen neurologique normal (Franckel E). Dix-neuf fractures etaient classees Magerl A et 1 Magerl C. Ils ont beneficie d’une corporectomie greffe et osteosynthese (aidee par un endodistracteur dans les 9 derniers cas). Nous avons etudie les complications peroperatoires et postoperatoires. Nous avons mesure la cyphose localisee et l’angulation regionale preoperatoire, postoperatoire et au dernier recul selon les travaux de Stagnara. L’arthrodese a toujours ete consideree comme fusionnee au dernier recul. Les seules complications notees sont 3 atelectasies regressives dans les deux mois. Les resultats globaux montrent une correction angulaire satisfaisante qui se maintient au recul. Le gain sur la cyphose localisee est de 13,71° en moyenne en postoperatoire immediat, avec un resultat durable dans le temps puisqu’a distance le gain est de 13,31°. Le gain sur l’angulation regionale corrigee est de 14° en postoperatoire immediat avec un gain durable dans le temps puisque de 14° au dernier recul. Le gain sur la cyphose localisee et sur l’angulation regionale est deux fois plus important lors de l’utilisation de l’endodistracteur que par manœuvres externes. Le taux de complications est minime. Les corrections obtenues sont comparables a celles de la litterature et durables dans le temps. Si l’on tient compte de la courbe d’apprentissage, les complications de l’abord mini-invasif video assiste sont moindres que pour une thoracotomie classique ou pour une chirurgie anterieure associee a un temps posterieur ; aussi bien pour les complications peroperatoires (saignement), postoperatoires et a distance. La correction obtenue est satisfaisante et durable dans le temps. Un ancillaire specifique de distraction est indispensable pour la reduction et la mise en place de la greffe anterieure sans perte de correction. La correction ainsi obtenue rejoint les meilleurs resultats obtenus par thoracotomie en limitant les complications liees a l’abord.

Disc prosthesis is the new treatment for degenerative disc disease in the lumbar spine. Key to assessing the interest in this new motion technique is evaluating the results in terms of functional and radiologic outcomes. This prospective study reports the outcome of 64 Maverick devices implanted between January 2002 and November 2003. The degree of improvement was equivalent to that obtained with anterior fusion cages using the mini-invasive technique. Radiographic follow-up in this series showed a degree of mobility close to normal. The technique is safe because the intra- and postoperative complication rate is low. The Oswestry score improved for 75% of patients. This improvement is significantly correlated with facet arthrosis and muscle fatty degeneration.

A prospective radiographic study of the influence of total disc replacement on spinal sagittal balance. The goal of this study was to prospectively determine the effect of a single-level, total disc replacement on the sagittal balance of the spine, especially on sacral tilt (ST), pelvic tilt (PT), and lumbar lordosis. It has been shown that lumbar fusion may deleteriously alter the sagittal balance of the spine, including a decrease in the ST and lumbar lordosis. Clinically, postfusion pain has been shown to be significantly related to a decreased ST, increased PT, and decreased lumbar lordosis, independent of other factors such as pseudoarthrosis. To our knowledge, the influence of total disc replacement on spinal sagittal balance has not yet been reported in the literature. This is a prospective study of 35 patients who received a single level disc replacement using the Maverick Total Disc Arthroplasty system (Medtronic Sofamor Danek, Memphis, Tennessee) by a single surgeon at one institution from March 2002 to September 2003. The preoperative and postoperative radiographic evaluation included standing anteroposterior and lateral full spine films that included the femoral heads. The parameters studied were ST, PT, global and segmental lordosis, and global kyphosis. The average age of the 35 patients studied was 44.3 years (range 35-57). There were 18 females and 17 males. The disc arthroplasty was performed at the L4-L5 level in 19 patients and at the L5-S1 level in 16 patients. The average follow-up was 14 months (range 6-22 months). The preoperative values of global lordosis, ST, and PT were 51.5 degrees , 37.8 degrees , 16.9 degrees and, at last follow-up, they were 51.4 degrees , 37.4 degrees , and 17.5 degrees , respectively. These changes were not significantly different. When the groups were separated according to the level operated, there was still no statistical difference with regard to the overall lordosis, ST, PT or kyphosis from pre- to postoperative period or when the two groups were compared with each other. The level above the prosthesis has always significantly less lordosis. In the present study with use of a motion-preserving Maverick prosthesis, it appears that the patient is able to maintain the preoperative sagittal balance. The prosthesis has enough freedom of motion to allow the patient to maintain the natural sagittal and spinopelvic balance needed to prevent potential undue stress on the muscles and the sacroiliac joint. Although the number of patients is small, this is the first study to our knowledge that evaluates the sagittal balance after motion-preserving total disc arthroplasty.

