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Spinal endoscopy is the result of an evolution of techniques and technologies in the service of an ever less invasive surgery. It allows the treatment of a large range of pathologies such as disc herniation or spinal stenosis and this range continues to increase. It has already proven its non-inferiority and cost-effectiveness compared to microsurgery despite a difficult learning curve. It has the potential to replace the microscopic «gold standard» as it allows a faster recovery for the patient and a shorter hospital stay.L’endoscopie spinale est le résultat d’une évolution des techniques et des technologies au service d’une chirurgie toujours moins invasive. Elle permet de traiter un bon nombre de pathologies telles que la hernie discale ou la sténose canalaire et ce nombre continue d’augmenter. Elle a déjà prouvé sa non-infériorité et son rapport coûts-bénéfices avantageux par rapport à la microchirurgie, et ce, bien que sa courbe d’apprentissage ne soit pas toujours aisée. Elle a le potentiel de remplacer le « gold standard » microscopique car elle permet une récupération plus rapide pour le patient et une hospitalisation plus courte.

"Herniated disc and occupational disease: words matter! Chronic diseases of the lumbar spine are one of the most frequent reasons for declaring an occupational disease. Issues related to their professional recognition are important for the patient. This recognition obeys specific rules, including the limiting nature of the diseases designated in the tables of occupational diseases. Regarding sciatica and cruralgia, the existence of a herniated disc with nerve root impingement of concordant topography is essential. However, the variability of the terminology used to describe disc herniation can be a source of ambiguity, with negative consequences for the patient concerning his administrative actions. After summarising principles of occupational diseases recognition in France, this article highlights certain pitfalls to avoid for physicians in order to provide optimal support to their patients and protect their rights.""Hernie discale et maladie professionnelle : la sémantique est importante ! Les affections chroniques du rachis lombaire constituent un des motifs les plus fréquents de déclaration de maladie professionnelle. Les enjeux liés à la reconnaissance de leur caractère professionnel sont importants pour le patient. Cette reconnaissance est régie par certaines règles, parmi lesquelles figure le caractère limitatif des maladies désignées dans les tableaux de maladies professionnelles. S’agissant des sciatiques et cruralgies, l’existence d’une hernie discale avec atteinte radiculaire de topographie concordante est indispensable. Or la variabilité de la terminologie utilisée pour la description des saillies discales peut être source d’ambiguïté. Cette ambiguïté a malheureusement tendance à être défavorable au patient dans ses démarches. Après un rappel sur les principes fondamentaux qui régissent la reconnaissance des maladies professionnelles en France, sont signalés certains écueils à éviter pour accompagner au mieux les patients dans leurs démarches et préserver leurs droits."

Diagnostic brought in lomboradicular pain in the lower limbs. Lower limbs radicular pain are frequent. Most of them are caused by lumbar disc herniation or osteoarthritis spinal stenosis. Interrogation and clinical examination are the key stages of the diagnosis, allowing to detect signs of gravity and to rule out the differential diagnosis. The progress of radiological technics, in particular the MRI, considerably simplified the diagnostic approach, but require confronting, with a rigorous objectivity, imaging with the clinical data. The diagnostic approach has to answer two questions: does the symptoms correspond to a common lomboradicular pain or to an other explanation, tumoral for example? In case of common lomboradicular pain, is it a disc herniation, osteoarthritis, or lumbar spinal stenosis?Conduite diagnostique devant une lomboradiculalgie des membres inferieurs. Les lomboradiculalgies des membres inférieurs sont fréquentes. Dans la grande majorité des cas, la cause est d’origine discale (hernie discale) et/ou arthrosique. L’interrogatoire et l’examen clinique sont les étapes clés du diagnostic, permettant également de rechercher des signes de gravité et d’écarter les diagnostics différentiels. Les progrès de l’imagerie, et notamment de l’imagerie par résonance magnétique, ont considérablement simplifié la démarche diagnostique, sous réserve de confronter avec une objectivité rigoureuse les images aux données cliniques. Ainsi, la conduite diagnostique doit permettre de répondre à deux questions : la douleur correspond-elle à une lomboradiculalgie commune (discale et/ou arthrosique) ou est-elle symptomatique d’une autre cause (tumorale par exemple) ? En cas de lomboradiculalgie commune, s’agit-il d’une hernie discale, d’une arthrose, d’un canal lombaire rétréci ?

