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Bilateral facet dislocation of the lumbosacral joint is an uncommon injury. We report on the imaging findings in a patient who had an acute disc herniation associated with a bilateral traumatic lumbosacral dislocation.
PURPOSE OF THE STUDY: The purpose of this work was to propose an objective radiographic evaluation of the antero-inferior gleno-humeral ligament for comparison with the clinical assessment proposed by Gagey. MATERIAL AND METHODS: A test radiogram was obtained from 32 healthy volunteers (15 men, 17 women, mean age, 29 years, age range 21-54 years) free of shoulder disease. The dynamic test image consisted in a strictly AP view of the shoulder in forced abduction in neutral rotation. The subjects were awake and in dorsal decubitus. Displacements of the scapulo-thoracic articulation were limited by a counter-force applied to the acromion, in accordance with the method described by Gagey. Bilateral images were obtained for comparison. Several angles were measured between the humeral shaft and the scapula to search for the most reliable and reproducible measurement. RESULTS: Three series of angles were measured between the axis of the humeral shaft and the scapula. The mean angle between the axis of the humeral shaft and line drawn from the lower rim of the glenoid cavity to the lateral border of the scapular tubercle was 130.3 degrees (range 110-148 degrees) on the dominant side and 131.5 degrees (108-148 degrees) on the non-dominant side; giving 38 degrees variability on the dominant side and 40 degrees variation on the non-dominant side and a standard deviation of 10.4 degrees on the dominant side and 11.5 degrees on the non-dominant side. The mean difference in gleno-humeral abduction was 3.8 degrees (range 0-14 degrees) between the dominant and non-dominant side. DISCUSSION: Among the different angles measured between the scapula and the humerus, the angle between the axis of the humeral shaft and the line drawn from the lower rim of the glenoid cavity to the lateral border of the scapular tubercle was the most reliable and reproducible. Inter-observer measurements were well correlated. We observed that the variability in the radiographic values of the scapulo-humeral angle was much greater than the clinical values described by Gagey who, finding very constant values during forced abduction, described "invariable" scapulo-humeral abduction of the shoulder. Our study demonstrates that scapulo-humeral abduction is not an invariable parameter. More interestingly, the difference in amplitude between the dominant and non-dominant sides showed very strong interindividual correlation. Interobserver variability was low and reproducibility was good. CONCLUSION: This dynamic radiographic test enables a precise quantified assessment of pure gleno-humeral abduction which depends on the antero-inferior gleno-humeral ligament. This test is reliable and reproducible. Variations in the length of the antero-inferior gleno-humeral ligament evaluated radiographically were greater than described clinically. We did not find any difference in pure gleno-humeral abduction greater than 14 degrees between the dominant and non-dominant sides in healthy subjects.
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 purpose of this study was to compare the sagittal alignment of the spine in a population of soccer players and a population of volunteers with no sports activities in order to assess the effect of sports activities on stress fractures of the isthmic region. MATERIAL AND METHODS: The group of athletes included 31 soccer players and the volunteer group 47 subjects with no sports activities selected from a 131 subjects database. The two groups were matched for sex and age. All athletes were licensed members of a soccer club and participated in regular sports activities at a moderate level (at least 4 hours per week for at least 2 years). Plain radiographs of the entire spine (lateral view) in the same reference position were obtained for all subjects. The following parameters were recorded: thoracic kyphosis, lumbar lordosis, sacral tilt, anteversion of the pelvis, sagittal alignment. The following morphology data were also recorded in this exclusively male population: weight, height, arm spread. RESULTS: Considering the other radiographic parameters, the sagittal alignment of the spine was comparable between the two groups. However, the statistical analysis demonstrated that the distribution of the spinal and pelvic parameters was different between the athletic and the non-athletic subjects. In athletes, spinal alignment was achieved by a less pronounced thoracic kyphosis and a more pronounced angle, sacral tilt and lumbar lordosis. DISCUSSION AND CONCLUSION: The particular spinal morphology observed in soccer players is comparable with that described in the literature for patients with or treated for spondylolisthesis with isthmic lysis.
Evaluation of the alignment of the spine in the frontal and sagittal planes is an important part in the work up of many disorders of the spine. This type of study requires only frontal and lateral 30 x 90cm radiographs performed in the standing position and including spine, pelvis and proximal femurs. The relationship between spine, pelvis and lower limbs is stressed.
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.
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.
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.
