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We report the first case of paraplegia observed after epidural steroid injection in the upper spine. The patient was a 42-year-old male who underwent surgery two years earlier for stenosis of the lumbar spine from L2 to the sacrum leading to early manifestations of an equina cauda syndrome. This first operation provided satisfactory function with complete resolution of the objective neurological symptoms. The patient later developed bilateral radiculalgia involving the L3 and L4 territories and was treated by radio-guided epidural steroid injection (125 mg hydrocortancyl) delivered in the L1-L2 interlaminar space. The injection was achieved with no technical difficulty and there was no injury to the dural sac. Immediately after the injection, the patient developed complete motor and sensorial paraplegia from T12. CT and MRI performed 30 min and 4h, respectively, after the accident revealed a medium-sized discal herniation behind the L2 body. No other lesion was observed. Emergency surgery was performed for radicular release but to no avail. The patient's neurological status remained unchanged and four days later the T2 MRI sequence revealed a high-intensity intramedullar signal in the cone. The diagnosis of ischemia of the medullary cone was retained, hypothetically by injury to the dominant radiculomedullary artery via an undetermined mechanism. This complication has been previously described after upper foraminal steroid injections but not after intralaminar epidural steroid injection.

Purpose of the Study: Experimentally, posterolateral fusion only provides incomplete control of flexion-extension, rotation and lateral inclination forces. The stability deficit increases with increasing height of the anterior intervertebral space, which for some warrants the adjunction of an intersomatic arthrodesis in addition to the posterolateral graft. Few studies have been devoted to the impact of disc height on the outcome of posterolateral fusion. The purpose of this work was to investigate the spinal segment immobilized by the posterolateral fusion: height of the anterior intervertebral space, the clinical and radiographic impact of changes in disc height, and the short- and long-term impact of disc height measured preoperatively on clinical and radiographic outcome., Materials and Methods: In order to obtain a homogeneous group of patients, the series was limited to patients undergoing posterolateral arthrodesis for degenerative spondylolisthesis, in combination with radicular release. This was a retrospective analysis of a consecutive series of 66 patients with mean 52 months follow-up (range 3-63 months). A dedicated self-administered questionnaire was used to collect data on pre- and postoperative function, the SF-36 quality of life score, and patient satisfaction. Pre- and postoperative (early, one year, last follow-up) radiographic data were recorded: olisthesic level, disc height, intervertebral angle, intervertebral mobility (angular, anteroposterior), and global measures of sagittal balance (thoracic kyphosis, lumbar lordosis, T9 sagittal tilt, pelvic version, pelvic incidence, sacral slope). SpineView was used for all measures. Univariate analysis searched for correlations between variation in disc height and early postoperative function and quality of fusion at last follow-up. Multivariate analysis was applied to the following preoperative parameters: intervertebral angle, disc height, intervertebral mobility, sagittal balance parameters, use of osteosynthesis or not., Results: At the olisthesic level, there was a 30% mean decrease in disc height and intervertebral angle. These variations were not correlated with functional outcome or quality of fusion observed at last follow-up. Disc height preoperatively did not affect these variations. The only factor correlated with decreased disc height was T9 sagittal tilt: disc height decreased more when T9 sagittal tilt approached 0 degrees ., Discussion: In this very restricted context (retrospective study, short arthrodesis for degenerative spondylolisthesis), we were unable to find any evidence supporting the notion that high disc height is an argument which should favor complementary intersomatic arthrodesis in combination with posterolateral fusion. Analysis of the spinal balance in the sagittal plane would probably allow a more pertinent assessment of the specific needs of individual patients.

Purpose of the Study: The short- and mid-term symptom-relief of surgical treatment for lumbar stenosis is generally acknowledged, but the probability of a long-term reoperation remains to be studied. The purpose of this work was to determine the long-term risk of reoperation after surgical treatment of degenerative lumbar stenosis and to search for factors influencing this probability., Material and Methods: All patients who underwent from 1989 to 1992 surgical treatment for degenerative lumbar spine stenosis were included in this work. At last follow-up, we noted functional outcome using a specific self-administered questionnaire, patient satisfaction, lumbalgia and radiculalgia using a visual analog scale, SF36 quality-of-life, reoperation or not with time since first operation if performed and the reasons and modalities of the reoperation. The probability of reoperation was determined with the acturarial method. A Cox model was used to search for factors linked with the probability of reoperation; variables studied were: age, comorbid factors, extent of the release, posterolateral arthrodesis or not, extent of the potential fusion, use or not of instrumentation for arthrodesis., Results and Discussion: The study included 262 patients. At last follow-up, 61 patients had died a mean 3.7+/-3 years after the operation; only one of these patients had a second operation 22 months after the first. Forty-four patients were lost to follow-up at mean 6.6+/-3 years. Among these 44 patients, four had a second operation during their initial follow-up at mean 47 months. One hundred fifty-seven patients were retained for this analysis at mean 15+/-1 years follow-up. Among these 157 patients, 29 had a second operation a mean 75 months after the first. There were four reasons for reoperating: insufficient release, destabilization within or above the zone of release, development or renewed zone of stenosis, development or renewed discal herniation. The risk of a second operation was 7.4% [95% CI 4.8-11.6], 15.4% [95% CI 10.7-21.1] and 16.5% [95% CI 11.7-219] at five, 10 and 15 years respectively after the first operation. Among the risk factors studied, only one had a significant impact on reoperation: extent of the zone of release (p=0.003). Compared with a release limited to one level, the risk of reoperation after release of three levels or more was five times greater [95% CI 1.8-12.7].