The definitive treatment of lumbar disc herniation with radiculopathy includes interventional spine procedures and surgical treatment (open or micro discectomy). It is indicated in emergency in specific situations: in case of cauda equina syndrome, motor deficit lower or equal to 3/5 or hyperalgic radicular pain resistant to maximal medical therapy, including opioid drugs. In these situations, there is no place for percutaneous treatment techniques; treatment is surgical. Except these emergency situations, a definitive treatment is indicated in case of ineffectiveness of complete medical treatment for at least six weeks. The objective is the treatment of radicular pain; the effect on the associated low back pain is unpredictable. In this context of functional surgery, patient selection is very important. Results of interventional procedures for disc herniation are still poorly documented and should be best carried in the context of evaluation protocols. At present standard treatment remains minimal invasive discectomy.Traitement chirurgical de la hernie discale lombaire. Le traitement radical de la hernie discale comporte les techniques de traitement percutané et le traitement chirurgical, idéalement à type de microdiscectomie. Il est indiqué en urgence dans des situations bien précises : devant un syndrome de la queue de cheval, un déficit moteur inférieur ou égal à 3/5 d’installation rapide ou une douleur radiculaire hyperalgique résistant au traitement médical maximal, y compris les opiacés. Dans ces contextes d’urgence, il n’y a pas de place aux techniques de traitement percutané, le traitement est chirurgical. En dehors de ces situations d’urgence, le traitement radical est indiqué en cas d’inefficacité d’un traitement médical bien conduit pendant au moins six semaines. L’objectif est le traitement de la douleur radiculaire, l’effet sur la lombalgie associée étant imprévisible. Dans ce contexte de chirurgie fonctionnelle, la sélection des patients est donc très importante. Le recours aux techniques de traitement percutanées est encore mal codifié et doit se faire au mieux dans le cadre de protocoles d’évaluation. Le traitement standard reste à l’heure actuelle la discectomie par voie mini-invasive.

Objectives A myriad of negative bodily health effects related to tobacco smoking is known while its detrimental effects on the spine in particular are less defined. The goal of the current study is to compare long-term outcome between smokers and non-smokers after non-instrumented lumbar spine surgery. Patients and methods Prospective observational study on n = 172 consecutive patients undergoing non-instrumented spine surgery for lumbar disc herniation (LDH) or lumbar spinal stenosis (LSS) with a follow-up (FU) of 4.5 years. Patients were dichotomized according to their smoking status at the time of surgery. Back pain and health-related quality of life (HRQoL) were assessed using the visual analogue scale (VAS) and the Short-Form (SF)-12. Any subsequent lumbar spine surgeries since the index surgery were registered. Logistic regression analysis was used to estimate the effect size of the relationship between smoking and the responder status to surgery in terms of pain and HRQoL-metrics. Results Complete FU data was available for n = 29 (55%) smokers and n = 75 (63%) non-smokers. At discharge, 1 month, 1 year and 4.5 years, smokers were as likely as non-smokers to achieve a favourable response to surgery in terms of VAS back pain and the SF-12 mental and physical component scale metric. A subgroup analysis on active smokers throughout the entire study interval did not find an inferior responder rate than in never-smokers. A trend for additional lumbar spine surgery performed in 17.2% of the smoking and 8.2% of the non-smoking patients during FU was observed (OR 2.39, 95% CI 0.67–8.57, p = 0.179). Conclusion Up to 4.5 years following non-instrumented lumbar spine surgery, there was no difference in the pain or HRQoL-responder status of smokers and non-smokers. Smokers may be more likely to undergo re-do surgery in the long term, but more data is needed to confirm this statistical trend.

Vascular complications of lumbar disc surgery are rare. Few cases have been reported. Arteriovenous fistulas are the most common. They are due to anatomical relationships between the last lumbar vertebrae, the corresponding discs, and the iliac vessels; degenerative lesions of the intervertebral discs facilitate instrumental vessel perforation, and operative difficulty. Computed tomography is particularly accurate for making the diagnosis. Treatment strategies consist in surgery or endovascular management. Percutaneous endovascular treatment using a stent-graft is a reasonable option for treating arteriovenous fistula. We describe the case of a 50-year-old patient who developed an iliocaval arteriovenous fistula following lumbar disc hernia surgery. The lesion was excluded by a stent-graft. The postoperative period was uneventful.

Lumbar disc herniation frequently affects young patients and is responsible for high rate of worker's compensation claims. The aim of this study is to evaluate at short and long-term the results of microdiscectomy in terms of pain control, quality of life and patient's satisfaction.In this prospective study, 28 patients were enrolled and operated on by microdiscectomy for lumbar disc herniation. Three questionnaires were administered preoperatively. They evaluated the pain, the quality of life and the expectation of the patients. Four questionnaires were administered at six months and two years postoperatively evaluating pain, quality of life, results and satisfactions.A 62.3% and 53.2% improvement of low back pain at 6 months and 2 years respectively, and a 91.7% and 88.4% improvement of radicular pain were reported. A 73.2% and 79.8% improvement in quality of life was recorded respectively. Patient's expectation was evaluated at 3.85 and results estimated 3.24. Patient's satisfaction was 93.3% and 88.3% respectively. It was positively correlated to radicular pain, and inversely correlated to patient's expectations.Microdiscectomy for lumbar disc herniation offers a marked improvement in back and radicular pain. Quality of life is much improved. Although satisfaction is high, it is somewhat decreased for patients with high expectations.

A lumbar disc herniation (LDH) is a condition frequently encountered in primary care medicine. It may give rise to a compression of one or more nerve roots, which can lead to a nerve root irritation, a so-called radiculopathy, with or without a sensorimotor deficit. The majority of LDHs can be supported by means of a conservative treatment consisting of physical therapy, ergotherapy, analgetics, anti-inflammatory therapy or corticosteroids, which may be eventually administered by infiltrations. If a clinico-radiological correlation is present and moderate neurological deficit appears suddenly, if it is progressive under conservative treatment or if pain is poorly controlled by well-conducted conservative treatment performed during four to six months, surgery is then recommended.

