OBJECTIVE: To assess the efficacy and safety of surgery for dysphagia in anterior cervical idiopathic hyperostosis. METHODS: This retrospective study included 11 consecutive patients presenting with dysphagia and anterior cervical idiopathic hyperostosis. Computed tomography scans and dynamic swallowing fluoroscopies were performed. The site of compression and the size and position of osteophytes were measured. The clinical outcomes and complications were recorded. RESULTS: Two patients with anterior esophageal compression were found to have dysphagia caused by lower esophageal sphincter dysfunction. In the remaining 9 patients, the level of maximal compression was between C3 and C5 with the size of the osteophytes ranging from 8 to 17 mm. Intubation was challenging in 7 patients. Postoperative transient worsening of dysphagia was encountered in 3 patients. Two patients experienced severe complications including aphagia and respiratory compromise. Within 2 months of the operation, all patients reported satisfactory improvement of symptoms and a considerable gain in quality of life. No recurrence had occurred at final follow-up. CONCLUSIONS: Anterior cervical hyperostosis causing dysphagia typically affects older men and results from compression between C3 and C5 from osteophytes of variable sizes. Operative intervention can provide long-lasting resolution of symptoms but is complicated by difficulty in endotracheal intubation, postoperative dysphagia, and rarely respiratory compromise. A systematic preoperative ear, nose, and throat consultation is recommended to reduce these complications.

Les fractures thoraco-lombaires et leur prise en charge sont un enjeu de santé publique à cause de leur sévérité et de leur fréquence. Selon les caractéristiques démographiques, cliniques et radiologiques, la prise en charge va des traitements conservateurs aux arthrodèses étendues. Ces deux dernières décennies, de nouvelles techniques chirurgicales ont émergé, telles que la kyphoplastie et les approches percutanées. L’objectif principal de cette étude était de décrire la prise en charge des fractures thoraco-lombaires en France en 2018. L’hypothèse principale de ce travail était que la prise en charge de ces fractures en France avait évolué ces dernières décennies. Les dossiers de 407 patients avec fracture du rachis thoraco-lombaire de T4 et L5 opérés dans 6 centres hospitalo-universitaires entre le 01 Janvier 2015 et le 31 Décembre 2016 furent revus. Les données préopératoires, chirurgicales et radiographiques au dernier recul furent analysées. Le test de Student était considéré comme significatif pour p < 0,05. L’analyse portait sur 531 fractures (27 % des patients ayant >1 fracture). La chirurgie était une ostéosynthèse pour 56 % des patients dont 17 % avec kyphoplastie associée. L’arthrodèse était réalisée pour 29 % des fractures et une kyphoplastie seule pour 15 % des fractures. 54 % des opératons étaient à ciel ouvert avec une voie d’abord postérieure, et 46 % étaient percutanées. L’angulation initiale sagittale n’était pas un critère décisionnel significatif pour l’instrumentation de la vertèbre fracturée (p = 0,8), ni pour la réalisation d’un temps antérieur secondaire à l’arthrodèse postérieure (p = 0,6). La correction sagittale post-opératoire était significativement meilleure en cas de chirurgie à ciel ouvert par rapport à une approche percutanée (p = 0,004), mais sans différence significative au denier recul (p = 0,8). La correction au dernier recul était meilleure lorsqu’un temps antérieur avait été adjoint à l’arthrodèse postérieure (p = 0,003). La prise en charge des fractures thoraco-lombaires en France a évolué au cours des dernières années : 46 % des fractures chirurgicales furent opérées par un abord postérieur percutané (28 % en 2013) ; 90 % n’ont eu qu’un temps postérieur isolé (83 % en 2013) tandis que les approches combinées sont restées stables. Concernant les burst fractures (Magerl/AOA4), 25 % furent traitées par une arthrodèse, ce qui peut être attribuable à l’absence d’IRM pré-opératoire (79 % des patients). IV, étude de cohorte rétrospective.

