Hemodialysis has considerably prolonged the life of patients suffering from terminal renal failure. However, long-term hemodialysis leads to new bone complications and spinal disorders such as destructive spondyloarthropathy (DSA). At the present time DSA is reported in 8% to 18% of the dialysed patients. Diagnosis is based on severe narrowing of the intervertebral disk, erosions and geodes of the adjacent vertebral plates simulating infectious spondylitis. Lesions progressively involve posterior joints and may lead to severe destruction of the spine. The pathogenesis of this syndrome is still unknown. Several factors have been implicated, including microcrystal deposition, amyloidosis, inflammatory and foreign body reactions and suggest that the pathogenesis of erosive spondyloarthropathies of hemodialysed patients is multifactorial. Spinal instability inducing myelopathy and radiculopathy were observed in 8% of the cases. Treatment must be accorded to the natural disease course and to the quality of the bone. We report the case of a chronic dialysed patient with destructive spondyloarthropathy involving the cervical and thoracic spine. Pathogenesis, radiological datas and therapeutic approach are discussed.

Le développement et la généralisation des techniques d'hémodialyse, tout en améliorant la qualité de vie et la survie des patients insuffisants rénaux, a sensiblement modifié les pathologies osseuses et, plus particulièrement, la pathologie rachidienne habituellement rencontrée dans cette population de patient. Après plusieurs années d'hémodialyse, on note l'apparition de spondylarthropathie érosive (SE) ou destructive. On estime la prévalence de 8 % à 18 % des patients hémodialysés. Elle présente un aspect destructeur qui s'étend progressivement du disque inter-vertébral au cartilage articulaire, au tissu osseux et au système disco-ligamentaire. Les lésions discales peuvent faire évoquer à tort une spondylodiscite infectieuse. L'étiopathogénie de ce processus n'est pas encore élucidée. Toutefois, l'examen microscopique en révélant des lésions inconstantes et diverses telles que des dépôts amyloïdes, des microcristaux ou une simple réaction inflammatoire non spécifique permet de considérer ces lésions comme le résultat d'une réaction inflammatoire influencée par de multiples facteurs. Ces lésions destructrices entraînent une instabilité rachidienne pouvant se compliquer d'une compression médullaire ou radiculaire nécessitant un traitement chirurgical dans 8 % des cas. La qualité mécanique du tissu osseux chez ces patients insuffisants rénaux et l'évolution naturelle de ces lésions sont des facteurs importants dans le choix thérapeutique. Nous rapportons l'observation d'un patient hémodialysé de longue date et présentant une spondylarthropathie érosive sévère intéressant à la fois le rachis cervical et le rachis thoracique. La revue de la littérature permet de recenser les données étiologiques, radiologiques, diagnostiques et thérapeutiques actuellement proposées. Hemodialysis has considerably prolonged the life of patients suffering from terminal renal failure. However, long-term hemodialysis leads to new bone complications and spinal disorders such as destructive spondyloarthropathy (DSA). At the present time DSA is reported in 8% to 18% of the dialysed patients. Diagnosis is based on severe narrowing of the intervertebral disk, erosions and geodes of the adjacent vertebral plates simulating infectious spondylitis. Lesions progressively involve posterior joints and may lead to severe destruction of the spine. The pathogenesis of this syndrome is still unknown. Several factors have been implicated, including microcrystal deposition, amyloidosis, inflammatory and foreign body reactions and suggest that the pathogenesis of erosive spondyloarthropathies of hemodialysed patients is multifactorial. Spinal instability inducing myelopathy and radiculopathy were observed in 8% of the cases. Treatment must be accorded to the natural disease course and to the quality of the bone. We report the case of a chronic dialysed patient with destructive spondyloarthropathy involving the cervical and thoracic spine. Pathogenesis, radiological datas and therapeutic approach are discussed.

A study was made of 100 homogeneous CT scans of the petrous part of the temporal bone to determine whether or not the arcuate eminence (AE) is a good landmark for the superior semicircular canal (SSCC) in the suprapetrous approach to the internal acoustic meatus which is used in the extirpation of acoustic neuromas. Direct measurements were made on consecutive coronal sections, 1 mm thick. The AE was absent from the petrous surface in 15% of cases. It corresponded to the relief of the SSCC in 37% of cases; laterally, however, it was separated from the petrous cortex by bone whose thickness varied from 0.5 to 5 mm. Finally, in 48% of cases, the AE was not a good landmark for the canal although nonetheless it participated in the development of this bulge in 46% of cases, always lying towards the medial border of the pneumatized eminence. In addition, study of the coronal sections with MRI allowed us to confirm that the AE does not routinely correspond to the imprint of a temporal sulcus. The AE, whose presence on the petrous surface is due to the combined effects of the SSCC, the air cells of the petrous part of the temporal bone and the temporal sulci, is only a good guide to the SSCC in 37% of cases and should not be considered as a reliable surgical landmark.

Low back pain is frequent and results in major disability for patients. This anatomical study was done to understand mechanisms involved in that pain. Two kinds of innervation are present in the lumbar spine: one depends on the somatic nervous system and the other on the sympathetic nervous system. The sympathetic nerves are the sinu-vertebral nerves and the rami communicantes which innervate the intervertebral disc, the ventral surface of the dura mater, the longitudinal dorsal ligament and the longitudinal ventral ligament. The sinu-vertebral nerve was described first by Luschka in 1850. This nerve is implicated in diffuse low back pain because of its pathway and its sympathetic component. This nerve cannot directly reach a somatic element at each level of the lumbar spine, so must first reach the L2 spinal ganglion. Thus, there is a "hole" in the somatic innervation between L3 and L5 because the dorsal nerves do not reach the skin at these levels. The pain therefore takes another route through the sympathetic system. Discogenic pain is mediated by the sinu-vertebral nerves, and through the rami communicantes reaches the L2 spinal ganglion. Anatomical and clinical features reinforce this hypothesis. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer Link server at http://dx.doi.org/10.1007/s00276-002-0084-8.

