Publications by authors named "Charles Court"

32 Publications

Can MRI differentiate surrounding vertebral invasion from reactive inflammatory changes in superior sulcus tumor?

Eur Radiol 2021 May 15. Epub 2021 May 15.

Department of Radiology, Gustave Roussy Cancer Campus, 114 Rue Edouard Vaillant, Villejuif, 94800, Paris, France.

Objectives: Vertebral invasion is a key prognostic factor and a critical aspect of surgical planning for superior sulcus tumors. This study aims to further evaluate MRI features of vertebral invasion in order to distinguish it from reactive inflammatory changes.

Methods: Between 2000 and 2016, a retrospective study was performed at a single institution. All patients with superior sulcus tumors undergoing surgery, including at least two partial vertebrectomies, were included. An expert radiologist evaluated qualitative and quantitative MRI signal intensity characteristics (contrast-to-noise ratio [CNR]) of suspected involved and non-involved vertebrae. A comparison of CNR of invaded and sane vertebrae was performed using non-parametric tests. Imaging data were correlated with pathological findings.

Results: A total of 92 surgical samples of vertebrectomy were analyzed. The most specific sequences for invasion were T1 and T2 weighted (92% and 97%, respectively). The most sensitive sequences were contrast enhanced T1 weighted fat suppressed and T2 weighted fat suppressed (100% and 80%). Loss of extrapleural paravertebral fat on the T1-weighted sequence was highly sensitive (100%) but not specific (63%). Using quantitative analysis, the optimum cut-off (p < 0.05) to distinguish invasion from reactive inflammatory changes was CNR > 11 for the T2-weighted fat-sat sequence (sensitivity 100%), CNR > 9 for contrast-enhanced T1-weighted fat-suppressed sequence (sensitivity 100%), and CNR < - 30 for the T1-weighted sequence (specificity 97%). Combining these criteria, 23 partial vertebrectomies could have been avoided in our cohort.

Conclusion: Qualitative and quantitative MRI analyses are useful to discriminate vertebral invasion from reactive inflammatory changes.

Key Points: • Abnormal signal intensity in a vertebral body adjacent to a superior sulcus tumor may be secondary to direct invasion or reactive inflammatory changes. • Accurate differentiation between invasion and reactive inflammatory changes significantly impacts surgical planning. T1w and T2w are the best sequences to differentiate malignant versus benign bone marrow changes. The use of quantitative analysis improves MRI specificity. • Using contrast media improves the sensitivity for the detection of tumor invasion.
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May 2021

Video-Assisted Thoracoscopic En Bloc Vertebrectomy for Spine Tumors: Technique and Outcomes in a Series of 33 Patients.

J Bone Joint Surg Am 2021 Jun;103(12):1104-1114

Orthopedic and Trauma Surgery Department, Kremlin Bicêtre Hospital and Paris Saclay University, Le Kremlin Bicêtre, France.

Background: In en bloc vertebrectomy, the posterior approach is associated with limited access to anterior structures (vertebral body, esophagus, aorta, azygos vein). Video-assisted thoracoscopic surgery (VATS) might prove to be advantageous during thoracic en bloc vertebrectomy by allowing a combined anterior-posterior access in the prone position. We describe the technique and review the outcomes of 33 cases of video-assisted thoracoscopic en bloc vertebrectomy.

Methods: A retrospective, single-center cohort study included all cases of VATS with a minimum follow-up of 1 year. A team of thoracic and orthopaedic surgeons performed the surgical procedure with the patient in a single, prone position. Anterior release was carried out thoracoscopically, followed by posterior en bloc tumor removal.