Radicular pain is a common reason for patients to consult at back pain clinics. While epidural steroid injections are widely done, some aspects are still controversial. The epidural space can be accessed via a transforaminal approach, an interlaminar route or by passing through the sacral hiatus. The aim of this article is to describe the epidural injection technique through the sacral hiatus that our team uses and to report our experience with it. Beyond the treatment effect, sacral hiatus corticosteroid injection can be useful as a diagnostic test or as an interim solution. Image-guided injection is recommended to ensure optimal positioning of the needle below S3. Sacral hiatus corticosteroid injection is a relevant alternative for treating lumbar radiculopathy in adults.

La présence d’une symptomatologie radiculaire est un motif de consultation fréquent en pathologie rachidienne. La réalisation d’infiltrations épidurales, bien que largement utilisées, reste encore sujette à discussion. Il est ainsi possible d’approcher l’espace épidural par une voie transforaminale, interlamaire ou en passant par le hiatus sacro-coccygien. L’objectif de ce travail est donc de décrire la technique d’infiltration épidurale par le hiatus sacro-coccygien et d’en rapporter notre expérience. Au-delà de l’effet thérapeutique, l’infiltration du hiatus sacro-coccygien peut avoir un intérêt en tant que test diagnostique ou en solution d’attente. Un guidage pour un positionnement optimal de l’aiguille sous S3 est recommandé. L’infiltration par le hiatus sacro-coccygien constitue donc une alternative intéressante dans la prise en charge de la radiculopathie lombaire chez l’adulte.

Background: Thoracolumbar fractures are a public health issue due to their severity and frequency. Management varies according to demographic, clinical and radiologic features, from non-operative treatment to extensive fusion. In the two last decades, improvements and new techniques have emerged, such as kyphoplasty and percutaneous approaches. The main goal of this study was to describe the management of thoracolumbar fractures in France in 2018. Hypothesis: The study hypothesis was that management of thoracolumbar fractures in France has progressed in recent decades. Material and methods: The files of 407 adult patients operated on between January 1, 2015 and December 31, 2016 for T4-L5 thoracolumbar fracture in 6 French teaching hospitals were retrospectively reviewed, at a mean follow-up at 10.2 +/- 8.2 [1; 42] months. Demographic, surgical and postoperative radiological data were collected. p-values < 0.05 on Student test were considered significant. Results: Five hundred and thirty-one fractures were analyzed (27% of patients presented more than one fracture). Surgery consisted in internal fixation for 56% of patients, including 17% with associated kyphoplasty; 29% had fusion, and 15% stand-alone kyphoplasty. Surgery used an open posterior approach in 54% of cases, and a percutaneous approach in 46%. Initial sagittal angulation was not a significant decision criterion for screwing (p = 0.8) or for a secondary anterior approach in case of fusion (p = 0.6). Immediate postoperative sagittal correction was significantly better with an open than a percutaneous approach (p = 0.004), but without significant difference at last follow-up (p = 0.8). Correction at last follow-up was significantly better with anterior associated to posterior fusion (p = 0.003). Discussion: Management of the thoracolumbar fractures has progressed in France in recent years: 46% of surgeries used a percutaneous approach, compared to 28% in 2013; 90% used a posterior approach only, compared to 83% in 2013; rates of combined approach were unchanged, at 6%. Twenty-five percent of burst fractures were treated by fusion, possibly due to lack of preoperative MRI in 79% of cases. (C) 2020 Published by Elsevier Masson SAS.