The authors describe an occipitocervical fixation procedure in which they use inverted occipital hooks inserted through a burr hole drilled in the squamous part of the occipital bone. Fifteen patients with unstable lesions of the occipitocervical junction underwent occipitocervical internal fixation. The mean follow-up period was 21 months (range 2-63 months). No implant failed, and postoperative immobilization was not required. The placement of a posterior occipitocervical graft (for which fusion is uncertain) can be avoided in certain conditions.

This 7-year-old boy with Hajdu-Cheney syndrome presented with cervical syringomyelia related to rapidly progressing platybasia. Decompressive craniectomy provided temporary improvement, and his clinical status was eventually stabilized after external immobilization, according to findings at 2.5 years of follow up. In a review of the literature the authors found 57 cases of the syndrome, only three of which were associated with syringomyelia. The youth of the patient, the severe form and rapid course of the disease, and the very specific anatomical conditions related to cranial and facial deformities raised various therapeutic problems.

The nerve supply of the upper limb, which is provided by the brachial plexus, is extremely important from a medical and surgical perspective. Muscles of the flexor compartment of the arm are destined to have their nerve supply from the musculocutaneous nerve, a branch from the lateral cord of the brachial plexus. Variations in the formation and branching of the brachial plexus are not uncommon. These variations have clinical significance during surgical procedures, in the brachial plexus block, and in diagnostic clinical neurophysiology.The study was carried out in the department of anatomy consisting of 56 limbs during routine undergraduate dissection classes. Dissection of the infraclavicular part of the brachial plexus was done. The variations in the origin, number, and distribution of the branches derived from the cords to the flexor compartment of the arm and their correlations to the coracobrachialis were noted.47 limbs (83.92%) showed a normal morphological pattern of formation and distribution of brachial plexus to the flexor compartment of the arm. 9 limbs (16.07%) showed variations in one form or the other. Two limbs (3.57%) showed an absence of musculocutaneous nerve (MCN). In 3 limbs (5.35%) coracobrachialis was not being supplied by MCN, and 4 limbs (7.14%) exhibited a communication between MCN and Median Nerve (MN).Variations in the nerves supplying the flexor compartment of the arm have clinical implications in post-traumatic evaluations and exploratory innervations of the arm for peripheral nerve restoration. It is important for surgeons, clinicians, and anatomists to be aware of these possible anatomical variations to avoid unexpected complications.

Ankylosing spondylitis (AS) is characterized by inflammation of the entheses and paravertebral structures, leading in time to bone formation at those sites. As well, vertebral bone loss is also a recognized feature of ASObjective: To calculate the prevalence and risk factors of osteoporosis and vertebral fractures in patients with AS.Methods: Eighty patients with AS were enrolled in the study. Clinical, biological and radiological status was assessed by the Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI), ESR and C-reactive protein (CRP), Bath AS Radiology Index (BASRI) and modified stoke AS spine score (mSASSS). BMD of the hip and spine was measured and vertebral fractures were defined using a combination of Genant semiquantitative (SQ) approach and morphometry by VFA (fracture vertebral assessment).Results: The years ± 11.8. The mean BMI was 22.8 kg/m2 ± 4.1 and the mean disease duration was 10.8 years ± 6.6. Prevalence of osteoporosis was 25%. 18.8% of patients had a vertebral fracture (grades 2 and 3). Factors associated with osteoporosis were low weight and BMI and longer disease duration, higher ESR, CRP, BASFI and BASDAI. Vertebral fractures were associated with advanced age, longer disease duration, higher BASFI, BASRI and mSASSS and reduced BMD and T-score at the hip site, presence of osteoporosis at any site. Multiple logistic regression analysis (Table 4) revealed that parameters significantly associated with osteoporosis were BASDAI (OR = 1.05, 95% confidence interval [CI]: 1.03–1.09); disease duration (OR = 1.13, 95%CI: 1.03–1.25); and BMI (OR = 0.82, 95%CI: 0.69–0.93). The presence of VFs (grades 2 and 3) were independently associated with disease duration (OR = 1.50, 95%CI: 1.07–2.10); and mSASSS (OR = 1.17, 95%CI: 1.05–1.30).Conclusion: Osteoporosis is common in patients with AS and seems to be related to disease activity while vertebral fractures appear to be related to the duration and structural severity of the disease rather than BMD.

Les lesions de diagnostic difficile L.es lhions ligamentaires : suspect&s devant un rachis raide ou une inversion de courbure, elles ne seront souvent reconnues que lors de la r&lisation de cliches dynamiques sous scopie, qu’il faut faire apres sedation de la contracture musculaire reflexe post-traumatique. L.es autres l&ions : la N sub-luxation >> est une v&itable luxation unilatkale, done instable a r6duire. Une fracture de l’odontoi’de peut se rtsumer aux signes radiologiques indirects d’hematome r&ropharyngien. Un torticolis doit dvoquer une luxation rotatoire de l’atlas, dont le diagnostic necessite un scanner. La hemie discale aigu& doit &re bvoquke lorsque les signes neurologiques n’ont pas d’explication radiologique.