Purpose of the Study: Bone comminution, serious cartilage damage, and the poor mechanical quality of osteoporotic bone create a difficult challenge for osteosynthesis of joint fractures in the elderly subject. Poor results with certain hip, elbow and shoulder fractures have lead certain authors to propose emergency arthroplasty in selected cases. We report our experience with four knee arthroplasties implanted for recent severe fracture of the proximal tibial epiphysis in elderly subjects., Material and Methods: Four independent patients aged over 75 years presented a severe comminutive fracture of the proximal epiphysis of the tibia (Three Schatzker 5, one Schatzker 4). After obtaining the patients' informed consent, early knee arthroplasty was performed. A long-stem cemented tibial piece was used on which the epiphysis was reconstructed. Implants providing support for ligament deficits were used in all cases. Immediate weight-bearing was authorized., Results: Follow-up ranged from two to seven years. The IKS function score (15, 60, 100, 100) depended on the patient's general status. The IKS knee score was excellent for three knees (90, 95, 95), and fair in one (45). Re-operations were not needed in any of the patients. All x-rays showed bone healing with correctly aligned limbs (less than 2 degrees deformation). There were no lucent lines at last follow-up., Discussion: Early arthroplasty for complex fractures of the proximal epiphysis of the tibia is a realistic option. Using a cemented long-stem tibial piece ensures primary stability sufficient for early weight-bearing before bone healing. Use of a constrained prosthesis, or better a hinged prosthesis, can be questioned but avoids the difficulty of ligament balance on an osteoporotic knee with a destroyed joint surface. None of the patients required reoperation and the results in terms of pain were excellent. The overall outcome depends on the general status of the patient.

Purpose of the Study: Several reports have examined the pathophysiology of degenerative spondylolisthesis. Very little work has however been devoted to the influence of spinal balance in the sagittal plane in its pathogenesis. The purpose of this work was to present a descriptive analysis of pelvic and spinal sagittal balance in a cohort of seventy patients treated for degenerative spondylolisthesis and to compare findings with those established in a population of 250 volunteers. The goal was to deduct pathophysiological hypotheses and identify therapeutic implications., Material and Methods: Seventy patients were included in this study. The following variables were noted: pelvic incidence and version, sacral slope, lumbar lordosis, thoracic kyphosis, T9 sagittal tilt and S1-S2 angle. These variables were measured on digitalized lateral views of the spine using a dedicated software (SpineView). Univariate analysis of the values obtained was performed to identify the variable distributions. Multivariate analysis was applied to study the relationships between these variables and to better define perturbations of spinal balance in the anteroposterior plane. The findings were compared with those obtained in a control population., Results: One of the essential characteristics of the cohort of patients with degenerative spondylolisthesis was the presence of an exaggerated pelvic incidence (62.6 degrees versus 54.7 degrees in the control population). The most significant determinants of T9 sagittal tilt (which reflects sagittal balance) were: pelvic version, pelvic incidence, lumbar lordosis, and L4-S1 local lordosis. One-third of our patients presented posterior tilt due to exaggerated thoracic kyphosis. The high pelvic incidence, via hyperlordosis and increased pelvic version, could be one of the factors favoring degenerative disease of the spinal unit., Conclusions: This work enabled us to better describe sagittal balance in patients with degenerative spondylolisthesis and to propose hypotheses concerning the underlying mechanism of progressive degeneration. We emphasize the diversity of spinal balance in these patients and the different therapeutic implications.