Results: From 2003 to 2019, 33 patients were included. Nine patients underwent total vertebrectomy (8 had single-level and 1 had 3-level), and 24 patients underwent partial vertebrectomy (1 had single-level, 8 had 2-level, 13 had 3-level, and 2 had 4-level). Ten patients had pulmonary resection. Histology revealed 18 cases (55%) of primary bone tumors, 6 cases (18%) of lung cancer invading the spine, 6 cases (18%) of solitary metastasis, and 3 other cases (9%). The margins were tumor-free in 28 cases (85%). The median operative time was 240 minutes (range, 150 to 510 minutes), with a median blood loss of 1,200 mL (range, 400 to 6,700 mL), and there were 2 cases of conversion to thoracotomy. A total of 33 complications occurred in 18 patients (55%), and these were predominantly pulmonary. One death was surgery-related (infection). One patient had a persistent monoplegia. At a median follow-up of 63 months (range, 12 to 156 months), there were 21 surviving patients (64%) with 2 local recurrences and 1 distant recurrence, and 2 patients (6%) were lost to follow-up. The survival rates were 94% at 1 year, 71% at 2 years, and 68% at 5 years.

Conclusions: VATS en bloc vertebrectomy may be indicated for T2-to-T11 spine tumors with the exception of massive tumors, substantial chest wall and/or mediastinal invasion, and lung cancer exceeding 7 cm. The technique yielded satisfactory surgical and oncologic outcomes.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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June 2021

Bilateral femoral shaft fracture in polytrauma patients: Can intramedullary nailing be done on an emergency basis?

Orthop Traumatol Surg Res 2021 05 20;107(3):102864. Epub 2021 Feb 20.

Hôpital Bicêtre, Le Kremlin-Bicêtre, France. Electronic address:

Introduction: Whether damage control orthopedics (DCO) or early total care (ETC) is the best way to treat polytrauma patients who have suffered a bilateral femoral shaft fracture remains unanswered. The aim of this study was to evaluate the morbidity of bilateral femur fractures treated by simultaneous intramedullary (IM) nailing according to ETC principles.

Materials And Methods: This retrospective single-centre study included all polytrauma patients who had suffered a femoral shaft fracture and were treated at our level I trauma centre. Demographic data, associated lesions, injury severity score (ISS) and occurrence of acute respiratory distress syndrome (ARDS) were collected prospectively in our trauma database. Unilateral fractures (UF) were compared to bilateral fractures (BF). The risk of ARDS was evaluated by multivariate logistic regression.

Results: Between 2010 and 2019, 176 UF (88%) and 25 BF (12%) were included. Patients with BF had a higher ISS (36 vs. 25, p<0.001) and more brain injuries (44% vs. 15%, p=0.001) than patients with a UF. More blood transfusions were done in BF than UF (4.0 vs. 1.6 units, p=0.002). The incidence of ARDS was higher in BF patients than UF (36% vs. 4%) with longer stay in intensive care (18 vs. 12 days, p=0.02) and in the hospital (32 vs. 23 days, p=0.006). There were no deaths in either group. The risk of ARDS was correlated to ISS, but not to bilaterality.

Discussion: Studies on DCO and ETC report similar mortality and ARDS rates for BF. ISS appears to determine the postoperative morbidity irrespective of how the patients are managed. In contrast with DCO, perioperative intensive care has a predominant role in ETC, allowing early definitive fixation of fractures, even in severely injured patients.

Conclusion: Bilateral femoral shaft fractures are a sign of severe trauma leading to high postoperative morbidity. The patient is likely to have concomitant severe injuries. Simultaneous ECM can be done emergently providing appropriate perioperative intensive care management.

Level Of Evidence: IV; retrospective study.
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May 2021

Efficacy and safety of oral metronomic etoposide in adult patients with metastatic osteosarcoma.

Cancer Med 2021 01 25;10(1):230-236. Epub 2020 Nov 25.

Department of Ambulatory Cancer Care, Gustave Roussy Cancer Institute, Villejuif, France.