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A 58-year-old man developed spinal cord compression at the T2-T3 level due to an Aspergillus epidural abscess. This presumably immunocompetent patient had been treated for two years by oral itraconazole (200 mg/day) for a lung aspergilloma that occurred seven years after removal of a lung adenocarcinoma. Surgical debridement was performed via a wide posterior approach associated with high-dose amphotericin B. Five months later, the patient's neurological deficit had not improved and the patient died from respiratory failure. Despite a long-term treatment with itraconazole, the infection spread locally from a lung aspergilloma to the epidural space.
PURPOSE OF THE STUDY: The main objective of this work was to determine the impact of osteosynthesis for posterolateral arthodesis on bone consolidation. We also tried to isolate factors predictive of nonunion and the effect of nonunion on the final outcome. MATERIAL AND METHODS: We recaIIed for assessment patients who had undergone surgery for stenosis of the lumbar spine and who had a posterolateral lumbar or lumbosacral arthodesis in addition to the spinal decompression. Among a total of 98 operated patients, 31 had arthrodesis without instrumentation. These 31 patients were matched for age, sex, smoking habits, and extent of the fusion with 31 other patients who had an instrumented arthrodesis. Radiological and clinical assessment obtained preoperatively and at 6, 12, and 24 months postoperatively were available for all 62 patients. RESULTS: Our two groups of patients were similar for comorbidity, number of arthodesis levels, fusion zone, extent and site of associated radicular release, lumbar lordosis, slope of the sacrum, global spinal mobility, and angular anteroposterior intersegmentary mobility of the different levels of the fusion zone, and interertebral sliding (site, degree, type, ante- or retrolisthesis). At last follow-up, rate of malunion was the same in the two groups (35 p. 100). Statistical analysis demonstrated three factors significantly associated with malunion: anteroposterior intersegmentary mobility, and especially angular mobility and disk height. Disk height was not however significant if it was associated with intersegmentary hypermobility. Other parameters studied, and notably use of ostheosynthesis material or not, preoperative comorbility, presence or not of preoperative intervertebral displacement, and level of the arthrodesis, had no effect. DISCUSSION: Considering the type of arthrodesis studied (short fusion on a globally minimally mobile spine) the series demonstrated that the use of osteosynthesis material does not significantly increase the rate of fusion of posterolateral arthrodesis and that the mobility of the spinal segment involved is probably a more important predictive factor for the quality of the fusion.
The effectiveness of a macroporous biphasic calcium phosphate ceramic was studied after laterovertebral arthrodesis in sheep. A ceramic with a TCP/HAP ratio of 35/65 was compared with autologous bone graft in an histomorphometric and biomechanical point of view. Quantitative analysis of the results indicated that the biphasic ceramic allows an arthrodesis after 12 months, although control graft is effective after six months. A large decrease of flexibility in all directions was obtained with the ceramic, similarly to autologous graft. No nonfusion case was observed. In conditions very close to the human surgery, a posterolateral fusion can be obtained using biphasic phosphate ceramic as bone substitute.
PURPOSE OF THE STUDY: Little is known about the impact of posterolateral arthrodesis on adjacent levels. In order to examine this question, we analyzed the radiological evolution of the lumbar spine in patients treated for lumbar stenosis, comparing cases where posterolateral arthrodesis was used with the other cases. Our aim was to determine whether the long-term radiographical modifications were affected by the arthrodesis. MATERIAL AND METHODS: Among our series of patients presenting with lumbar stenosis between 1984 and 1992, we retained two groups: patients in group 1 (n=46) who underwent single-level decompressions at L4-L5 or L4-L5 and L5-S1 level; and patients in group II (n=81) who underwent decompressions on the same levels associated with posterolateral arthrodesis extending from L4 to the sacrum with or without instrumentation. We compared the course of the two levels above the decompression (L2-L3 and L3-L4) between the two groups. We compared three radiological parameters: disc height, intervertebral slipping, and intersegmental mobility. We also examined the correlations between radiological modifications and functional outcome. Mean follow-up for these 127 patients was 9 years. RESULTS: The two groups were comparable for age, gender, follow-up, and presurgical functional score, disc height and intervertebral slipping at equivalent levels. At last follow-up, disc narrowing was observed at L2-L3 and L3-L4; it was significantly greater in the group with complementary arthrodesis. At L3-L4, intervertebral slipping also worsened more in the arthrodesis patients. Use of osteosynthesis significantly increased the risk of developing such radiological lesions. These lesions were associated, solely in the arthrodesis group, with poorer functional outcome. CONCLUSION: Our findings allow the conclusion that, despite the effect of physiological aging, the observed long-term degenerative lesions in patients undergoing treatment of lumbar stenosis are related to the associated arthrodesis which increases their frequency and severity, deteriorating the functional outcome.