The rate, risk factors and consequence of adjacent level disease (ALD) in cervical disc arthroplasty (CDA) remains unclear. The purpose of this study is to determine the rate, risk factors and clinical outcome of ALD in CDA. Methods: Retrospective review of 166 patients with a minimum five-year follow-up of a CDA was performed. Multi-level surgeries, including hybrid procedures, were included. Multiple implant types were included. The two inter-vertebral discs (IVD) cranial of the CDA were monitored for radiologic degeneration. No funding was attained for this study and the authors declare no conflict of interest. Results: The rate of ALD in CDA was 28.3%, with most affecting the immediately adjacent IVD (27.4% and 7.6% respectively p=0.000). Age (p=0.209) and sex (p=0.201) did not relate to ALD, nor did preoperative degeneration (p=0.117) or spondylolisthesis (p=0.315) adjacent to the CDA. The number of operated levels (p=0.890), number of fused levels (p=0.354), implant alignment (0.255), ROM (p=0.569) and implant induced spondylolisthesis (p=0.402) did not affect the rate of ALD. However, fusion of the most cranial implant significantly increased the rate of ALD (p=0.032). The visual analogue pain scale (VAS) was significantly worse in those patients with ALD (VAS neck 2.7 versus 1.5 p=0.029; VAS arm 0.9 versus 2.3 p=0.002). The five-year functional outcomes were worse in those who developed ALD (NDI 20.1 versus 12.3 p=0.011). No patients required a reoperation during the course of this study. Conclusion: ALD is common after CDA and worsens the patient’s functional outcome, but not their need for revision surgery within five years. Fusion of the most cranial implant is a major risk for developing ALD, whereas the initial implant alignment and function do not construe a risk.

Purpose Cervical disc herniation is a common pathology. It can be treated by different surgical procedures. We aimed to list and analyzed every available surgical option. We focused on the comparison between anterior cervical decompression and fusion and cervical disc arthroplasty. Results The anterior approach is the most commonly used to achieve decompression and fusion by the mean of autograft or cage that could also be combined with anterior plating. Anterior procedures without fusion have shown good outcomes but are limited by post-operative cervicalgia and kyphotic events. Posterior cervical foraminotomy achieved good outcomes but is not appropriate in a case of a central hernia or ossification of the posterior ligament. Cervical disc arthroplasty is described to decrease the rate of adjacent segment degeneration. It became very popular during the last decades with numerous studies with different implant device showing encouraging results but it has not proved its superiority to anterior cervical decompression and fusion. Anterior bone loss and heterotopic ossification are still to be investigated. Conclusion Anterior cervical decompression and fusion remain the gold standard for surgical treatment of cervical disc herniation.

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

OBJECTIVE The objective of this study was to identify the risk factors of anterior bone loss (ABL) in cervical disc arthroplasty (CDA) and the subsequent effect of this phenomenon. METHODS The authors performed a retrospective radiological review of 185 patients with a minimum 5-year follow-up after CDA (using Bryan, Discocerv, Mobi-C, or Baguera C). Postoperative radiographs were examined and compared to the initial postoperative films to determine the percentage of ABL. The relationship of ABL to potential risk factors was analyzed. RESULTS Complete radiological assessment was available in 145 patients with 193 CDRs and 383 endplates (average age 45 years, range 25-65 years, 54% women). ABL was identified in 63.7% of CDRs (48.7% mild, 11.9% moderate, 3.1% severe). Age (p = 0.770), sex (p = 0.200), postoperative alignment (p = 0.330), midflexion point (p = 0.509), maximal flexion (p = 0.080), and extension (p = 0.717) did not relate to ABL. There was no significant difference in the rate of severe ABL between implants. Multilevel surgery conferred an increased risk of any and severe ABL (p = 0.013 for both). The upper endplate, defined as superior to the CDA, was more commonly involved (p = 0.008), but there was no significant difference whether the endplate was between or not between implants (p = 0.226). The development of ABL did not affect the long-term range of movement (ROM) of the CDA, but did increase the overall risk of autofusion. ABL was not associated with pain or functional deficits. No patients required a reoperation or revision of their implant during the course of this study, and there were no cases of progressive ABL beyond the first year. CONCLUSIONS ABL is common in all implant types assessed, although most is mild. Age, sex, postoperative alignment, ROM, and midflexion point do not relate to this phenomenon. However, the greater the number of levels operated, the higher the risk of developing ABL. The development of ABL has no long-term effect on the mechanical functioning of the disc or necessity for revision surgery, although it may increase the rate of autofusion.

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

To understand whether a spondylolisthesis in the sub-axial spine cranial to a cervical disc arthroplasty (CDA) construes a risk of adjacent level disease (ALD).