There is a relatively high prevalence of osteoporotic vertebral compression fractures (VCFs) in the elderly population, especially in women aged 50 or older. The result of these VCFs is increased morbidity and mortality in the short and long term. Medical treatment of these fractures includes bed rest, orthotics, analgesic medication and time. Percutaneous vertebroplasty (PVP) consists of percutaneous injection of biomaterial, such as methylmethacrylate, into the VCF to produce stability and pain relief. Biomechanical testing has shown that PVP can restore strength and stiffness of the vertebral body to the pre-fracture levels. Clinical results show immediate and maintained pain relief in 70-95% of the patients. Possible major complications include cement leakage into the spinal canal or into the venous system. Additionally, percutaneous vertebroplasty may alter the normal loading behavior of the adjacent vertebral body, and there is an increased risk of adjacent segment VCF. Kyphoplasty is a new technique, which introduces a balloon into the vertebral body transpedicularly to reduce the VCF while creating a cavity for the cement injection. This technique has the benefit of kyphosis reduction as well as less cement leakage. Research continues into the development of injectable biomaterials that are resorbable and allow for new bone formation. Vertebroplasty and kyphoplasty are safe and effective in the treatment of osteoporotic VCFs. They may allow for a faster return to function, and thus avoid the morbidity associated with medical treatment.

Resumen Las fracturas de los platillos tibiales, incluso despues de una decision y una conducta terapeutica adaptadas, siempre estan expuestas a la aparicion de complicaciones secundarias con gran repercusion funcional. Las manifestaciones mas temibles y frecuentes siguen siendo la rigidez articular y la artrosis femorotibial. El desarrollo en los ultimos quince anos de la cirugia protesica de la rodilla representa un progreso importante en el tratamiento de estos pacientes. Si bien la cirugia no debe sustituir a los tratamientos conservadores, representa un avance notable en las opciones terapeuticas para tratar estas complicaciones.

The purpose of this study was to evaluate the inter- and intra-observer variability of the computerized radiologic measurements using Keops(®) and to determine the bias between the software and the standard paper measurement.Four individuals measured all frontal and sagittal variables on the 30 X-rays randomly selected on two occasions (test and retest conditions). The Bland-Altman plot was used to determine the degree of agreement between the measurement on paper X-ray and the measurement using Keops(®) for all reviewers and for the two measures; the intraclass correlation coefficient (ICC) was calculated for each pair of analyses to assess interobserver reproducibility among the four reviewers for the same patient using either paper X-ray or Keops(®) measurement and finally, concordance correlation coefficient (rc) was calculated to assess intraobserver repeatability among the same reviewer for one patient between the two measure using the same method (paper or Keops(®)).The mean difference calculated between the two methods was minimal at -0, 4° ± 3.41° [-7.1; 6.4] for frontal measurement and 0.1° ± 3.52° [-6.7; 6.8] for sagittal measurement. Keops(®) has a better interobserver reproducibility than paper measurement for determination of the sagittal pelvic parameter (ICC = 0.9960 vs. 0.9931; p = 0.0001). It has a better intraobserver repeatability than paper for determination of Cobbs angle (rc = 0.9872 vs. 0.9808; p 0.0001) and for pelvic parameter (rc = 0.9981 vs. 0.9953; p 0.0001).We conclude that Keops(®) has no bias compared to the traditionally paper measurement, and moreover, the repeatability and the reproducibility of measurements with this method is much better than with similar standard radiologic measures done manually in both frontal and sagittal plane and that the use of this software can be recommended for clinical application.Diagnostic, level III.

The aim of this work was to assess the clinical results in 13 snapping scapulas treated between 1990 and 1996. This is an infrequent source of shoulder discomfort characterized by painful, audible and palpable abnormal scapulothoracic motion. It may or may not have a demonstrable mechanical etiology, but often no obvious cause can be identified with imaging techniques. We report a series of 13 cases, of whom 8 were operated. The mean age was 23 years; there were 4 women and 9 men. All patients underwent a CT-scan and X-ray imaging. Initial treatment was conservative in 10 cases without obvious etiology, and surgical in three osteochondromas. Five patients who did not improve by a nonoperative approach were operated. After a mean follow-up of 24 months, pain and snapping were completely relieved. Surgery was the appropriate treatment in the cases of failure of conservative treatment and allowed patients to return to normal activities and work.

Bone graft substitute success depends on the formation of healing bone tissue that will bring about the incorporation of the implant, in a sequence of discrete phases. Each of these phases may be influenced by the nature of the implant used. The biological, biochemical, and physicochemical parameters involved may be measured, quantified, and checked. All those involved in the manufacture or the use of these substitutes must thoroughly understand these aspects in order to be able to control them. Tricalcium phosphate, Hydroxyapatite and the biphasic compounds are currently the most widely used materials. TCP, whether used by itself, or as one of the constituents of the biphasic calcium phosphates, will eventually disappear, leaving the bone graft substitute to be gradually osseointegrated. This osseointegration will ensure the biocompatibility of the implant, since resorption occurs without the interposition of a fibrous tissue layer.