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Resume Introduction La simulation dans la formation des internes prend une place croissante en chirurgie. Le gold standard de l’enseignement theorique de la visee pediculaire reste la pratique sur sujets anatomiques. La disponibilite des corps represente une limite de cet enseignement. L’objectif principal de cette etude etait de verifier si un enseignement sur modele en os synthetique premier permettait d’ameliorer l’apprentissage du positionnement de vis pediculaires. L’objectif secondaire etait de verifier l’influence de l’experience prealable de l’interne en chirurgie du rachis. Hypothese L’hypothese principale etait qu’un enseignement theorique couple a une mise en pratique sur os synthetique etait superieur a un enseignement theorique seul. Materiel et methode Vingt-trois internes en orthopedie ont beneficie d’une formation theorique sur la methode de vissage pediculaire a main levee. Six internes avaient une experience prealable du vissage pediculaire. Apres tirage au sort, 11 internes ont beneficie d’un enseignement premier sur os synthetique (groupe 1) et 12 internes n’ont eu qu’un enseignement theorique (groupe 2). Chaque etudiant a ensuite positionne 2 vis thoraciques (T7–T11) et 2 vis lombaires (L1–L5) sur cadavre. Les visees pediculaires etaient analysees par tomodensitometrie selon la classification de Gertzbein (grades 0 et 1 = bon positionnement ; grades 2 et 3 = effraction > 2 mm). Resultat Les taux de bons positionnements sur cadavre etaient de 64,0 % et de 62,5 % en thoracique, de 72,7 % et de 66,6 % en lombaire pour les groupes 1 et 2 respectivement. En comparant les internes des groupes 1 et 2, il n’y avait pas de difference significative du taux d’effractions sur cadavre (p = 0,1809). Un interne ayant beneficie d’un entrainement en simulation avait une chance de diminuer le score de Gertzbein avec un odds-ratio de 1,7714 [0,7710–4,1515]. L’odds-ratio etait de 4,5188 [0,0456–0,8451] lorsqu’on comparait les internes avec une experience prealable du vissage pediculaire aux internes novices. Discussion L’enseignement theorique associe a un modele de simulation est interessant pour enseigner la technique chirurgicale. Un atelier de simulation ponctuel sur os synthetique semble insuffisant pour aboutir a une meilleure precision du vissage pediculaire par rapport a un simple enseignement theorique de la visee pediculaire. L’experience progressive et la repetition de gestes techniques au cours du compagnonnage en chirurgie du rachis avaient une influence sur la precision du vissage pediculaire. Niveau de preuve II.

Study design This was a retrospective clinical review. Objective The objective of this study was to analyze failure mechanisms after total lumbar disk replacement (TDR) and surgical revision strategies in patients with recurrent low back pain (LBP). Summary and background data Several reports indicate that TDR revision surgery carries a major risk and that it should not be recommended. The clinical results of posterior instrumented fusion using the prosthesis like an interbody cage have not been well analyzed. Materials and methods From 2003 to 2018, 48 patients with recurrent LBP after TDR underwent revision surgery. The average age was 39 years (24-61 y). The mean follow-up was 100.4 months (24.6-207.7 mo). Clinical data, self-assessment of patient satisfaction, and Oswestry Disability Index collected at each clinical control or by phone call for the older files and radiologic assessments were reviewed. The surgical revision strategy included posterior fusion in 41 patients (group A) and TDR removal and anterior fusion in 7 patients (group B), of which 6 patients had an additional posterior fixation. Results Facet joint osteoarthritis was associated with TDR failure in 85%. In 68% the position of the prosthesis was suboptimal. Range of motion was preserved in 25%, limited in extension in 65%, and limited in flexion in 40%. Limited range of motion and facet joint osteoarthritis were significantly related (P=0.0008). The complication rate in group B was 43% including iliac vein laceration. Preoperative and 2-year follow-up Oswestry Disability Index were 25.5 and 22.0, respectively, in group A versus 27.9 and 21.3 in group B. Conclusions Posterior osteoarthritis was the principal cause of recurrent LBP in failed TDR. The anterior approach for revision carried a major vascular risk, whereas a simple posterior instrumented fusion leads to the same clinical results. Level of evidence Level IV.