En France, la chirurgie de la hernie discale lombaire est désormais réalisée en ambulatoire dans certaines structures mais la prise en charge du rachis cervical dans ces conditions reste débattue en raison de la crainte de l’hématome suffocant. Nous décrivons l’expérience de 30 rachis cervicaux opérés en ambulatoire au sein de notre service. Depuis 2014, 30 patients (âge moyen : 47,2 ans, 16 hommes et 14 femmes) présentant une névralgie cervicobrachiale liée à une pathologie mono-étagée du rachis cervical (19 C5–C6 et 11 C6–C7) ont été opérés au sein d’une unité de chirurgie ambulatoire. Treize prothèses et 17 arthrodèses ont été réalisées par cervicotomie antérieure. La durée opératoire moyenne était de 38 min, la surveillance postopératoire de 7 h30. Les patients ont passés 10 h10 dans la structure de soins. Une patiente (3 %) a été transférée en unité conventionnelle d’hospitalisation (déficit neurologique ayant nécessité une reprise chirurgicale sans étiologie retrouvée). Deux patients (7 %) ont été ré hospitalisés à j1 pour des dysphagies spontanément résolutives. Le taux de « succès ambulatoire » est donc de 90 % (27/30). Aucune autre complication n’a été relevée avec un excellent taux de satisfaction globale (9,6/10) La prise en charge en ambulatoire des rachis cervicaux opérés par voie antérieure est largement pratiquée aux États-Unis. Nous présentons ici la première série française puisque seule une équipe norvégienne a franchi le cap en Europe. Les taux de complications sont très faibles (< 2 %) voire inférieurs aux patients hospitalisés dans des séries appariées. Toutefois ces patients sont sélectionnés car certains facteurs de risque de complications ont été clairement identifiés (âge, > 3 niveaux, comorbidités/ASA > 2). Aucun décès dans les 30 jours postopératoires n’a été relevé dans la littérature. L’hématome suffocant est exceptionnel dans les séries ambulatoires (0,2 %). Les quelques cas mentionnés ont pu être détectés et évacués avant la sortie du patient. La morbidité de cette chirurgie est plutôt représentée par la dysphagie (8 à 30 %) La chirurgie du rachis cervical peut se pratiquer en ambulatoire dans une structure dédiée chez des patients sélectionnés (pour notre part : âge < 65 ans, 1 niveau, ASA < 2, morphotype cervical habituel). Les taux de complications et de réadmission sont faibles. Une hémostase soigneuse associée à une surveillance étroite postopératoire de 6 h minimum permet de limiter le risque d’hématome suffocant. La prévention de la dysphagie postopératoire doit être au centre de la prise en charge.

Cervical spine surgery can be performed in an ambulatory surgery center in carefully selected patients. Our criteria are patients less than 65 years of age, single-level disease, ASA <2, and standard cervical morphology. The complication and readmission rates are low. Careful hemostasis combined with close postoperative monitoring for at least 6hours helps to reduce the risk of neck hematoma. Prevention of postoperative dysphagia must be a focus of the care provided.

To assess the efficacy of bisphosphonate therapy in the management of spinal aneurysmal bone cysts (ABCs).

