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BACKGROUND A high degree of vigilance is warranted for a spinal infection, particularly in a patient who has undergone an invasive procedure such as a spinal injection. The average delay in diagnosing a spinal infection is 2-4 mo. In our patient, the diagnosis of a spinal infection was delayed by 1.5 mo. CASE SUMMARY A 60-year-old male patient with a 1-year history of right-sided lumbar radicular pain failed conservative treatment. Six weeks to prior to surgery he received a spinal injection, which was followed by increasing lumbar radicular pain, weight loss and chills. This went unnoticed and surgery took place with right-sided L4-L5 combined microdiscectomy and foraminotomy via a posterior approach. The day after surgery, the patient developed left-sided lumbar radicular pain. Blood cultures grew Staphylococcus aureus (S. aureus). Magnetic resonance imaging showed inflammatory aberrations, revealing septic arthritis of the left-sided L4/L5 facet joint as the probable cause. Revision surgery took place and S. aureus was isolated from bacteriological samples. The patient received postoperative antibiotic treatment, which completely eradicated the infection. CONCLUSION The development of postoperative lower back pain and/or lumbar radicular pain can be a sign of a spinal infection. A thorough clinical and laboratory work-up is essential in the preoperative evaluation of patients with spinal pain.

Many authors tried to explain proximal junctional kyphosis (PJK) after adolescent idiopathic scoliosis (AIS) surgery by looking for risk factors. Latest publications focus on sagittal alignment. Each healthy adolescent has a specific thoracic kyphosis (TK) depending on their pelvic parameters and lumbar lordosis (LL). The objective of this work is to determine if the difference between TK at follow-up (TKFU) and the patient-specific TK (PSTK) plays a role in PJK occurrence after AIS surgery. The secondary objective was to find other risk factors. We analyzed retrospectively 570 thoracic AIS who underwent a posterior thoracic fusion from nine centers. The series was separated in two groups: with and without PJK. PSTK was calculated with the formula PSTK = 2(PT + LL-PI). TK Gap was the difference between TKFU and PSTK. Logistic regression was utilized to test the impact of TK Gap and other known risk factors on PJK occurrence. Univariate analysis showed 15 factors significantly different between the groups. In a multivariate analysis, three factors had a strong significant influence on PJK: TKFU, TK Gain and TK Gap. Four additional factors affected the rate of PJK: Posterior translation on two rods, preoperative TK, preoperative LL and number of instrumented vertebrae. PJK is related to the insufficient TK at follow-up, compared to the specific TK that every patient should have according to their pelvic parameters. PJK incidence is significantly reduced by a strong gain in TK and a thoracic selective fusion which leaves the proximal lumbar vertebrae free. Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding

Background Enhanced recovery after surgery (ERAS) protocols aim to reduce the physiological stress induced by surgery. These protocols are persistently associated with improved outcomes and reduced costs in several orthopaedic subspecialties. Recently, spine surgery has been explored in the literature as a potential and beneficial domain for ERAS protocols. The aim of this study was to compare the short-term postoperative spine surgery follow-up between patients who underwent the ERAS protocol and those who recovered conventionally. Hypothesis The ERAS protocol developed in our department since 2016 is beneficial to patients undergoing spinal surgery. Patients and methods A retrospective analysis of data collected prospectively was performed to include all patients who underwent spinal surgery and went through the ERAS protocol in our clinic between January 2017 and January 2018. A control group was paired using a propensity score. Length of hospital stay (LOS), complications, rate of readmissions, postoperative pain, function and satisfaction were compared between the two groups. Results A total of 193 patients received the ERAS protocol during the study period. After pairing, 193 couples were selected resulting in a final database of 386 patients for the analysis. There was a significant difference in mean LOS, defined as the average number of days spent in hospital, between the two groups (ERAS group, mean LOS = 2.6 days [median 2 days, range 1–7], control group mean LOS = 4.4 days [median 4 days, range 2–14]; p Discussion The ERAS protocol decreased hospital LOS, without resulting in additional adverse events after spinal surgery. These findings support the application of our ERAS protocol after spinal surgery. Level of evidence III, retrospective analysis.

Resume Contexte Les programmes de recuperation amelioree apres chirurgie (RAAC) ont pour objectif de reduire le stress physiologique induit par la chirurgie. Ces protocoles sont associes a une amelioration des resultats et a une reduction des couts dans differentes specialites en chirurgie orthopedique. Recemment, la chirurgie du rachis a ete evoquee dans la litterature, comme domaine d’application potentiellement bien adapte aux programmes RAAC. L’objectif de cette etude etait de comparer les resultats postoperatoires a court terme apres chirurgie du rachis des patients ayant beneficie d’un protocole de recuperation amelioree avec ceux ayant suivi un protocole de recuperation classique. Hypothese Le protocole RAAC developpe dans notre departement apporte un benefice aux patients operes du rachis. Patients et methode Une analyse retrospective de donnees collectees prospectivement etait realisee pour inclure tous les patients operes du rachis et ayant beneficie du protocole RAAC dans notre etablissement entre janvier 2017 et janvier 2018. Un groupe de controle etait selectionne en utilisant la methode d’appariement sur score de propension. La duree de sejour hospitalier, les complications, le taux de readmission, la douleur postoperatoire, le score fonctionnel et la satisfaction des patients etaient compares entre les deux groupes. Resultats Cent quatre-vingt-treize patients avaient beneficie du protocole RAAC pendant la periode etudiee. Apres appariement, 193 paires etaient selectionnees pour constituer une base de donnees finale de 386 patients a analyser. Il y avait une difference significative de la duree d’hospitalisation moyenne, definie comme le nombre de jours moyen passe a l’hopital, entre les deux groupes (groupe RAAC, duree d’hospitalisation moyenne = 2,6 jours, (mediane 2 jours, etendue 1–7), groupe controle duree d’hospitalisation moyenne = 4,4 jours, (mediane 4 jours, etendue 2–14) ; p Discussion Le protocole RAAC diminuait la duree d’hospitalisation, sans generer d’effets indesirables supplementaires apres chirurgie du rachis. Ces resultats plaident en faveur de la mise en place de ce protocole de recuperation amelioree apres chirurgie du rachis. Niveau de preuve III, analyse retrospective.