Spinal cord infarction is a rare but devastating pathology causing acute neurological deficits. The incidence has been estimated to 1% of all strokes. In that case report, our patient has presented anterior spinal artery infarction in C5-C6. The only risk factor founded was a multileveled discopathy wich is known to be an uncommon cause of anterior spinal artery syndrome.

Major vessel injury is a rare complication of spinal surgery. Iliac artery injury is the most common. Frequently, a chronic arteriovenous fistula develops.We describe the case of a 63-year-old woman who had developed a chronic arteriovenous fistula following lumbar disc hernia surgery. The patient was treated using an Anaconda™ stent graft (Vascutek Terumo). After 2years, the prothesis thrombosed and an aorto-iliac bypass was performed.A gel soft prosthesis 18/9 (Vascutek Terumo) was implanted by laparotomy. The postoperative period was uneventful. A month later, the patient had recovered good lower limb function.The choice between endovascular versus open surgery must take into account the patient's age, the risk of long-term complications, and the need for radiographic surveillance. Curative open surgery remains a valid option for young patients.

We report on two cases of spontaneous resorption of a calcified thoracic hernia. This phenomenom is widely recognised in lumbar and cervical hernia, but is exceptional at the thoracic level. The potential mechanisms underlying this resorption are discussed trough a review of the literature. We think this could be another argument for a "wait and watch" period before a surgical decision in the patients who have few symptoms.

Paralysing lumbar disc herniation (LDH): what and when to do? Few studies have analyzed the optimal timing of surgery in case of paralysing LDH.Twenty-four charts were retrospectively reviewed of patients suffering of LDH with severe motor deficit.There were 16 men and eight women. Mean age was 45.1 years. Seventeen patients suffered of lumbar pain, 15 of radicular pain and all of a severe motor deficit, implying mostly the ankle flexion (17 patients). LDH was most frequently located at L4/L5 or L5/S1 level. Surgery was proposed to all patients at the end of the consultation. Nine patients were operated within 48 hours. The mean interval between onset of motor deficit and operation was 20 days. The statistical analysis did not reveal any significant difference among different prognostic factors between the 17 patients with good motor recovery and the seven patients with poor motor recovery. In particular the operative delay did not appear to influence the degree of motor recovery. Literature review on paralysing LDH provides five published series since 1996, including 28 to 116 patients. Two series, including the single prospective one, conclude that the degree of recovery of motor function is inversely related to the degree and duration of motor deficit.Our retrospective series of 24 operated paralysing LDH did not reveal any prognostic factor for motor recovery. There is no evidence based medicine data in the literature about the optimal timing of decompressive surgery. A relative consensus exists among spine surgeons for paralysing LDH: since operative indication is obvious, surgery should be done as soon as possible.

We report the case of bilateral peroneal neuropathy following massive weight loss after bariatric surgery. A few months after a gastric by-pass, the patient developed sequentially within 6 months a L2-L3 herniated disc that required surgery, a severe right peroneal nerve palsy that led to decompressive surgery and finally contralateral peroneal nerve palsy also operated. The electrophysiological analysis confirmed the clinical suspicion of peroneal nerve compression at the fibular head. Postoperative course was favorable. Literature reports peroneal nerve palsy after slimming, mostly when weight loss is fast and marked although the issue is rarely bilateral.

Although systemic glucocorticoids are frequently used for the treatment of radicular pain due to disc herniation, there are only few studies available. No trial has successfully demonstrated the superiority of systemic glucocorticoids compared to placebo. Therefore their use is not recommended. Spinal injection using radiographic guidance appears to provide some beneficial short-term effect on pain. It might be offered when pain treatments according to the WHO steps have failed. Because rare but serious adverse events have been reported, transforaminal periradicular injections should only be used after thorough analysis of risks and benefits with the patient.

Various techniques are available for lumbar disc surgery. But failure and severe adverse events still occur during such procedures. Recent work concluded that the use of microscope was not mandatory for such procedures.The first 70 spinal procedures for lower limb radicular syndrome by a surgeon at the beginning of this activity where studied. Particular interest was paid on adverse events, especially complications and failures.Average duration of surgery (50min) and rate of reoperation (six reoperations needed out of 65 patients, five of them by the same surgeon) where, as expected, a bit higher than published in experienced hands. But no battered-root syndrome, injury to neighboring structures or other severe complication was observed. Noteworthy is that no patient was neurologically worsened by surgery.If the use of microscope may not be needed for lumbar disc open surgery in experienced hands, we strongly advice surgeons at the beginning of their practice to use it. At least, to avoid unforgiving mistakes such as picking out the root instead of the herniation.

We report a case of a 51-year-old man who underwent a third kidney transplantation that was complicated by tetraparesia due to a C5-C6 cervical disc hernia decompensation in the immediate postoperative period. Preoperative consultation for long-term haemodialysis patients could be perfected by further neurological investigation and additional imagery.

Klippel-Feil syndrome (KFS) is defined as a congenital fusion of at least two cervical vertebrae. Patients with KFS are known to be at high risk for spinal cord injury in case of cervical trauma even with weak kinetic. We report the case of a patient with C4-C5 and C6-C7 congenital fusion, harbouring C5-C6 post-traumatic spinal cord injury, associated with an odontoid fracture type 2 of Anderson and D'Alonzo classification following a motorbike accident.