Resume Introduction Le traitement par kyphoplastie et osteosynthese percutanee peut etre indique pour les fractures A3 de T12-L1. Le devenir des disques adjacents reste controverse. Le but de cette etude retrospective etait d’analyser la degenerescence discale adjacente a la fracture et de verifier le lien avec l’âge, la deformation vertebrale et les scores cliniques. Materiel et methodes Vingt-neuf patients (âge moyen 47 ans, 27–63 ans, 11 femmes, 18 hommes) ont ete revus a 2,2 (2,0–2,5) ans de recul. Les mesures radiographiques etaient : cyphose regionale, cyphose locale, sagittal index, taux de compression vertebral, index de hauteur discale. Le grade de Pfirrmann etait verifie sur l’IRM au dernier recul. L’evaluation clinique comprenait l’EVA, l’EQ-5D-3L, l’ODI. Le lien entre l’echelle de Pfirrmann, l’âge et les parametres radiographiques de deformation traumatique etait analyse. Resultats La cyphose locale diminuait de 12,4° a 7,3° en postoperatoire (p Conclusion Le risque de degenerescence discale apres fracture A3 traitee par kyphoplastie et osteosynthese percutanee est faible. Une perte de correction dans le disque crânial est objectivee apres ablation du materiel. La degenerescence est liee a l’âge du patient et la deformation traumatique. La qualite de vie ne semble pas influencee par la degenerescence discale.

Low-grade isthmic spondylolisthesis (ISPL) is generally treated by circumferential fusion with interbody graft, although there is no consensus on technique.The various interbody fusion strategies provide satisfactory fusion rates and clinical results.A multicenter retrospective study analyzed lumbar interbody fusion for low-grade ISPL performed between March 2016 and March 2019. Techniques comprised: circumferential fusion on a posterior or a transforaminal approach (PLIF, TLIF: n=57), combined anterior (ALIF) + posterolateral fusion (ALIF+PLF: n=60), and ALIF + percutaneous posterior fixation (ALIF+PPF: n=55). Function was assessed on a lumbar and a radicular visual analog scale (AVS-L, VAS-R, Oswestry Disability Index (ODI) and Short Form 12 (SF12).85.3% of the 129 patients showed fusion (Lenke 1 or 2), with no significant differences between the ALIF-PLF or ALIF-PPF groups and the PLIF or TLIF groups (p=0.3). Likewise, there was no difference in fusion rates between the ALIF-PPF and ALIF-PLF subgroups (p=0.28). VAS-L (p0.001) and VAS-R (p0.0001), ODI (p0.001) and SF12 physical (PCS) (p0.01) and mental component sores (MCS) (p0.001) all showed significant improvement at 12 months. Combined approaches provided greater clinical efficacy than TLIF or PLIF for lumbar (p0.0001) and radicular pain (p0.05), ODI (p0.0001) and SF12 PCS (p0.01). At 12 months, there was no clinical difference between the ALIF-PPF and ALIF-PLF subgroups. However, patents with interbody non-union (Lenke 3 or 4) had lower SF12 PCS scores (p0.004) and VAS-L ratings (p0.001) than Lenke 1-2 patients.Low-grade ISPL treated by circumferential arthrodesis and interbody graft showed 85.3% consolidation at 2 years, with equivalent outcomes between anterior and posterior techniques. Successful fusion was associated with better clinical results.IV.

Low-back pain requires comprehensive care using a biopsychosocial model. The psychologic dimension plays an important role, but the link between sagittal alignment and a given psychopathological profile is little studied. The aim of this study was to analyze the psychopathological profiles and sagittal parameters of a population with low-back pain and to assess the link.205 patients, with a mean age of 49.6 years (range, 18-70 years), presenting chronic common low-back pain without radicular involvement, were included prospectively. Mood scores comprised: the self-administered "Hospital Anxiety and Depression Scale" (HAD), Hamilton Anxiety Scale (HAM-A), Hamilton Depression Scale (HAM-D) and Young Mania Rating Scale (YMRS). Radiological parameters, measured on lateral full-spine radiographs, included: L1-S1 lordosis, T1-T12 kyphosis, pelvic incidence, pelvic tilt, sacral slope, sagittal vertical axis (SVA), T1 slope, and Roussouly type.Mean HAM-A score was 16.1; 54% of patients had scores ≥14, indicating anxiety disorder. Mean HAM-D score was 10.8; 55% of patients had scores ≥10, indicating depressive disorder. Mean YMRS score was 2.6; only 1 patient had a score ≥20, indicating manic disorder. The 112 patients with HAM-A score14 showed mean 51.6° L1-S1 lordosis (p = 0.356), 48.3° T1-T12 kyphosis (p = 0.590), -4.3mm C7 SVA (p = 0.900), and 29.3° T1 slope (p = 0.451). In case of HAM-A14, there were no significant differences. The 113 patients with HAM-D score10 showed significant differences in T1-T12 kyphosis (mean 49.0°; p0.05) and T1 slope (30.2°; p0.05); mean L1-S1 lordosis was 50.5° (p = 0.861) and C7 SVA 1.6 mm (p = 0.462). In case of HAM-D10, T1-T12 kyphosis was 45.5° (p0.05) and T1 slope 26.2° (p0.05); mean lordosis was 50.9° (p = 0.861) and mean C7 SVA -7.1mm (p = 0.259). Multivariate analysis found no significant link between Roussouly type and psychiatric scores: HAD (p = 0.715), HAM-A (p = 0.652), and HAM-D (p = 0.902).More than 50% of patients with common low-back pain presented a mood disorder. Depressive disorder was associated with greater T1-T12 kyphosis and T1 slope. There was no relationship between psychiatric scores and overall sagittal alignment.II.

