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Resume Introduction Deux cent trente-neuf osteotomies vertebrales ont ete realisees chez 215 patients entre 1980 et 2006, pour reprises de deformations rachidiennes dans 58,43 %, deformations rigides operees de premiere intention dans 19,21 %. Patient et methodes Quatre types d’osteotomies furent utilises et ont fait l’objet d’une etude radiologique, en particulier de l’equilibre sagittal, de la morbidite peroperatoire et postoperatoire. Resultats Les resultats montrent la difficulte d’obtenir une correction des deformations, equilibree dans le plan sagittal, en particulier dans le cadre des osteotomies posterieures isolees et dans le cadre des osteotomies plus agressives lorsque la composante cyphotique est superieure a 80°, et en presence de troubles neurologiques medullaires. Conclusion Les parametres incidence, version pelvienne, localisation et angulation de la cyphose permettent de proposer une strategie chirurgicale dont la realisation possible est a confronter avec le score ASA des patients.

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’osteotomie transpediculaire (OTP) est destinee a restituer l’equilibre sagittal du rachis. Les series publiees peu nombreuses ne permettent pas toujours d’evaluer les resultats et les risques de cette intervention majeure. Notre serie bicentrique comprend 34 patients : 19 dos plats postoperatoires, 6 cyphoscolioses, 5 spondylarthrites ankylosantes et 4 cals vicieux. De 1996 a 2003, 20 femmes et 14 hommes (âge moyen 46,5 ans) ont ete operes par OTP lombaire. Au recul moyen de 4 ans, les deux series ont ete analysees a l’aide du logiciel Spineview et un questionnaire de satisfaction clinique y etait associe. La correction sagittale moyenne lombaire a ete de 31 degres pour un angle moyen d’osteotomie de 28,9 degres avec restitution du porte a faux C7 proche de 0. Les parametres pelviens ont ete modifies : reduction de la version pelvienne de 16 degres et augmentation de la pente sacree de 8 degres. Le saignement moyen peroperatoire a ete de 1400 cc (300 a 4500 cc) pour une duree moyenne de 260 mn. On deplore 4 breches durales suturees sans consequence ; 2 cruralgies et 2 sciatiques postoperatoires spontanement resolutives. Les patients ont ete leves au 4 e jour avec sortie au 12 e jour et la reprise d’activite s’est effectuee a 6,73 mois sans reconversion dans 6 cas sur 10. Nous deplorons 8 pseudarthroses (25 %) avec rupture du materiel d’osteosynthese (vide anterieur, insuffisance de correction) necessitant une reprise posterieure avec greffe anterieure associee. L’indice clinique de satisfaction a ete de 90 % avec pour 28 % des patients une transformation de l’image corporelle. L’OTP sur un niveau corrige de plus de 30 degres le plan sagittal et reequilibre les differentes gites en sectionnant les trois colonnes sous controle neurologique direct. La planification preoperatoire garantit la stabilite de la correction considerant la gite de T9 et les versions passee et future. Une osteosynthese etendue est necessaire. La constitution d’une solution de continuite faite par les disques voisins et la fermeture posterieure relative de l’OTP, doit faire discuter une arthrodese anterieure associee devant toute ouverture discale excessive avant la faillite de l’osteosynthese. L’OTP offre de grandes possibilites de correction de l’equilibre sagittal. Une greffe anterieure associee devrait mettre a l’abri des demontages.