PROGRESSIVE DEFORMATION DURING ADULTHOOD: Though not commonly recognized, lumbar and thoracoscoliosis can progress during adulthood. This slow, insidious evolution concerns not only the anatomic configuration of the spinal curatures (three dimensional angular deformation) but also spinal function (development or aggravation of spinal or radicular pain and/or impaired equilibrium). This fact emphasizes the importance of regular prolonged surveillance of all patients with spinal deformations. RADIOLOGICAL CHANGES: Three anatomic elements affecting function are evidenced on serial x-rays: development of rotational dislocation, stiffening of the main curvature, especially in the lumbosacral spine, and progressive instaliation, thoracolumbar kyphosis. TREATMENT: Three types of treatment can be proposed: physical therapy, orthopedic treatment, surgery. Physical therapy and orthopedic treatment can relieve pain and improve equilibrium but cannot change the progressive pattern of the spinal deviation. Surgery also provides effective symptom relief and has the advantage of definitively stopping the progression of the deformation. INDICATIONS: Indications are much more complex than simply determining an angle of deformation beyond which surgery is needed. For each case, indications are established on knowledge of the type of deformation, its extent, potential or ongoing modifications in the main curvature and compensatory curvatures, the patient's age, as well as the functional impairment and the patient's general status.
STUDY DESIGN: Retrospective study of bone regrowth after decompressive surgery for lumbar spinal stenosis. OBJECTIVES: To assess bone regrowth at the operation site, to compare the bone regrowth rate calculated from plain radiographs with computed tomographic image examinations, to determine the effects of bone regrowth on clinical outcome, and to investigate the factors promoting bone regrowth. SUMMARY OF THE BACKGROUND DATA: Moderate or marked bone regrowth in a surgical defect has been reported in most patients after decompression for lumbar spinal stenosis. Postoperative bone regrowth is related to recurrence of neurologic symptoms in the middle of and later on in follow-up periods. METHODS: Twenty-three patients who underwent decompressive surgery for lumbar spinal stenosis, with an average follow-up of 8 years, were evaluated retrospectively regarding the degree of bone regrowth at the posterior arch. Early postoperative radiographs and computed tomographic images were compared with those obtained at final follow-up. Bone regrowth at the operation sites was evaluated as a regrowth percentage of the original laminectomy site. RESULTS: Decompressive surgery caused bone regrowth to occur at the operation site in most of the patients. However, this regrowth was mild because the mean bone regrowth rate evaluated from plain radiographs averaged 11% and from computed tomographic images 7.7%. In only 20% of the patients was the bone regrowth rate more than 20%. Changes were found to be more elevated at the facet joint level than at the pedicle level. Evaluations of regrowth obtained from plain films and computed tomographic image examinations were compared. Radiographs seemed to overestimate the bone regrowth. The association of postoperative spinal instability with the development of new bone was statistically significant. No relation between bone regrowth and clinical outcome was found. CONCLUSIONS: Bone regrowth in a surgical defect occurs in most patients after posterior decompression. In this study the bone regrowth rate was mild and did not affect the clinical outcome.
STUDY DESIGN: A retrospective radiographic and medical record analysis of 58 patients. OBJECTIVES: To describe the incidence and consequences of cervical spinal deformity and instability after multilevel laminectomy in adult patients with myelopathy caused by cervical spondylosis and to determine the usefulness of preoperative dynamic roentgenographic films in the prevention of postoperative destabilization. SUMMARY OF BACKGROUND DATA: Extensive cervical laminectomy has been widely used in the treatment of progressive myelopathy secondary to stenotic conditions. Complications of this procedure, including spinal instability, accelerated spondylotic changes, postoperative spinal deformity, and constriction of the dura mater by formation of extradural scar tissue formation have been recognized. However, the frequency of these complications is probably overestimated, and their effect on clinical outcome remains unknown. METHODS: Fifty-eight patients older than 30 years who underwent a laminectomy at more than three levels without fusion for myelopathy secondary to cervical spondylosis were reviewed retrospectively with an average follow-up of 3.6 years. Functional results were evaluated according to the Japanese Orthopaedic Association's scoring system. Lateral views in neutral position, in flexion, and in extension of the preoperative cervical roentgenograms were analyzed in comparison with the last follow-up films to identify the changes in the curvature of the cervical column, in the range of motion of the neck, and in the intervertebral angular mobility and anteroposterior displacement of the vertebral bodies and finally to quantify the incidence of spinal instability. RESULTS: In 18 patients (31%), postoperative changes in the type of cervical spine curvature developed. Fifteen patients (25%) had destabilization at one or more levels. Deformities of the cervical spine occurring after surgery do not appear to cause symptoms or neurologic abnormalities. Destabilization required repeat surgery in 3 patients. All the levels appearing to be destabilized on the postoperative films were hypermobile on the preoperative dynamic radiographs. Preoperative olisthesis Without hypermobility is not a factor of risk in postoperative destabilization. CONCLUSIONS: The use of preoperative dynamic radiographs should improve the selection of patients undergoing laminectomy for the treatment of multilevel cervical cord compression. Dynamic radiographs may also reinforce the need for such adjunctive procedures as fusion and instrumentation, to prevent postoperative destabilization. Preoperative olisthesis with hypermobility in sagittal or horizontal planes must be fused and instrumented.