Therapeutic options in patients with metastatic osteosarcoma are limited and effective systemic treatments are needed in this setting. The aim of this case series was to assess the efficacy and toxicity of oral metronomic etoposide in adult patients with progressive metastatic osteosarcoma. We retrospectively reviewed the electronic records of patients treated with oral metronomic etoposide (25 mg thrice daily, 3 weeks out of 4) from December 2002 to December 2018 at Gustave Roussy (Villejuif, France). The primary endpoint was progression-free rate (PFR) at 4 months; secondary endpoints were: best response (according to RECIST v1.1), progression-free survival (PFS), overall survival (OS) and safety. With a median follow-up of 9.8 months, 37 patients were eligible for this analysis: 68% males, median age 42 (range: 21-75), 19% with synchronous metastases, 92% with lung metastases, median PS: 1 (range: 0-3). Median number of previous treatment lines in the metastatic setting was 1 (range: 0-4). Progression-free rate at 4 months was 40.3% (95% CI: 24.5-56.2). Best response was partial response in 11% and stable disease in 35% of patients (disease control rate: 46%). Median PFS was 3.1 months (95% CI: 2.5-4.7) and median OS was 9.8 months (95% CI: 5.1-12.3). Toxicity profile was acceptable, with 13% grade 3 haematological toxicities (anaemia and neutropenia), without any grade 3-4 non-haematological toxicity. In our experience, oral metronomic etoposide demonstrated effective palliation along with acceptable toxicity in patients with progressive metastatic osteosarcoma.
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January 2021

Long-term Outcomes of Oral Vinorelbine in Advanced, Progressive Desmoid Fibromatosis and Influence of Mutational Status.

Clin Cancer Res 2020 12 1;26(23):6277-6283. Epub 2020 Sep 1.

Department of International Patients Care, Gustave Roussy Cancer Institute, Villejuif, Paris, France.

Purpose: Desmoid-type fibromatosis (DF) are locally aggressive neoplasms, with a need for effective systemic treatment in case of progression to avoid the short- and long-term complications of local treatments.

Experimental Design: We retrospectively analyzed the outcomes of adult patients with DF treated with oral vinorelbine (90 mg once weekly) at Gustave Roussy Cancer Institute (Villejuif, Paris, France). Only patients with documented progressive disease according to RECIST v1.1 for more than 3 months (±2 weeks) before treatment initiation were included.

Results: From 2009 to 2019, 90 out of 438 patients with DF were eligible for this analysis. Vinorelbine was given alone in 56 patients (62%), or concomitantly with endocrine therapy in 34 patients, for a median duration of 6.7 months. A partial response was observed in 29% and stable disease in another 57%. With a median follow-up of 52.4 months, the median time to treatment failure (TTF) was not reached. Progression-free rates at 6 and 12 months were 88.7% and 77.5%, respectively. Concomitant endocrine therapy was associated with longer TTF in women [HR, 2.16; 95% confidence interval (CI), 1.06-4.37; = 0.03). Among 64 patients with documented mutational status, p.S45F or p.S45P mutations were associated with longer TTF compared with p.T41A or wild-type tumors (HR, 2.78; 95% CI, 1.23-6.27; = 0.04). Toxicity profile was favorable, without grade 3-4 toxicity, except for one grade 3 neutropenia.

Conclusions: Oral vinorelbine is an effective, affordable, and well-tolerated regimen in patients with advanced, progressive DF. Prolonged activity was observed in patients with tumors harboring p.S45F or p.S45P mutations.
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December 2020

Influence of preoperative biological parameters on postoperative complications and survival in spinal bone metastasis. A multicenter prospective study.

Orthop Traumatol Surg Res 2020 Oct 1;106(6):1033-1038. Epub 2020 Aug 1.

SOFCOT, 56, rue Boissonade, 75014 Paris, France.

Introduction: Onset of spinal bone metastasis is a turning point in the progression of tumoral disease; although incidence is increasing, management is not standardized. Various prognostic scores are available, but advances in medical and surgical treatment have made them less well adapted, and sometimes discordant for a given patient. It would therefore be useful to develop new prognostic instruments. The aim of the present study was to identify biologic risk factors for onset of postoperative complications and death following spinal bone metastasis surgery.