We report a case of total spinal cord disruption confirmed surgically. The spinal cord injury resulted from a traumatic event involving the thoracic spine which did not provoke any bone lesion. The patient presented joint injury and unilateral ligament damage. No spinal fracture was observed. In patients with neurological signs, the imaging work-up should associate CT-scan and magnetic resonance imaging to obtain a complete study of the bone and joint structures as well as the ligaments and the spinal cord.

Tear-drop fracture of the axis is an exceptional spinal fracture which generally occurs after high-energy trauma with hyper-extension of the cervical spine. Purely anterior fracture can occur with no real impact on stability. Orthopedic treatment provides good results in this situation. If the fracture is posterior, it continues into the C2-C3 intervertebral disc and the common posterior vertebral ligament, leading to C2C3 instability and possible retrolisthesis of C2 over C3 and neurological involvement. We report a case of tear-drop fracture of C2 with C3 instability without neurological involvement. This patient underwent posterior fixation with C2C3 arthrodesis which provided good quality bone fusion without secondary displacement or clinical aggravation.

Purpose of the Study: Incidence of complications following lumbar or lumbosacral fusion is still an imprecise notion. The aim of this prospective observational study was to determine the frequency of intraoperative and early postoperative complications after this procedure and to analyze favoring factors., Material and Methods: Twenty-one orthopedic units participated in this study which included 872 patients who underwent lumbar or lumbosacral fusion procedures involving the sector limited by L1 and S1. A minimum of 6 months follow-up was required for inclusion. Four types of complications were studied: general complications, infection, neurological and meningeal complications, mechanical problems. The following preoperative and intraoperative parameters were recorded: epidemiological and morphological data, history of lumbar spine surgery, comorbid conditions, indication for surgery, and technical aspects of the fusion. Two types of analysis were performed. The first was a descriptive analysis designed to determined the overall incidence of complications and the incidence of each type of complication. A multivariate analysis was then performed in order to determine factors influencing occurrence of complications., Results: Mean follow-up was 13 months, mean age of the cohort was 51 +/- 15.5 years. Prior lumbar surgery was noted in 12% of the patients. A decompression procedure was associated in 40% of the patients due to lumbar stenosis. Posterolateral arthrodesis was used in 71% of the patients and 91% were instrumented. Most of the fusions were short, involving one or two levels. One or more intraoperative or early postoperative complications were observed in 200 patients (23%). The incidences of the four types of complications expressed in percent of the total cohort were 9.7%, 5.6%, 8.6%, and 3.6% for general, infectious, neurological and meningeal, and mechanical complications respectively. Three factors exhibited a significant correlation with occurrence of complications, irrespective of the type: excess weight, presence of several comorbid conditions, and extent of the zone of fusion., Conclusion: This study enabled a precise assessment of the incidence of complications subsequent to lumbar or lumbosacral fusion: 23%. The incidence of serious complications requiring a reoperation was 14.7%. This finding, together with the factors found to influence occurrence of these complications should be kept in mind when determining indications for lumbar or lumbosacral fusion.

We propose a new technique for sacroiliac fixation for the treatment of pelvic fracture with vertical and horizontal instability (Tile class C). This fixation technique allows control of vertical displacement while allowing, if needed, a certain degree of movement in the horizontal plane to facilitate reduction of anterior lesions. The technique involves insertion of two sacral screws, one in S1 and one in S2, and two iliac screws. The iliac screws are inserted in the posterior iliac crest through two sacroiliac connectors placed on a rod linking the two sacral screws. Vertical displacement is controlled by blocking the screw heads on the connecting rod. If needed, a certain degree of horizontal mobility of the half pelvis can be allowed by loosening the connectors on the rods. This technique was used for 4 patients. Anatomic reduction was achieved and no secondary movement of the osteosynthesis material nor secondary displacement were observed. The quality of the fixation allowed rapid weight bearing in the standing position and early walking without crutches. This type of fixation can only be used for type C12 fractures in the Tile classification.