The load-displacement behaviour of six fresh human cadaveric L2–L3 spinal segments was studied through in vitro testing in flexion, and torsion. The lumbar spinal units were tested firstly intact, then instrumented by the SB Charite III intervertebral disc prosthesis with respect to the surgical requirements. These experiments highlighted an increase of mobility yielded by the implantation of the prosthesis, especially in torsion. Numerical models of both the L2–L3 spinal segment and the disc prosthesis were used. Simulations were performed on an intact spinal segment model, as well as on an instrumented segment model, by reproducing the same boundary conditions as used experimentally. The results of these simulations indicated a realistic behaviour of the model when comparing numerical results to experimental ones. This allowed us to validate our numerical models and to use them to calculate compressive forces transmitted by the posterior facets. Numerical results indicated an increase of the facet loading during torsion, yielded by the implantation of the prosthesis. Three technical changes to the original design were then simulated. These changes were meant to increase the global stiffness of the implanted segment, and to reduce articular facet loading in torsion. One of the solutions reduced axial rotation in torsion without decreasing articular loading. This observation is explained through a simple mechanical model of a lumbar spinal unit in torsion. This mechanical model was used to define the last solution, which succeeded in both reducing axial rotation and intra-articular loading.

The implantation of a « Charite » prosthesis has to be solved through a biomechanical compromise between the size of the implants and it’s positioning in the intervertebral space. A retroperitoneal approach allows one to minimise complications and especially to see and protect the hypogastric nerve. Generally, the anatomy of the great vessels offers a wide approach on the anterior aspect of the disc, except in the case of a high bifurcation of the vena cava with a left iliac vena outside and over the iliac artery and having a straight downwards direction. This situation is infrequent, 1 for 1,000 anterior approaches in our experience.

The aim of this study was to analyze x-ray results in patients who underwent pedicle subtraction osteotomy for complex deformations (flat back, kyphosis) leading to fixed sagittal imbalance.Thirty-four patients underwent surgery between 1996 and March 2003 in two centers, the orthopedic surgery unit devoted to spinal surgery and sports traumatology at the Strasbourg University Hospitals and the spinal surgery unit at the Chenove Clinic (Dijon). The series included 20 women and 14 men, mean age 46.5 years (range 14-74 years) treated for: postoperative flat back (n = 19), kyphoscoliosis (n = 6), ankylosing spondylarthritis (n = 5), and malunion (n = 4). After careful planning to achieve the necessary degree of correction, the patient was installed on a Cotrel table with a stable support enabling limited blood loss and facilitated reduction maneuvers via elevation of the lower limbs. The technique started by resection of the posterior arch, the transverse processes, and the pedicles, followed by partial resection of the body with a chisel under fluoroscopic control. The closure was achieved by in situ reduction with compressive rotation. Adjacent discs were then evaluated to search for any opening which could be filled by an anterior graft to complete the stabilization. The osteosynthesis used 2-, 4-, and 6-rod assemblies. The 6-rod assemblies enabled anchoring the fixation above and below before the osteotomy. Two prebent rods completed the assembly at reduction after osteotomy. Weight-bearing started on day 4. A protective corset was worn for three months by 19 patients. The patients resumed their occupational activities on average 6.73 months postoperatively without change in activity for 63%. Overall satisfaction was close to 90% excellent outcome.All clinical results were analyzed with the Profil software of Surgiview. X-ray data were analyzed with Spineview. A self-administered clinical questionnaire was used to evaluate pain, result of the operation, and the impact on the patient's body image. On average, the wedge osteotomy measured 28.9 degrees for correction of lumbar lordosis by 31.5 degrees with a maximum of 65 degrees. The misalignment at C7 was reduced from 51 mm to 2 mm. At the pelvic level, version improved 16 degrees, sacral slope 8 degrees. There were four dura mater breaches which had to be sutured, but with no clinical consequence (one progression to meningocele). Mean intraoperative blood loss was 1400 cc (300-4500cc) for a mean operative time of 260 minutes (165-450 min). There were two early infections at day 15 postop which resolved with antibiotics. Four patients developed resolutive sciatica (n = 2) or cruralgia (n = 2) during the following months. The short-term follow-up revealed eight non-unions (25%) with rupture of osteosynthesis material and loss of correction. The opening in the adjacent discs and the insufficient posterior closure explained this mechanical complication.Pedicle subtraction osteotomy is an original operative technique reserved for specialized centers. A well-experienced team is needed to control the risks involved. Sagittal balance should be one of the important goals for modern spinal surgery.