Recurrent radiculopathy after lumbar microdiscectomy may decrease the quality of life of operated patients. Epidural fibrosis is considered to be one of the mechanisms that could be responsible for the pain. Therefore, the use of a resorbable gel to separate the lumbar nerve roots from the surrounding bone, muscles and disc remnants, could reduce scarring and postoperative pain, improve clinical outcome and make revision surgery easier. We reviewed the literature about efficacy and complications of adhesion prevention in the lumbar spine. Although the first attempts to achieve adhesion prevention were not conclusive, the results of the most recent trials about polyethylene oxide/carboxymethylcellulose based or polyethylene glycol based gels provide encouraging safety evidences and promising efficacy results.

Spinal cord injury with no radiographic bone lesion described as spinal cord injury without radiographic abnormality (SCIWORA) in childhood is less often reported in adults than in children. This study was undertaken to report our experience in the management of nine cases over 25 years.This was a retrospective study from 1985 to 2009 concerning nine adult patients who sustained spinal cord injury with no radiographic abnormality. The ratio among all cervical spine traumas for the same period was 2.21%. Magnetic resonance imaging (MRI) was performed in all the patients. The patients' clinical status at the time of admission and discharge was evaluated using the Frankel's grading system. We report the results based on the clinical, epidemiologic and radiological findings and outcomes.The mean age of our population was 37.43 years, ranging from 18 to 60 years. All the patients were men. The main etiology was falls (5/9) followed by road traffic accidents (4/9). According to the Frankel's grading system, four patients (44.45%) were grade A, four were grade B (44.45%), and one was grade C (11.11%). On MRI, medullar lesions were: contusion, non-compressive cervical disc herniation, cervical spine stenosis, and two cases of normal cervical spine. Four patients were operated on via the posterior cervical spine approach (laminectomy, C3-C7 in three cases and C1-C3 in one case). The other five patients were treated orthopaedically for 6 to 8 weeks. Three patients (3/9), who were Frankel's grade B and C with no demonstrable injury on MRI, improved to Frankel a useful neurological grade (Frankel's grades D or E) at the time of discharge. One patient evaluated as Frankel's grade A died from cardiovascular disturbance.Spinal cord injury with no radiographic abnormality accounted for 2.21% of cases of spinal cord injury in our series. MRI is the investigation of choice, having diagnostic and prognostic value because it demonstrates neural and extraneural injuries and helps to identify surgically correctable abnormalities.

Necessity of physical activities restriction after lumbar discectomy have been described in the literature.The aim of this study was to determine if early rehabilitation could favorably influence the prognosis of military patients who had undergone lumbar disk surgery.We performed a retrospective study involving patients who have had lumbar disk surgery, and had undergone physical rehabilitation program. A clinical evaluation, an assessment of pain and a functional assessment by the Arabic version amended self-questionnaire Oswestry have been made for these patients before and after a rehabilitation program started since the 40th postoperative day.We have collected 50 cases: 40 men and 10 women of average age 30 years. All these patients have been improved after surgery with no radiculalgies, but with persistence lumbar pain syndrome. After rehabilitation program, we noted a reduction of 42.85% of pain and functional improvement with a reduction in the average score of Oswestry index of 61.18%. The average work incapacity was 4 months. A workstation adaptation was indicated for all patients.Intensive rehabilitation program started early after lumbar disk surgery can improve the functionality of patients operated, and allows early return to professional activities with reduction of the healthcare cost.

Objective To evaluate trunk and knee muscle strength in patients with chronic sciatica. Patients and method Twenty-eight patients with right-side chronic sciatica (group 1, G1) and 40 healthy controls (group 2, G2) were evaluated using an isokinetic dynamometer (Cybex Norm II). Quadriceps and hamstring muscle strength were evaluated at concentric velocities of 60 and 120°/s and the trunk muscles were evaluated at concentric velocities of 60 and 90°/s. Results G1 comprised 15 women and 13 men (mean ± SD age: 34.787 ± 6.06; weight: 65.85 ± 5.33 kg; height: 165 ± 6.92 cm). G2 comprised 20 women and 20 men (mean ± SD age: 35.92 ± 6.66; weight: 67.07 ± 6.12 kg; height: 165.82 ± 7.65 cm. There were no significant inter-group differences concerning these parameters. In G1, the peak torque values for the trunk extensors were 123.71 ± 32.45 and 108.85 ± 32.07 Newton metres (Nm) at angular velocities of 60 and 90°/s, respectively. In G2, the values were 192.73 ± 64.24 and 168.65 ± 53.96 Nm, respectively. In G1, the peak torque values for the trunk flexors were 134.32 ± 30.77 and 124.39 ± 32.59 Nm at angular velocities of 60 and 90°/s, respectively. In G2, they were 177.44 ± 44.1 and 157.81 ± 39.01 Nm, respectively. The difference between G1 and G2 was statistically significant. The peak torque for the right quadriceps in G1 was 100.03 ± 24.45 and 78.71 ± 22.92 Nm at angular velocities of 60 and 120°/s, respectively. In G2, these values were 160.5 ± 36.34 and 131.05 ± 33.42 Nm. The peak torque for the hamstrings in G1 was 56.42 ± 13.02 and 50 ± 13.55 Nm at angular velocities of 60 and 120°/s, respectively. In G2, these values were 97.77 ± 33.32 and 84.72 ± 31.41 Nm. Again the difference between G1 and G2 was statistically significant. We also noted a statistically significant difference between G1 and G2 in terms of the peak quadriceps and hamstring torque values on the left side. In G1, the quadriceps and hamstrings were significantly weaker on the sciatica side than on the unaffected side. Conclusion The present study demonstrated trunk and knee muscle weakness in patients with chronic sciatica, when compared with healthy subjects. This weakness was predominant on the sciatica side. Consequently, the management of these patients should include a knee muscle reinforcement programme.