Purpose of the Study: Some discussion remains concerning the quality of the long-term functional outcome after surgical treatment of lumbar spinal stenosis. The purpose of this retrospective observational study was to evaluate outcome ten years after surgical treatment of lumbar spinal stenosis and to determine the rate of reoperation as well as to identify factors influencing outcome at last follow-up., Material and Methods: Between January 1990 and December 1992, 141 patients underwent surgery for lumbar stenosis all were included in present study. Mean follow-up was ten years. At last follow-up, functional signs were assessed with a designated self-administered questionnaire with items for lumbar and radicular pain, signs of radicular ischemia, and patient satisfaction and two visual analog scales for lumbar and radicular pain. Other data recorded included: epidemiological and morphological features of the study population, comorbidities, presence or not of objective neurological signs, anatomy of the stenosis, and results of two self-administered questionnaires on quality of life (SF36) and anxiety-depression (GHA28). Two data analysis methods were applied. The first was a descriptive analysis to quantify the importance of functional signs observed at last follow-up, patient satisfaction, and rate of recurrence as well as reasons for reoperation. The second was a multivariate analysis designed to identify factors influencing the score obtained on the designated stenosis self-administered questionnaire., Results: Fifteen patients had undergone a revision procedure on the lumbar spine. At last follow-up overall satisfaction was 71%. The best results were obtained for radiculalgia and intermittent neurogenic claudication. Residual lumbalgia was the main complaint at last follow-up. The patient's psychological profile was found to be the predominant factor influencing functional outcome. Other factors having an effect in this population were: reoperation, persistence of objective neurological disorders, degree of comorbidity., Conclusion: For the majority of patients, surgical treatment of lumbar spinal stenosis provides good long-term results and patient satisfaction. At ten years, the risk of reoperation was 10% in this population. Compared with data in the literature, these results are better than with medical treatment. Surgery enables these patients to have a quality of life similar to an age-matched control population.

Purpose of the Study: Sagital balance of the spine is a fundamental element necessary for understanding spinal disease and instituting proper treatment. The aim of this prospective work was to establish the physiological values of pelvic and spinal parameters of sagital balance of the spine and to investigate their interactions., Material and Method: Pelvic and spinal parameters were measured on the standing radiographs of 250 healthy volunteers. The following parameters were measured on lateral views including the head, the spine and the pelvis: lumbar lordosis, thoracic kyphosis, sagital tilt at T9, sacral inclination, pelvic incidence, pelvic version, intervertebral angulation, and the vertebral cuneiformization from T9 to S1. These measurements were taken after digitalization of the radiographs. Two types of analysis were performed: a descriptive univariate analysis to characterize the angular parameters and multivariate analysis (correlation, principal component analysis) to detail the relative variations of these parameters., Results and Discussion: Mean values were: maximal lumbar lordosis 61 +/- 12.7 degrees, maximal thoracic kyphosis 41.4 +/- 9.2 degrees, sacral inclination 44.2 +/- 8.5 degrees, pelvic version 13 +/- 6 degrees, pelvic incidence 55 +/- 11.2 degrees, sagital tilt at T9 10.5 +/- 3.1 degrees. There was a strong correlation between sacral inclination and pelvic incidence (r=0.86), pelvic version and pelvic incidence (r=0.66), lumbar lordosis pelvic incidence pelvic version and thoracic kyphosis (r=0.9) and finally between pelvic incidence and the following parameters: sagital tilt at T9, sacral inclination, pelvic version, lumbar lordosis, and thoracic kyphosis (r=0.98). The relations between the different parameters studied demonstrated that saggital tilt at T9, which reflects spinal balance, is determined by three independent factors. The first is a linear combination of pelvic incidence, lumbar lordosis, and sacral inclination. The second is pelvic version. The third is thoracic kyposis., Conclusion: This work provided a useful tool for analyzing and understanding anteroposterior imbalance in patients with spinal disease and also a means of calculating corrections to be made with treatment, established from the linear regression equations which were elaborated.

Purpose of the Study: Parameters determining sagittal balance are essential for optimal analysis and treatment of many spinal disorders. The purpose of this work was to validate a software designed to measure the principal parameters involved in sagittal balance of the spine., Material and Methods: Six parameters (lumbar lordosis, thoracic kyphosis, sagittal tilt at T9, pelvic index, pelvic tilt, slope of the sacrum) were measured on lateral views of the spine from 100 healthy volunteers free of any spinal disease. Two measurement techniques were used: manual measurement and automatic computerized measurement with this software. We hypothesized that manual measures could be accepted as reference values because they are currently the most widely used and because the computerized measurements were obtained using digitalized images that may have modified interpretation. The software was therefore validated by comparing the angles measured manually with the computer output. Inter- and intraobserver coefficients of variation were calculated for the two measurement techniques. One operator performed both series of measurements (manual and computerized). Two other operators preformed two series of independent measures using one of the measurement techniques. Finally, two new operators performed a complete series of measurements using both measurement techniques. Comparisons were performed with the t test for paired variables with calculation of the coefficients of correlation. Intraclass coefficients of correlation were determined for inter- and intra-observer variability., Results: There was an excellent correlation between the manual measurements and the computerized measurements with intra-class coefficients of correlation varying from 0.82 to 0.96. Inter- and intra-observer variabilities were comparable for the two measurement techniques used to determine thoracic kyphosis, lumbar lordosis, pelvic index, pelvic tilt, and slope of the sacrum. Inter- and intra-observer variability was lower when the sagittal tilt was measured with the software specially designed., Conclusion: This comparison between two techniques for measuring pelvic and spinal parameters of sagittal balance of the spine demonstrated a good correlation between manual and the computerized measurements obtained with the software to be evaluated. Computer-assisted measurements not only provided a saving in time but also minimized inter- and intra-observer variability for the estimation of certain parameters.