During past decades, major progress has been accomplished in the management of acute asthma. Most recent recommendations include evidence-based rationale. The improved quality of clinical guidelines makes them efficient models for medical education. The pediatric pharmacopoeia provides a great variety of choices of drugs as well as for asthma medical devices. These innovations dramatically facilitated the medical management of asthmatic children, but they did not solve all problems. Physicians now use higher doses of salbutamol, but the early prescription of systemic glucocorticoids for moderate exacerbation of asthma is still underused, given the most recent clinical guidelines and meta-analysis. Furthermore, repeated emergency department visits to the wards and lack of primary care physician should systematically be appraised when evaluating severity, as they are both major risk factors for severe exacerbations, even though they are not considered in acute asthma severity scores. Finally, initiating (or reinforcing) patient education at the time of exacerbation also presents important challenges, as emergency visits are a favorable moment to commence the therapeutic education of the child and his family. Indeed, framing the controller medications and educating families about how to manage the disease and to improve their domestic environment are the genuine tools available for the prevention of asthma exacerbations, and particularly those most severe.

To evaluate the completeness of personal child health record in France.Cross-sectional multicentric study, based on child health records analysed and parents' interviews; 1685 children were included: 863 infants aged from 12 to 18 month and 822 children aged from three and a half to four and a half years.One Apgar score was recorded in 96% of cases; the sitting position's acquisition was registered in 91%; the age of walk in 81%. Growth curves were plotted in 64% of cases for weight and in 62% for height in infant's records and 22% of cases for both in older children's records. Ten per cent of the last visit to a physician were not recorded in infants health records, 19% in those of children; as well an hospitalisation for respectively 1,5% and 3,3% and a performed operation for 1,8% and 5,1% respectively. Immunization batches were exhaustively indicated in 68% and 50% of the records.Many important data for medical follow-up are missing in the child health records, especially for the oldest children. Physicians and parents should be incited to a better use of the personal record.

An independent examiner, V. Sauty, M.D. in 1996, reevaluated a series of 105 patients originally evaluated in 1994 undergoing SB Charite™ Artificial Disc replacement with consistent baseline characteristics. The average age of patients was 39.2 years (range 24 to 50 years) and the after follow up was 51 months. The average preoperative progression of the low back pain and radicular pain was 6 years, and the average length of uninterrupted time lost from work exceeded 7 months. Fifty patients (48%) had previously undergone one or more operative procedures (one operation in 35 patients; two operations in 10 patients; and three or more surgical procedures in 5 patients). The vertebral level of prosthetic insertion, category of work, and general statistics for the 105 patients are listed in Table 13.1.

A case of retention of urine after ophthalmic zoster is reported. The sphincter vesicae disorder was of central origin, being caused by a meningoencephalitis. The patient progressively recovered. The respective responsibilities of brain suffering and meningeal involvement in these urinary tract disturbances are discussed.

Commande multivariable d'une colonne avec prelevement lateral. Le controleur est compose d'un nouveau compensateur de retard multivariable couple a des controleurs PI classiques

Radiographs of the lumbar spine frequently demonstrate asymmetry of posterior articular facets, but this is asymptomatic in patients with good abdominal and lumbar muscles when the anomaly is only of a moderate degree. It can, however, cause rotatory instability of the subjacent vertebra leading to lumbago. It is then frequently associated with osteo-articular complications affecting the posterior arch, this being a logical consequence of a sequence of changes which can be explained by simple mechanical factors.

A case is described of a child aged twelve with rib abnormalities, a Klippel-Feil syndrome and a complete fusion between C2 and C7. The atlas showed abnormal ossification of the anterior and posterior arches. No similar description has been found in the literature. A posterior spine fusion between C1 and C2 was performed.

On account of the numerous cervical spine injuries and varying treatment concepts, we propose an anatomo-pathological classification in order to try and to improve accurate therapeutic indications.

International audience

International audience