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When performing posterior spinal fusion for adolescent idiopathic scoliosis (AIS), it is of major importance to address both coronal and sagittal deformities. Although several techniques have been described, few data exist comparing them. Our objective was to compare four techniques (in situ bending (ISB), rod derotation (RD), cantilever (C) and posteromedial translation (PMT)) for the correction of spinal deformity in AIS including thoracic deformity.We conducted a multicenter retrospective study including 562 AIS patients with thoracic deformity with at least 24-month follow-up. Radiographic analysis was performed preoperatively, postoperatively and at last follow-up. The main outcomes were main curve correction and thoracic kyphosis restoration (TK).Coronal correction rate was significantly different among the four treatment groups (ISB 64% vs C 57% vs RD 55% vs PMT 67%, p 0.001). Multivariate regression revealed that correction technique did not influence correction rate, whereas implant density, convex side compression and use of derotation connectors did. TK increase was significantly higher in the PMT group (average + 13°) than in DR (+ 3°), while ISB (-3°) and cantilever (-13°) resulted in TK decrease (p 0.001). Multivariate analysis revealed that TK increase was only influenced by the reduction technique (p 0.001) and preoperative TK (p 0.001).The four techniques had the same ability to correct spinal deformity in the coronal plane. Three factors were identified to improve correction rate: implant density, convex compression and use of derotation connectors. On the other hand, PMT was more effective in restoring TK, particularly in hypokyphotic patients.

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.

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.

Objective: To evaluate the clinical and radiological outcomes of patients undergoing one-level oblique lumbar interbody fusion (OLIF) combined with posterolateral fusion (PLF) with pedicle screws for the treatment of degenerative lumbar spondylolisthesis (DS) with a minimum follow-up of 1 year. Methods: A retrospective analysis of prospectively collected data was performed. Patients who underwent combined OLIF and PLF between March 2013 and December 2019 were considered for study eligibility. Patients were evaluated using the Oswestry Disability Index (ODI) and the Short Form-12 (SF-12) (physical PCS, mental MCS), self-evaluation of pain with a Visual Analog Scale (VAS) and walking distance. Compensation and sagittal balance were assessed using the Gille classification by full spine stereoradiography (EOS Imaging, Paris, France). Mechanical complications were also collected. Results: A total of 131 patients were included (mean (SD) age: 64.2 ± 10.4 years), and 127 patients were evaluated after a mean follow-up of 22 ± 12.3 months. The mean ODI at the last follow-up was 13.8 ± 12.9% (gain of 32.3 ± 15.5%; p 40 mm) had a significant improvement in SVA of 19.8 ± 32 mm (p = 0.025). Sagittal imbalance (Gille type 3) was not associated with a change in postoperative functional score (p = 0.52). Conclusions: OLIF improved functional scores at 1 year, with excellent outcomes in 80% of our patients with a low morbidity. Sagittal imbalance did not adversely affect the clinical outcomes. Level of evidence: 4 (cohort study).

Cage impactions (CI) of Oblique Lumbar Interbody Fusion (OLIF) appear to be a frequent mechanical complication with a potential functional impact.To determine the rate of CI occurrence, their risk factors and clinical implications in the case of combined single-level arthrodesis.A retrospective analysis of prospectively collected data was performed. All our patients with degenerative spondylolisthesis initially underwent OLIF combined with pedicle screw fixation (PSF). Intraoperative control with an image intensifier and a standard radiograph in the immediate postoperative period made it possible to assess the occurrence of CI, depending on the position of the implant. Secondary subsidence was sought on the standing radiological examination using EOS biplanar radiography during follow-up. The pelvic parameters were analyzed, as well as the occurrence of bone fusion. The clinical evaluation was made at≥1 year, by the Oswestry Disability Index (ODI), the walking distance (WD) and the Visual Analogue Scale (VAS).In all, 130 patients out of the 131 included were analyzed. A CI occurred in 25.3% (n=33) of cases and of these, 94% (n=32) occurred intraoperatively. Postmenopausal women had more CI with an odds ratio (OR) of 5.8 (P=0.034). The "CI" group had a 9.5% lower ODI score than the "non-CI" group (P=0.0040), but both provided excellent ODI gains of 30.8±16 and 32.9±15.5% (P0.0001). An "anterior" position of the implant allowed a greater gain in lumbar lordosis (P0.001) but was associated with greater CI occurrence (P0.001), with an OR of 6.75 (P=0.0018).The occurrence of intraoperative cage impaction is a frequent event when performing OLIF. Postmenopausal women have an approximately 6 times greater risk of impaction than men, and patients with an "anterior" implant placement have a 7 times greater risk than with central placement. The negative impact of cage impactions on the clinical score (ODI) was significant after one year of follow-up.IV, non-comparative cohort study.