Metal artifact reduction (MAR) algorithms are used with cone beam computed tomography (CBCT) during augmented reality surgical navigation for minimally invasive pedicle screw instrumentation. The aim of this study was to assess intra- and inter-observer reliability of pedicle screw placement and to compare the perception of baseline image quality (NoMAR) with optimized image quality (MAR). CBCT images of 24 patients operated on for degenerative spondylolisthesis using minimally invasive lumbar fusion were analyzed retrospectively. Images were treated using NoMAR and MAR by an engineer, thus creating 48 randomized files, which were then independently analyzed by 3 spine surgeons and 3 radiologists. The Gertzbein and Robins classification was used for screw accuracy rating, and an image quality scale rated the clarity of pedicle screw and bony landmark depiction. Intra-class correlation coefficients (ICC) were calculated. NoMAR and MAR led to similarly good intra-observer (ICC > 0.6) and excellent inter-observer (ICC > 0.8) assessment reliability of pedicle screw placement accuracy. The image quality scale showed more variability in individual image perception between spine surgeons and radiologists (ICC range 0.51–0.91). This study indicates that intraoperative screw positioning can be reliably assessed on CBCT for augmented reality surgical navigation when using optimized image quality. Subjective image quality was rated slightly superior for MAR compared to NoMAR.

Minimally invasive surgery (MIS) techniques have been developed for the surgical treatment of thoracolumbar spinal metastases to reduce the morbidity associated with the operation. The purpose of our study was to compare the mean length of stay, change in pain levels, neurological symptoms, complications and survival after open versus MIS surgery.This is a single-center retrospective study based on a register of patients treated for vertebral metastases between January 2014 and October 2016. The collection included demographic data, cancer-related data, clinical data, the characteristics of the surgery, the length of stay, assessment of pain and the occurrence of death. These data were compared between open and MIS surgery groups.Out of 59 patients, 35 were treated with open surgery and 24 were treated with MIS surgery. The two groups were comparable in terms of age, gender and body mass index. Breast, kidney, prostate and lung cancers were the most frequent primary tumors. Prognostic and instability scores were comparable. Short- and medium-term pain assessment showed comparable results. Median survival was 208 days in the open surgery group and 224days in the MIS group (p=0.5299).MIS techniques aim to limit the surgical approach and allow a faster introduction of adjuvant treatments than after open surgery. Our study did not find any differences between open and MIS surgery in terms of pain, neurological evolution or survival time in patients treated for thoracolumbar spinal metastases.IV; retrospective study.

The two-dimensional fluoroscopic method of percutaneous pedicle screw instrumentation has been clinically described as reliable method in the caudal thoracic and lumbosacral spine. Its accuracy has not been clearly reported in the cranial thoracic spine. The aim of this in vitro study was to investigate percutaneous pedicle screw placement accuracy according to pedicle dimensions and vertebral levels. Six fresh-frozen human specimens were instrumented with 216 screws from T1 to S1. Pedicle isthmus widths, heights, transversal pedicles and screws were measured on computed tomography. Pedicle cortex violation ≥ 2 mm was defined as screw malposition. The narrowest pedicles were at T3–T5. A large variability between transversal pedicle axes and percutaneous pedicle screw was present, depending on the spinal level. Screw malposition rates were 36.1% in the cranial thoracic spine (T1–T6), 16.7% in the caudal thoracic spine (T7–T12), and 6.9% in the lumbosacral spine (L1–S1). The risk for screw malposition was significantly higher at cranial thoracic levels compared to caudal thoracic (p = 0.006) and lumbosacral (p