Material And Methods: A prospective multicenter study included all patients operated on for spinal bone metastasis between November 2015 and May 2017. The main epidemiologic data and biologic data (CRP, albuminemia, calcemia) were collected preoperatively. Surgical strategy, death and/or postoperative complications were collected prospectively.

Results: Five of the initial 264 patients died during the immediate postoperative course, and 107 within 6 months. At 1 year, 57 patients remained alive. Twenty-six (10%) were lost to follow-up. Preoperative albuminemia<35g/L (29% of patients), calcemia>2.6 nmol/L (8%) and CRP>10mg/L (47.5%) were associated with significantly elevated mortality. Only CRP elevation correlated with postoperative complications rate.

Conclusion: The study confirmed the prognostic value of 3 biologic parameters (CRP level, albuminemia, calcemia) for survival after spinal bone metastasis surgery. A hybrid score taking account of not only clinical but also biologic parameters should be developed to improve estimation of survival.
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October 2020

What are the differences in outcomes between simple and complicated FSF managed by early IMN?

Arch Orthop Trauma Surg 2020 Aug 16;140(8):1037-1045. Epub 2019 Dec 16.

Department of Orthopedic and Traumatology Surgery, Bicetre University Hospital, AP-HP Paris, Paris-Sud University ORSAY, 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France.

Purpose: To compare the outcomes of simple versus complicated femoral shaft fracture (FSF) treated by early intramedullary nail.

Methods: Retrospective cohort study in level 1 trauma center including patients with FSF. Management consisted of intramedullary nailing (IMN) after adequate resuscitation within 24 h. Data were prospectively collected on admission (trauma base) consisted of demographics, biological parameters, associated injuries and injury severity score (ISS). Complicated fractures consisted of type C fracture or any type associated with bilateral femur fracture, floating knee, associated femoral neck fracture, dislocated hip, concomitant neurovascular injury. Simple fractures were Isolated type A and B fracture. Simple and complicated fracture groups were compared using stratification by ISS (ISS < 16; 16 ≤ ISS < 25; ISS ≥ 25).

Results: Inclusion of 191 consecutive patients: simple FSF (N = 109) versus complicated FSF (N = 82) (type 32C, n = 36; bilateral, n = 44; associated neck of femur fracture, n = 15; floating knee, n = 36; concomitant femoral artery injury, n = 3 or sciatic nerve injury, n = 7). Complicated fractures were associated with higher rate of associated injuries (thoracic, 56.1 vs. 40.4%, p = 0.04; head 25.6 vs 10.1%, p = 0.005) and ARDS (12.2% vs. 3.7%, p = 0.046); longer ICU stay (12.8 vs. 7.3 days, p = 0.019) and hospital stay (24.3 vs. 15.7 days, p < 0.001). After stratification, differences in morbidity between simple and complicated FSF were significant solely in range 16≤ISS < 25. Complicated fractures had longer operation duration (297 vs. 151 min, p < 0.001) due to additional IMN (tibial, humeral) requirements (24% vs. 1.8%, p < 0.001) and longer femoral IMN duration (133 vs. 104 min, p < 0.05). Pseudarthrosis was higher in complicated fracture group (9.6 vs. 3.7%, p = 0.002).

Conclusion: Complicated femoral fractures are associated with higher morbidity, especially in less severely injured polytrauma, which eventually results in longer hospital stay. Patients with moderate ISS and complicated fracture may have an increased risk of ARDS.
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August 2020

Surgical strategies for primary malignant tumors of the thoracic and lumbar spine.

Orthop Traumatol Surg Res 2020 02 13;106(1S):S53-S62. Epub 2019 Dec 13.

Université Paris Sud, hôpital Bicêtre, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France.

Background: Primary malignant tumors of the thoracic and lumbar spine are rare. They are mainly hematologic malignancies and more rarely sarcomas or chordomas. Giant-cell tumors and osteoblastomas, while benign, are locally very aggressive and their excision should be discussed as an option. Other possibilities are tumors from nearby organs invading the spine, which are actually carcinomas, but may benefit from radical excision in select cases.