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.

Objectives: To assess early clinical outcomes of stand-alone minimally invasive ALIF for patients with DDD at L4-L5 and determine whether the procedure affects spino-pelvic parameters. Methods: The authors reviewed the records of all patients with DDD that underwent stand-alone minimally invasive ALIF at L4-L5 using the self-locking SynFix cage (DePuy Synthes, PA, USA). Patients were evaluated using the Oswestry Disability Index (ODI), Short Form 12, and lower back and legs pain on Visual Analog Scale. Spino-pelvic parameters were measured from whole-spine standing radiographs. Results: From the initial cohort of 48 patients, 3 could not be reached, and 4 were reoperated due to pseudarthrosis using posterior instrumentation with bone graft, leaving 41 for clinical and radiologic evaluation. At a follow-up of 18.2 ± 7.3 months, all 5 clinical scores improved from pre-operative values. Multi-variable regressions revealed no significant associations between independent variables and ODI. Comparing pre- and post-operative radiographs: global lumbar lordosis increased by 3.6 ± 7.7° (p = 0.001), L4-L5 lordosis increased by 7.4 ± 6.1° (p

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.

Objectif Decrire l’utilisation de rhBMP2 dans la fusion du rachis en France dans une etude retrospective multicentrique de 1 an ( NCT02280187 ). Methodes Quatre cents patients enroles dans 10 sites francais ont subi une chirurgie du rachis (2011–2012) utilisant la rhBMP2. Donnees recueillies : donnees demographiques et donnees intra-operatoires ; taux de fusion et d’evenements indesirables (EI) d’interet a la chirurgie, a 6 semaines, a 6 et 12 mois de suivi. Resultats Âge moyen des patients : 54,5 ans ; femme : 59 % ; IMC moyen : 26,0. Au moment de la chirurgie, 27,5 % des patients etaient fumeurs et 7,3 % diabetiques. Les indications de diagnostiques primaires les plus frequents etaient la maladie degenerative du disque (32,3 %) et les spondylolisthesis (29,8 %). Le temps moyen entre l’indication du diagnostic principal et la chirurgie etait de 299 jours. La majorite des procedures a ete effectuee par voie ouverte conventionnelle (89,5 %) et dans la plupart des cas, un ou deux niveaux ont ete traites (64,5 % et 26,3 %). Cependant, jusqu’a 16 niveaux ont ete traites par patient. Les niveaux les plus frequemment traites etaient L4–L5 (33,8 %) et L5–S1 (29,8 %). Des dispositifs de fusion intersomatiques ont ete utilises dans 56,0 % des niveaux traites. La matrice humidifiee de rhBMP2 a ete le plus souvent placee dans l’espace intersomatique (58,4 %) ou dans la position laterale posterieure (42,6 %). La stabilisation a ete effectuee dans 84,4 % des niveaux traites. Pour 62,5 % des niveaux traites, la rhBMP2 a ete utilisee en association avec un materiel de greffe. Le taux de fusion par patient lors des dernieres evaluations effectuees sous 12 mois (n = 226) a ete rapporte comme un succes pour 73,3 % des patients et un echec pour 26,7 %. Le taux de fusion par patient a 12 mois de suivi (n = 182) a ete rapporte comme un succes pour 94,5 % des patients et un echec pour 5,5 %. Un total de 31 EI d’interet a ete enregistre chez 28 patients. Un EI a ete considere comme lie a l’utilisation de rhBMP2, 9 avaient une relation inconnue, et 21 ont ete consideres comme independants. Neuf patients ont subi une chirurgie additionnelle non planifiee du rachis lors du dernier suivi. Conclusion Il s’agit de la premiere etude multicentrique decrivant l’utilisation de rhBMP2 dans la fusion du rachis en France. Elle confirme le taux de fusion eleve decrit dans la litterature et un faible nombre d’EI d’interet.