Posterior épidural migration of a lumbar disc herniation is rare. Clinical symptoms frequently indicate severe radicular compression. Cauda equina syndrome is very unusual. Three cases of cauda equina syndrome from posterior epidural migration of a lumbar disc herniation along with a review of the literature are presented to illustrate the Imaging features of this entity and related diagnostic difficulties. Finaly, early surgical management is the treatment of choice for optimal symptomatic recovery.

The knowledge on radiculopathy due to lumbar disc herniation has considerably improved over the last years. The physiopathology has been better characterised, new drugs are under investigation and thanks to high quality studies, and the role of surgery is now better defined. This review focused on practical principles for the general practitioner.

Objectives Mechanical low back pain (LBP) is a major public health problem. Today's standard care strategy involves a combination of drug-based and non-drug therapies. The use of conservative orthopaedic brace treatment is subject to debate. The lack of data and consensus in the literature on the value of this treatment in chronic LBP prompted to us to seek to estimate the modalities and indications for brace use in France. Materials and method We performed a questionnaire-based survey of physician members of the French Society of Physical Medicine and Rehabilitation (SOFMER). Results We received 55 completed questionnaires. Although the indications for this treatment were very heterogeneous (in both clinical and paraclinical terms), the prescribing behaviour was rather uniform. The brace is worn during the day for less than 3 months (with a progressive reduction in use over 1 to 2 months), together with physiotherapy before and after immobilization. The patient keeps the brace at the end of the treatment period. Orthopaedic treatment appears to be prescribed in many chronic LBP situations. Analysis of spinal posture and magnetic resonance imaging results (and Modic changes in particular) influence the therapeutic decisions. Conclusion Clinical and paraclinical indications of this treatment must be precisely defined and evaluated in prospective, multicenter studies with homogeneous cohorts.

To evaluate the efficacy of CT-guided epidural and transforaminal steroid injections in patients with diskogenic radiculopathy.Seventy patients underwent CT guided injections after failure of medical management. Only patients with minimal degenerative changes and diskogenic monoradicular symptoms were treated. Only two patients with fibrosis were included.78.6% of patients experienced persistent symptomatic improvement. No difference was noted between lumbar segments and there was no more failures with epidural injections compared to transforaminal injections. Cervical disk herniations responded better than lumbar disk herniations. Good results were obtained in younger patients (M=46.25 years), symptomatic for 3-4 months or less, and with clear radicular symptoms and clinical neurological deficits (hypoesthesia, absent DTR) without motor deficit. No patient with severe spinal stenosis (S-) was included and the disk herniations were small (b1, b2, c1, c2 or d1, d2). Only a single injection was needed. Cortivazol provided superior results compared to dexamethasone.CT-guided injections should be included in the therapeutic armamentarium after standard medical management, with cure as the goal.

Radiculopathy is a common condition, characterized by a spontaneous regression: in 95 percent of patients, it resolves without surgery, within 1 to 12 months. To shorten the course of this disease, enable patients to resume social and professional activities and avoid chronicity, several therapeutic solutions have been assessed. Based on scientific evidence supporting effectiveness, physicians may prescribe analgesics, NSAID and epidural infiltrations, which probably relieve the pain and improve the quality of life without really modifying the mid-term prognosis. Following a specialized physical, social and professional assessment, surgery may be offered to patients who keep experiencing radicular (and not lumbar) pain. The complication rate is approximately 1 to 3 percent. The effectiveness of surgery is well established, especially with an improved recovery time (50 percent as compared to medical treatment). However, the superiority of a particular surgical technique has not been demonstrated. To date, we are still lacking evidence to demonstrate the effectiveness of percutaneous techniques in good methodological conditions. Finally, confinement to bed, cortisone administered per os or IV, localized spinal manipulations, corsets, vertebral tractions and physiotherapy have no demonstrated impact on the course of sciatica.

Anterior lumbar interbody fusion (ALIF) has gained popularity for the treatment of degenerative disease of the lumbar spine. In this report, we present our experience with the ALIF procedure for treatment of failed back surgery syndrome following lumbar discectomy in a noncontrolled retrospective cohort.From 1st January to 31 December 2005, we performed an ALIF in 46 patients presenting with low back pain with or without radiculopathy. All patients had a history of intractable pain resistant to conventional medical treatment and failed posterior lumbar surgery. Clinical and radiological outcomes were recorded. Neurological pain and functional outcomes were measured postoperatively (at 1, 3 and 12 months). Operative data, intraoperative complications, and the fusion rate were recorded.Forty-six patients with a preoperative diagnosis of failed back surgery syndrome underwent ALIF. The mean follow-up was 21 months. Back pain and leg pain completely disappeared in 60.9% of patients, decreased but required occasional medication in 28.3%, and 10.8% declared no benefit from ALIF surgery.On the basis of our results, we found ALIF to be a safe and effective procedure for the treatment of failed back surgery syndrome.