Severe motor weakness is an infrequent symptom in the course of lumbar stenosis. The objectives of this study are threefold: to describe the motor deficit, evaluate the prognosis factors, and determine the type of stenosis most likely to be complicated by motor loss. Fifty consecutive patients with a mean age of 65 years, operated on for a lumbar stenosis and with a severe motor deficit, have been retrospectively studied with a mean follow-up of 38 months. The overall functional result was evaluated according to the Beaujon scoring system. The motor capacity was rated from 0 (complete paralysis) to 5 (normal strength). Prognosis factors were investigated with a multivariate analysis model. Motor weakness was rated as zero 11 times, as one 8 times, as two 8 times, and as three 23 times. According to our rating scale, the overall results were considered excellent in 25 cases, good in 17 cases, and fair in the 8 remaining cases. Regression of motor weakness was complete 15 times, partial 25 times, and null 10 times. In this study, favorable prognosis parameters of motor weakness recovery were as follows: association with a discal herniation, stenosis at one level, preoperative duration of motor weakness <6 weeks, age <65, and monoradicular deficit. In contrast, severity of the initial motor weakness, association with sphincter abnormalities, presence or not of degenerative spondylolisthesis, or of a complete block on the myelogram were not influential variables.
PURPOSE OF THE STUDY: Extensive cervical laminectomy has been widely used in the treatment of progressive myelopathies secondary to stenotic conditions. Complications of this procedure such as spinal instability, accelerated spondylotic changes, postoperative spinal deformity and constriction of the dura mater by extradural scar tissue formation have been recognized. However, the frequency of these complications is probably overestimated and their consequences on the clinical outcome remain unknown. The purpose of this report was to describe the incidence and consequences of cervical spinal deformity and instability after multilevel laminectomy in adult patients with myelopathy caused by cervical spondylosis and to determine the usefulness of preoperative dynamic films in the prevention of postoperative destabilization. MATERIALS AND METHODS: 30 patients older than 30 years who underwent a laminectomy of more than 3 levels without fusion for myelopathy secondary to cervical spondylosis were reviewed retrospectively with an average follow-up of 5 years. Functional results were evaluated according to the Japanese Orthopaedic Association scoring system. Lateral views in neutral position, in flexion and in extension of the preoperative cervical roentgenograms were analyzed in comparison with the last follow-up one in order to identify the changes in the curvature of the cervical column, in the range of motion of the neck, in the intervertebral angular mobility and antero-posterior displacement of the vertebral bodies, and finally to identify the incidence of spinal instability. RESULTS: 18 patients (31 per cent) developed postoperative changes in cervical spine curvature. 15 patients (25 per cent) had one or more destabilized levels. Deformities of the cervical spine occurring after surgery do not appear to cause any symptom or neurologic abnormalities. Destabilization required repeat surgery in 3 patients. All the levels found destabilized on the postoperative films were hypermobile on the preoperative dynamic radiographs. A preoperative olisthesis without hypermobility was not a risk factor for postoperative destabilization. CONCLUSION: The use of preoperative dynamic radiographs should improve the selection of patients undergoing laminectomy for the treatment of multilevel cervical cord compression. Dynamic X-rays may also reinforce the need for possible adjunctive procedures such as fusion and instrumentation, in order to prevent a postoperative destabilization. A preoperative olisthesis with a hypermobility in sagittal or horizontal planes must be fused and instrumented.