Compared with other approaches, anterior lumbar interbody fusion (ALIF) is believed to be more effective at restoring segmental lordosis and reducing risks of adjacent-segment disease. It remains controversial, however, whether ALIF improves global lumbar lordosis or influences pelvic parameters, possibly because of the heterogeneity of implants and levels studied.To report clinical outcomes of stand-alone ALIF with anterior plate fixation for L5-S1 and to determine the effect on global lumbar lordosis and pelvic parameters.This is a retrospective case series.Patients that underwent isolated mini-ALIF with anterior plate fixation for L5-S1.Oswestry Disability Index (ODI), Short Form 12, lower back and legs pain on Visual Analog Scale, as well as spino-pelvic parameters.The authors reviewed the records of all patients that underwent retroperitoneal mini-ALIF for single-level L5-S1 fusion between August 2012 and December 2016. A total of 129 patients were included, but 9 patients had incomplete preoperative radiographic data, and one patient had schizophrenia and was unable to respond to outcome questionnaires, leaving 119 patients eligible for outcome assessment. At a minimum follow-up of 1 year, seven patients refused to participate in the study or could not be reached, which left a final cohort of 112 patients.Nine patients were reoperated without implant removal (four pseudarthrosis, two hematomas, one sepsis, one L4-L5 disc hernia, and one L4-L5 disc degeneration). At a mean of 20±9 months, all scores improved significantly from baseline values, with net improvement in ODI of 23.3±19.9. Multivariable analyses confirmed better postoperative ODI in patients that received 18° cages (β=-9.0, p=.017), but revealed no significant trends for net improvement in ODI. Comparison of preoperative and last follow-up radiographs revealed that global lumbar lordosis increased by 4.2±7.1° (p.001), L5-S1 segmental lordosis increased by 11.8±6.7° (p.001), and L4-L5 segmental lordosis decreased by 1.9±3.3° (p.001). All pelvic parameters changed: pelvic incidence increased by 0.6±2.7° (p=.003), pelvic tilt decreased by 2.5±4.1° (p.001) and sacral slope increased by 3.3±4.7° (p.001).Stand-alone mini-ALIF with anterior plate fixation for L5-S1 can change pelvic parameters while improving global and segmental lumbar lordosis. The procedure resulted in a fusion rate of 96% and comparable improvements in ODI to other studies.

Background This is a Phase IV, national, multicentre, retrospective study to observe the real-world use of rhBMP-2 in France. Hypothesis There was no statistical hypothesis, the statistical analyses were descriptive in nature. Patients and methods Data was collected from patient medical files in 10 French spinal centres. Primary objectives were to understand which patients were treated with rhBMP-2, commercialised in Europe as InductOs™ and how rhBMP-2 was used during spinal fusion surgery in France between 2011 and 2012. Results Four hundred patients (634 levels) treated with rhBMP-2 were included in the analysis. The most frequent primary diagnostic indication for rhBMP-2 use was degenerative disc disease (DDD; 129/400; 32.3% of patients) followed by spondylolisthesis (119/400; 29.8%), deformity (59/400; 14.8%) and pseudoarthrosis (29/400; 7.3%). The most frequently treated level was L4–L5 (33.8% of levels in 53.5% of patients); followed by L5–S1 (29.8%, 47.3%), L3–L4 (16.7%, 26.5%), and L2–L3 (7.3%, 11.5%), all other levels (less than 5% of patients). No interbody fusion device was used in 42.7% of levels. Wetted matrix of rhBMP-2 was placed in the interbody space in 58.4% of levels (370/634). The most common procedure for rhBMP-2 treatment was posterior lumbar fusion (PLF) (221/634; 34.9% of levels), followed by anterior lumbar interbody fusion (ALIF) (188/634; 29.7%), posterior lumbar interbody fusion (PLIF) (111/634; 17.5%), lateral lumbar interbody fusion (LLIF) (106/634; 16.7%), transforaminal lumbar interbody fusion (TLIF) (4/634; 0.6%) and ‘other’ (4/634; 0.6%). Thirty-one adverse events of Interest (AEI) were recorded in 27 patients. One AEI was considered related to rhBMP-2. Unplanned secondary spine interventions at index level treated with rhBMP-2 were required in 4 patients. Discussion In years 2011 and 2012 when the surgeries captured in this retrospective study were done, rhBMP-2 was indicated for single level (L4–S1) anterior lumbar spine fusion as a substitute for autogenous bone graft in adults with DDD. The most common procedure for the treatment with rhBMP-2 was PLF (off-label use), followed by ALIF (on-label use). The safety findings confirm a predictable and manageable safety profile. Level of evidence IV.