The purpose of this study was to determine whether spinal fusion using radiotransparent cages can be an appropriate treatment for traumatic injury of the cervical spine.This series included 30 patients aged 17-84 years (average 46 years) treated between October 1999 and June 2003 for traumatic injury of the cervical spine without neurological deficit or cord injury. There were two bifocal cases so that the study concerned 32 fusions. Injuries were: tear drop (n=1), serious flexion sprain (n=8), biarticular dislocation (n=4), serous hyperextension sprain (n=4), dislocation-fracture (n=1), uniarticular fracture (n=7), fracture-separation of the facet joints (n=4), post-traumatic herniation (n=3). For each injury, we measured pre and postoperatively and at last follow-up: the intersomatic angle, anterior displacement, and height of the intersomatic space at the center of the intervertebral disc. All x-rays were read twice, by two independent investigators. In the event of disagreement, the x-rays were read again by a senior surgeon and the main author of this article. Anterior fusion was achieved using a Poly Ether Ether Ketone (PEEK) (32%) and knitted carbon (68%) cage (cologne, Ostapek, Nexis) filled with cancellous bone harvested percutaneously from the iliac crest. The cage was associated with an anterior titanium plate fixation (Senegas, Euros and Orion, Medtronic). A posterior approach was associated if further stability was required (n=4 fusions). All patients were reviewed at minimum five months follow-up. Intersomatic fusion was verified on the standard x-rays (plus stress images and computed tomography at three months). Fusion was considered to be achieved if continuous bone lines crossed the graft and angle measurements remained stable, with the cage in the same position on successive examinations.One patient died from lung cancer five months after spinal fusion. All other patients survived with a mean follow-up of 24 months. Fusion was achieved in all cases, at mean 78 days. The mean intersomatic angle increased from 12 degrees kyposis preoperatively to 13 degrees lordosis postoperatively at last follow-up. Anterior displacement of the fractured vertebral body was 3 mm preoperatively and 0.3 mm postoperatively. Height in the middle of the intersomatic space was 5.3 mm preoperatively and 8.2 mm postoperatively. There were no cases of secondary displacement.This study demonstrated that fusion with an intersomatic cage associated with anterior plating can be used in spine trauma victims, providing an outcome as good as in patients with degenerative disease. This method enables nearly anatomic reduction without secondary displacement and fusion in a short delay (which can be explained by the mechanical properties of the assembly and by the use of pure cancellous graft from the iliac crest). There is very little morbidity in our experience. For us, this technique is more reliable than fusion using a tri-cortical iliac crest graft.The use of an intersomatic cage is a simple, reliable technique for intersomatic spinal fusion with little morbidity for unstable traumatic injury of the spine without spinal cord injury.

Lumbosacral dislocation is uncommon. We report a case of traumatic lumbosacral dislocation which occurred in a 33-year-old pedestrian traffic accident victim. The posterior impact produced lumbar injury with diffuse pain exacerbated at the lumbosacral junction. Ecchymotic diffusion involving the entire lumbar region fluctuated due to the presence of a subcutaneous hematoma. The neurological examination revealed incomplete L5 paraplegia. Standard x-rays revealed L5-S1 spondylolisthesis and fracture of the L5 spinous process as well as fractures of the L3, L4, and L5 transverse processes. Computed tomography disclosed biarticular L5-S1 fracture dislocation and a voluminous herniation of the L5-S1 disc. Emergency surgery was performed and revealed subaponeurotic detachment from T4 to S1 and bald iliac pyramids. After L5 laminectomy and extraction of the voluminous herniation of the L5-S1 disc, a short L5-S1 posteriolateral fusion was achieved using pedicular screws and two rods on either side as well as a posterolateral iliac autograft. The clinical course was satisfactory with nearly complete neurological recovery (persistent levator ani paresis). This clinical case and a review of the literature illustrate the pathogenic, clinical, radiological and therapeutic aspects of lumbosacral fracture dislocation.