STUDY DESIGN:Inter- and intraobserver reliability study. OBJECT:To assess the reliability of a new radiographic classification of degenerative spondylolisthesis of the lumbar spine (DSLS). SUMMARY OF BACKGROUND DATA:DSLS is a common cause of chronic low back and leg pain in adults. To this date, there is no consensus for a comprehensive analysis of DSLS. The reliability of a new DSLS classification system based on sagittal alignment was assessed. METHODS:Ninety-nine patients admitted to our spinal surgery department for surgical treatment of DSLS between January 2012 and December 2015 were included. Three observers measured sagittal alignment parameters with validated software: segmental lordosis (SL), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sagittal vertical axis (SVA). Full body low-dose lateral view radiographs were analyzed and classified according to three main types: Type 1A: preserved LL and SL; Type 1B: preserved LL and reduced SL (≤5°); Type 2A: PI-LL ≥10° without pelvic compensation (PT <25°); Type 2B: PI-LL ≥10° with pelvic compensation (PT ≥25°); Type 3: global sagittal malalignment (SVA ≥40 mm). The three observers classified radiographs twice with a 3-week interval for intraobserver reproducibility. Interobserver reproducibility was calculated using Fleiss κ and intra-class coefficient. Intraobserver reproducibility was calculated using Cohen κ. RESULTS:Mean age was 68.8 ± 9.8 years. Mean sagittal alignment parameters values were the following: PI: 60.1° ± 12.7°; PI-LL was 12.2° ± 13.9°, PT: 24.7° ± 8.5°; SVA: 44.9 mm ± 44.6 mm; SL: 16.6° ± 8.4°. Intraobserver repeatability showed an almost perfect agreement (ICC > 0.92 and Cohen κ > 0.89 for each observer). Fleiss κ value for interobserver reproducibility was 0.82, with percentage agreement among observers between 88% and 89%. CONCLUSION:This new classification showed an excellent inter- and intraobserver reliability. This simple method could be an additional sagittal balance tool helping surgeons improve their preoperative DSLS analysis.

L’incidence pelvienne (IP) est une référence anatomique considérée comme invariable. Les variations posturales influencent la colonne lombaire mobile, mais la lordose lombaire (LL) et le pelvis sont habituellement analysés en position debout statique. Est-ce que les autres positions de la vie courante ont une influence sur la relation IP-LL ? Nous supposons que la lordose lombaire et la pente sacrée sont corrélées à l’incidence pelvienne, quelle que soit la posture. Le but de cette étude est de confirmer ou d’affirmer cette hypothèse en utilisant deux positions standardisées (position couchée et position assise) différentes de la position debout habituellement utilisée. L’objectif de l’étude est d’analyser les relations entre la LL et les paramètres pelviens en position debout, assise et couchée. Les radiographies de 15 volontaires asymptomatiques adultes de moins de 50 ans ont été réalisées dans les 3 positions puis les paramètres lombo-pelviens analysés. Les valeurs moyennes et écarts-types étaient calculés et comparés. Les corrélations étaient obtenues par le test de Spearman. L’incidence pelvienne était fixe et non modifiée par les différentes positions. La LL L1-S1 debout était de 54,8° ± 9,8, assis : 15,9° ± 14,6 et couché : 50,2° ± 9,6. Les valeurs de version pelvienne (VP) étaient respectivement 12,1° ± 6,3° ; 37,7° ± 10,4° et 9,5° ± 5,1°. Les valeurs de pente sacrée (PS) 37,1° ± 6,3°, 11,3° ± 10,8°, 41° ± 7,2°. Les corrélations IP/LL (r = 0,72), LL/PS (r = 0,9) et IP/PS (r = 0,84) étaient plus fortes en position couchée. Alors que l’IP est constante, l’orientation du sacrum et la lordose lombaire changent significativement avec les positions de la vie courante, notamment en position assise. L’ajustement de la LL avec l’IP lors des chirurgies d’arthrodèses est fondamental même chez les patients à activité réduite. IV.

BACKGROUND CONTEXT: Patients over 85 are considered frail. Proposing non-vital spinal surgery for lumbar spinal stenosis (LSS) to these patients is controversial. Most studies assessing the impact of age on surgical outcome included patients over 80 and showed good clinical outcomes with high rates of complications and mortality. However, further analysis shows that mortality increases dramatically after an 80–85 year-old threshold. To our knowledge, no study has previously included patients exclusively over 85. Performing lumbar spinal decompression with or without fusion on patients over 85 was deemed feasible with no morbidity or mortality increase compared with literature data on geriatric series.

There is no consensus for a comprehensive analysis of degenerative spondylolisthesis of the lumbar spine (DSLS). A new classification system for DSLS based on sagittal alignment was proposed. Its clinical relevance was explored.

The purpose of this study was to evaluate the safety and tolerance of lumbar spine surgery in patients over 85.