Purpose of the Study: The main objective of this prospective observational study of a consecutive series of patients was to determine the rate of per- and postoperative complications of surgical treatment of lumbar spinal stenosis. A second objective was to describe these complications and search for factors favoring their occurrence., Material and Methods: All patients who underwent surgical treatment of spinal stenosis without significant spinal deviation in our unit between January 1998 and January 2000 were enrolled in this study. The series thus included 306 patients with at least six months follow-up. Three types of data were recorded before surgery: demographic data including comorbidity, data related to the type of stenosis operated, and data related to the type of procedure (simple release, release with fusion, etc.). A special observation chart was designed to record all complications during the hospital stay and follow-up visits at three, six and twelve months. Four categories of complications were recorded: general complications, early or late infections, early or late mechanical disorders, and neurological complications including meningeal involvement and surgery-related neurological disorders. Univariate analysis was performed to determine the overall rate of complications and the incidence within each category of complications. Multivariate analysis using logistic regression was performed to examine factors favoring occurrence of complications., Results: The overall rate of complications was 26.5%. The incidence of general, infectious, neurological, and mechanical complications was 13, 4.5, 2.6 and 2% respectively. The incidence of serious complications and/or events requiring reoperation was 12%. Comorbidity, body mass index, operative time, and reoperation were found to favor the occurrence of complications., Discussion and Conclusion: The rates of complications reported in the literature have varied greatly. Most have been calculated from retrospective series, making it difficult to compare them with our results. Our work emphasizes the importance of certain favoring factors which should be re-examined in a larger series.

Purpose of the Study: The main aim of this prospective, multicentric, observational study was to validate a self-administered quality-of-life questionnaire for patients with lumbar spine stenosis treated surgically., Material and Methods: The self-administered questionnaire was composed of eight questions exploring three dimensions: lumbalgia, radiculalgia, radicular ischemia. This questionnaire was associated with an index of neurological involvement (to take into account objective neurological data), and with an index of patient satisfaction (to assess the patient's perception of the impact of surgery on lumbalgia, radiculalgia, and gait disorders). The scoring scale was validated by studying the structure of the questionnaire (to ascertain the pertinence of the proposed three dimensions), by determining the questionnaire's reproducibility (intraobserver variability) and sensitivity to change, and by examining the contents of the questions (to assess the capacity of the scale to effectively measure the parameters it was designed to measure). Cronbach's alpha coefficient and principal component analysis were used to assess the questionnaire's structure. Reproducibility was tested on 49 patients who completed the self-administered questionnaire twice at a 15-day interval; intraclass correlation coefficients were determined. Sensibility was tested by correlating variation in the scores obtained pre- and postoperatively with the index of satisfaction; mean standard responses were determined. The validity of the questionnaire's content was assessed by correlating the scores obtained with the questionnaire to those obtained with three other self-administered questionnaires: SF36, EIFEL2 and GHA38., Results: This work included 104 patients, 96 of whom were reviewed at consultations 6 and 12 months after surgery. The principal components analysis confirmed the presence of the three dimensions. The global Cronbach alpha coefficient was 0.86. The global intraclass coefficient of correlation was 0.95, varying from 0.86 to 0.97 depending on the dimension studied. There was a good correlation (0.82) between changes in the score studied and the index of satisfaction. All the mean standardized responses were higher than 1, indicating good sensitivity to change. There was also a good correlation between the questionnaire tested and the EIFEL2 self-administered questionnaire and the following dimensions of the SF36: physical activity, physical pain, vitality, and limitation due to physical pain., Discussion and Conclusion: Associating a simple 8-question self-administered questionnaire with an index of satisfaction (4 questions) and an objective index of neurological involvement provided a reliable, sensitive, and reproducible assessment of the changes in functional disorders resulting from lumber stenosis before and after surgical treatment.

A 38-year old man developed compressive myelopathy due to radiation-induced osteochondroma at T7. The patient had been given radiotherapy at the age of 7 years for a lymphosarcoma situated at the lower part of the neck. Radiation is an exceptional cause of spinal compression which can be avoided by regular surveillance of patients given radiotherapy in the spinal area as children.