The purpose of this study was to examine short-term clinical results with a lumbar disc prosthesis in comparison with anterior interbody fusion for the treatment of chronic low-back pain resulting from disc degeneration.This was a consecutive series of 32 patients who underwent surgery between 2002 and 2005 performed by the same surgeon. Patients were randomly assigned to one of two treatment arms: a Charité (Depuy) disc prosthesis was implanted in group 1; an intersomatic KLA cage (Scient'x) was implanted in group 2. All patients presented primary or postdiscectomy discopathy: Modic 1 or 2 on MRI and one level (L4-L5 or L5-S1) positive on discography. A visual analog scale (VAS) and the Oswestry test were noted preoperatively, at six months and at last follow-up and compared with Student's t test. The quantitative analysis was based on the rate of excellent results (60% gain on the VAS and 50% gain on the Oswestry), rate of return to work at three months and level of patient satisfaction.Patient follow-up ranged from one to three years. Mean age was 39 years in group 1 and 44 in group 2. The quantitative analysis showed an improvement in the VAS in both groups: 75% in group 1 and 67% in group 2. The difference was not statistically significant. For the Oswestry score, the gain in function was improved 51% in group 1 and 37% in group 2, with a statistically significant difference in favor of the prosthesis group (p=0.125). The qualitative analysis demonstrated that patient satisfaction (87 and 88%) was similar in the two groups, but with a clear difference for return to work at three months, with a better rate in the prosthesis group (61.5%) than the fusion group (42.8%). The rate of excellent outcome was greater in group 1 (77%) than in group 2 (55%).There is only one study in the literature, which can be compared with ours. Using the same methodology, that study observed less favorable results for the disc prosthesis than with anterior lumbar fusion.The lumbar disc prosthesis offers a possible alternative to lumbar arthrodesis for the treatment of severe disc degeneration at one level in the young subject. It has been found to enable more rapid and superior functional results.

To study the epidemiologic and semiotic characteristics of uncomplicated sciatica in patients in a university hospital in Côte d'Ivoire.This retrospective study included 143 patients with an uncomplicated herniated disc hospitalized in the Cocody University Hospital from 1998 through 2002; patients were excluded if they were excessively sensitive to pain, had related motor deficits, cauda equina syndrome, or were resistant to medical treatment.Patients' average age was 42.5 years (range: 15-81), 58% were women, and mean body mass index (BMI) was 26.16. Ninety-nine (69.2%) reported relatively sedentary work. The disorder was characterized by an antalgic position (in 46.9%), an abnormal Schöber index in 117 (81.8%), the "bell sign" (in 63.6%) and a cough impulse in 58.7%. Lasègue's sign was homolateral at 114 (79.7%), and the average amplitude 42.2 degrees (range: 10 to 80). Paresis of 3/5 or higher was observed in 32 patients (22.4%). Radiography showed a disc disorder in 63% of cases; posterior osteoarthritis in 39.2% and a narrowed lumbar channel in 14 %. Computed tomography was performed for 56 patients and confirmed the presence of a hernia (median: 42,8%; paramedian: 48,2%; foraminal: 8,0%) of L4-l5 in 43 patients (77%); a large hernia, defined by a size greater than half of the rachidian channel, was found in eight (14,3%). After medical treatment, the course was favourable during this hospitalisation.Contrary to preconceived ideas, uncomplicated sciatica of black subjects has the same characteristics as in the white population.

The purpose of this study was to evaluate a minimally invasive surgical technique for the treatment of lumbar far lateral disc herniation. This technique combines the tubular retractor with the operative microscope.This retrospective study analyzed the files of 26 patients: 15 men and 11 women. The average age was 56 years (range, 19-83 years). The most commonly operated level was L3-L4 (46%), then L4-L5 (30.5%) and finally L2-L3 (15.5%). All patients were operated under general anesthesia. The intraoperative radioscopic location was absolutely necessary. A 12-15 mm paramedian incision was made on the side of the herniation (30 mm from the medial line). We then inserted the tubular muscular retraction system followed by the 14 mm diameter working channel. Guided by operating microscope, the articular isthmus was reamed to expose the root and the disc. The disc herniation was then removed after opening and removing the inter-transverse ligament.The average duration of the surgery was 55 min. This operating time decreased as the surgeons gained experience. The radicular pain, estimated using the analogical visual scale, varied from seven before surgery to two during the postoperative period. All the patients were standing up the day after surgery. The average duration of the postoperative stay in the hospital was three days (range, 1-5 days). We noted no complications from the surgical procedure. The average duration of the follow-up was two years (range, 6-36 months).This technique combines the advantages of endoscopic surgery (less muscular and osseous damage) and microscope-guided surgery (three-dimensional vision) and provided good functional results in this series.

Lower urinary tract dysfunction related to herniated disk can raise complex diagnostic and management problems. This article reviews the two main clinical situations encountered: documented lower urinary tract dysfunction in a context of cauda equina syndrome secondary to herniated disk and lower urinary tract dysfunction representing the only clinical sign of herniated disk with no other alteration of the neurological examination. Regardless of the neurological signs, urodynamic assessment is essential to characterize any lower urinary tract dysfunction and to determine the modalities of long-term surveillance.

In this paper, the imaging features of traumatic injuries of the spine in an emergency department will be reviewed. Three themes are discussed. 1) Review of current indications for additional imaging work-up. Conventional radiographs are not always mandatory, especially at the cervical level since validated criteria are available from the literature. The low sensitivity of conventional radiographs often requires additional imaging by CT (bone lesions) or MRI (disk and ligamentous lesions). The degree of urgency in scheduling these different examinations will be defined by the clinical setting and risk level (low/intermediate/high) of the injury. 2) Review of imaging features associated with stable and unstable lesions. The analysis of conventional radiographs is based on biomechanical concepts. The features of the main lesions will be illustrated by clinical cases and diagrams. 3) Review of key points that must urgently be transmitted to clinicians. The preliminary radiology report is an essential document for the management of patients with traumatic injury to the spine. It will have an impact on the type of immediate management (medical, orthopedic or surgical). A final report validating the initial interpretation should, of course, soon follow.