Introduction Simulation workshops for surgical training of residents are becoming popular. The gold standard for teaching thoracolumbar pedicle screw placement are cadaver labs; however, the availability of human bodies is limited. The primary objective of this study was to determine if training on a synthetic bone model improves the apprenticeship of accurate pedicle screw placement. The secondary objective was to check the influence of residents’ previous experience in spine surgery. Hypothesis The main hypothesis was that theoretical learning with practical application on synthetic bone was superior to theoretical learning alone. Methods Twenty-three orthopedic residents were taught about free-hand pedicle screw placement using a theoretical presentation. Six residents had previous experience with screwing techniques. After randomization in two groups, 11 residents (group 1) participated in a workshop on synthetic bone, whereas 12 residents received only theoretical instruction (group 2). Each resident was asked to place two thoracic screws (T7-T11) and two lumbar screws (L1-L5) on a cadaver. Screw placement accuracy was analyzed using the Gertzbein classification on computed tomography (grades 0 and 1 = accurate positioning; grades 2 and 3 = malposition > 2 mm). Results Rates of accurate screw positioning were 64.0% and 62.5% for thoracic levels, and 72.7% and 66.6% for lumbar levels in group 1 and 2, respectively. There was no significant difference in malposition rates on cadavers between the groups (p = 0.1809). A resident who was first trained by simulation had a chance of decreasing the Gertzbein score with an odds-ratio of 1.7714 [0.7710–4.1515]. The odds ratio was 4.5188 [0.0456–0.8451] when comparing residents with previous experience in spinal surgery to novice residents. Discussion Theoretical teaching associated with a simulation model is relevant for learning a surgical technique. A single simulation workshop on synthetic bone seems insufficient to improve pedicle screw placement accuracy compared to theoretical teaching alone. Progressive experience and the repetition of technical gestures during hands-on supervised learning in spine surgery with a senior surgeon had an influence on the accuracy of pedicle screw placement. Level of evidence II.

A long global thoracolumbar kyphosis is common in ankylosing spondylitis. Surgical correction of fixed sagittal malalignment by pedicle subtraction osteotomy (PSO) might improve disability and quality of life (QoL). Two-level osteotomies represent major procedures with a risk of hemorrhage. Combined open and minimal invasive surgery has not been described and might be considered. A 30-year-old female with ankylosing spondylitis was treated by golimumab and teriparatide. The treatment was stopped during pregnancy which led to vertebral compression fractures and kyphosis of 50° between T11 and L3. A PSO was planned at the kyphotic apex L2. The second PSO was planned at L4 according to the pelvic incidence of 56°, matching with a spinopelvic alignment Roussouly type 3. A derived full balance integrated method was used to calculate the amount of correction. During the first stage surgery, an open approach was performed from L1 to pelvis and combined with percutaneous cement-augmented instrumentation in already fused segments T5–T12, thus reducing perioperative morbidity. A stepwise approach including L2 PSO closure with temporary rods and L4 PSO with final instrumentation was used. Blood loss was estimated around 1100 ml. The patient was able to walk on the second day after surgery. A secondary anterior fusion with LLI cages from L2 to L5 and an ALIF at L5–S1 were performed because of high non-ossified intervertebral disks to reduce the risk for nonunion and rod fractures. At 2-year follow-up, the patient’s QoL had significantly improved and full spine radiographs showed stable normalized sagittal parameters. The combined open and percutaneous approach was feasible and might be considered as an alternative option to conventional open surgery when planning major deformity correction in ankylosing spondylitis.

Percutaneous instrumentation and kyphoplasty can be used to treat A3 fractures at T12-L1. However, the effect on adjacent intervertebral discs remains controversial. The purpose of this retrospective study was to analyze the degeneration of the discs adjacent to the fracture and to determine its relationship with age, vertebral body deformity and clinical scores.Twenty-nine patients (11 females, 18 males; average age 47 years, 27-63 years) were examined at 2.2 years' follow-up (2.0-2.5). Radiographic measurements were taken preoperatively, postoperatively, at follow-up: regional and local kyphosis, sagittal index, vertebral body compression ratio, and disc height index. The Pfirrmann grade was determined on an MRI taken at the final assessment. Clinical scores were the pain level (VAS), EQ-5D-3L, and ODI. The relationships between Pfirrmann grades, age and radiographic parameters were analyzed.Local kyphosis decreased from 12.4° to 7.3° postoperatively (p0.0001), increased to 8.4° after instrumentation removal (p=0.139) and remained stable at the last follow-up (p=0.891). The sagittal index decreased from 12.3° to 7.3° postoperatively (p0.0001) increased to 8.3° before the instrumentation was removed (p=0.764) and increased to 10.6° (p0.05) at the last follow-up. The vertebral body compression ratio decreased from 23% to 14% postoperatively (p0.0001) and remained stable at 17% at the last follow-up (p=0.310). The cranial disc height index was 32% preoperatively, 31% postoperatively (p=0.073), 29% at 1year (p=0.650), and decreased again to 23% at 2 years (p0.0001). There was a significant relationship between disc degeneration and age (p=0.015), local kyphosis (p=0.008) and vertebral body compression ratio (p=0.002). The disc adjacent to the fracture was more likely to have a higher Pfirrmann grade than the control disc above it (OR=269.5). At the final assessment, the average pain level was 2.3, the EQ-5D-3L was 0.862, and the ODI was 11.8%. There was no significant relationship between the Pfirrmann grades and the clinical scores.The risk for cranial disc degeneration after percutaneous instrumentation and kyphoplasty of A3 fractures is low. The height of the cranial disc decreased after the instrumentation was removed. The risk for disc degeneration is related to age and vertebral body deformity. Disc degeneration does not appear to impact quality of life.