Vascular complications are unusual after lumbar disc surgery. Iliac artery injury is the most common. The vascular injury may cause severe bleeding and hypotension. If the injury is missed, an arteriovenous fistula may develop. This complication is fortunately the most common. We describe the case of a 41 year-old man who was operated on for lumbar disc herniation. A few hours after surgery, he had developed prolonged hypotension leading to the diagnosis of iatrogenic vascular injury. The CT scan confirmed the diagnosis of right common iliac tear with voluminous retroperitoneal haematoma. Emergent surgery was carried on with success.

We present a case of intracanalar extrusion of a L5S1 Biocompatible Orthopaedic Polymer (BOP) graft associated with a L4L5 disc herniation 19 years after a lumbar intersomatic fusion for a L5S1 disc herniation. Radiological aspect of this complication should be recognized by neurosurgeons.A 55-year old man presented with a right L5 sciatic pain. Neurological examination found a severe weakness in dorsal flexion of the foot. A lumbar CT scanner disclosed aspects consistent with right L4L5 and huge calcified L5S1 lumbar disc herniation.The patient was operated via a bilateral paravertebral approach and a L5 laminectomy. A dense and extensive epidural scarring was seen. The right L4L5 herniated disc was excised. At the left L5S1 level, fibres from a BOP graft had separated into large fragments extruded into the vertebral canal through the dura. The fibres could only be removed partially because of nerve roots adherence. The patient developed postoperative cerebrospinal fluid (CSF) leakage that required a second operation for dural closure. The postoperative course was uneventful and the patient recovered the right L5 root deficit.Neurosurgeons should be aware of the radiological aspect of this complication. If it is recognized on CT scan and asymptomatic, conservative management should be proposed because of the risk of nerve roots injury or postoperative CSF leakage.

We report two cases of exceptional first thoracic disc herniation in a 60-year-old man and a 55-year-old woman. The man was treated surgically and the woman medically. Osteoarthritis appeared to be the predominant cause of the disc herniation in both patients. Unlike the usual calcification in the medioposterior position for middle or lower thoracic spine herniations, a soft posterolateral herniation was observed here. The symptoms are limited, as observed in both patients, to a T1 radiculopathy, to be distinguished from C8 radicopathy. Myelopathy is rare. Claude-Bernard-Horner syndrome is not constant but highly suggestive. Both of these signs were absent in our patients. T1-T2 disc herniation should be suspected in patients presenting cervico-brachial medial neuralgia. MRI provides the diagnosis. Anterior surgery can be achieved without sternotomy. Careful radiographic analysis is needed preoperatively to identify the upper limit of the sternum.

To assess the efficacy of percutaneous laser disc decompression for patients with radicular pain due to lumbar disc hernia and to identify factors that may predict outcome.The study included all patients treated with percutaneous laser disc decompression from May 2003 through May 2005 at Reims University Hospital and the Courlancy Clinic of Reims. Each patient had previous undergone at least six weeks of conventional medical treatment. The same technique, with either a laser diode or Nd: YAG, was used under endoscopic control and with neuroleptanalgesia. They were seen at 1, 3, 6 and 12 months. The principal evaluation criteria were the course of radicular pain, return to work, and need for surgery.We reexamined 149 patients 1 month after the procedure, 135 after 3 months, 102 after 6 months and 59 a year after the procedure. At a month after surgery, radicular pain had decreased by at least half, and sometimes even completely disappeared in 63.1% of patients at 1 month, 66.6% at 3 months, 73.5% at 6 months, and 83.1% at 12 months, while 24%, 50,4%, 61.2%, and 67.3%, respectively, had returned to work. No patient had serious complications. Finally, 45 of the 149 (30.2%) patients chose to have a traditional surgical procedure after percutaneous laser disc decompression.Percutaneous laser disc decompression is effective, noninvasive and well tolerated for patients with radicular pain due to lumbar disc hernia.

The purpose of this study was to report our initial experience with a new percutaneous spine fixation system, avoiding open exposure, excessive blood loss and extensive muscle dissection. With the specially designed plates, this system can be used whatever the conformation of the segment instrumented is kyphotic or lordotic.Sixteen patients (9 men and 7 women ranging in age from 27 to 78 years, mean 54.9) underwent percutaneous pedicle fixation using this device. Twelve patients underwent single level fusions (discogenic lowback pain in 6 cases, spondylolisthesis in 1), and 4 underwent two-level fusions (2 for lumbar fracture and 2 for spondylolisthesis). TLIF by intersomatic cages were inserted at the same time in two patients with spondylolisthesis. The follow-up period ranged from 3 to 15 months (mean 5 months).Improvement in pain control was assessed using a specially designed scale, allowing qualitative self-evaluation of pain control. Pain control was excellent in 12 patients, good in 3 and poor in one case due to loss of independence related to multiple associated disabling conditions.Percutaneous pedicule screw insertion using this device is a safe and reliable technique. Further improvements in the system which allows a certain degree of spinal mobility after screw placement are in process. Early results shown in this study illustrate the perspectives.