Methods: Excision of these tumors is complex and must be integrated in the diagnostic and therapeutic strategy established by a specific multidisciplinary tumor board at a designated cancer center. Surgical resection must combine tumor excision with long-lasting reconstruction of the spine and neighboring soft tissues. The initial excision must be as complete as possible as the possibilities of repeat excision are nearly impossible if the first resection is not complete.

Results: An exhaustive preoperative imaging workup is essential for determining the tumor's spread and for determining the best surgical strategy. This will often require participation of other surgical specialties, which are well versed in teamwork. Thanks to this multidisciplinary care, especially the participation of thoracic and plastic surgeons, significant progress has been made recently. The first is the possibility of doing very extensive tumor excisions at the spine and in the neighboring organs, thus expanding the surgical indications to patients who were previously considered as being inoperable. We will discuss the surgical strategy and surgical approaches by spine level. Bone and soft tissue reconstruction is more effective thanks to the introduction of new spinal instrumentation and coverage flaps, which have drastically reduced the intra- and postoperative complications. Lastly, the risk factors for neurological complications are better understood, making them easier to prevent and to treat, if they were to occur.

Conclusion: These advances have translated to better cancer outcomes, especially better control of the tumor with neoadjuvant therapies (targeted chemotherapy) and preoperative conformal radiotherapy.
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February 2020

IgG4-related disease: rare presentation as a soft-tissue mass in the thigh of an adolescent.

Skeletal Radiol 2020 Jan 4;49(1):155-160. Epub 2019 Jun 4.

Orthopaedic Department, Bicêtre Hospital, APHP, Le Kremlin-Bicêtre, France.

We report a case of a 16-year-old boy who presented a soft-tissue mass in the anterior compartment of the right thigh discovered by positron emission tomography/computed tomography within the work-up of unexplained prolonged inflammatory syndrome. The mass has no calcification. Subsequently, magnetic resonance imaging of the femoral triangle was carried out. Axial short tau inversion recovery images showed a 3.5-cm ill-defined mass in the femoral triangle with focal areas of hypointensity, which suggests that there might be fibrosis or hemosiderin within the tumor. Axial T1-weighted images showed a slight hyperintense mass involving the iliopsoas muscle. Contrast-enhanced fat-suppressed T1-weighted imaging showed a heterogeneous solid enhancement. Adjacent thick fascia enhancement of the vastus intermedius and the vastus lateralis muscles extending from the mass as a tail-like margin suggested the infiltrative spread of the tumor along the fascial plane. The mass and the lymphadenopathy were excised. Immunohistochemically, tumor cells were staining for muscle actin and desmin. Many plasma cells were IgG4+ (175per high-power field) with a ratio IgG4+/IgG+ of 50%. The diagnosis of IgG4-related disease (IgG4-RD) was made. Although a diffuse array of musculoskeletal symptoms has been observed in IgG4-related disease, reports of biopsy-proven musculoskeletal involvement of the limb are rare. We showed the radiological features of IgG4-RD presenting as a soft-tissue mass of the thigh. Musculoskeletal involvement, clinical significance, and treatment of IgG4-RD are also discussed.
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January 2020

Surgical treatment of thoracic disc herniation: an overview.

Int Orthop 2019 04 8;43(4):807-816. Epub 2018 Nov 8.

Orthopedic and Traumatology Surgery Department (Pr Ch Court), Bicetre University Hospital, Assistance Publique Hôpitaux de Paris, Paris-Sud University ORSAY, 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France.

Background: Surgical treatment of thoracic disc herniation (TDH) is technically demanding due to its proximity to the spinal cord.

Methods: Literature review.

Results: Symptomatic TDH is a rare condition predominantly localized between T8 and L1. Surgical indications include intractable back or radicular pain, neurological deficits, and myelopathy signs. Giant calcified TDH (> 40% spinal canal occupation) are frequently associated with myelopathy, intradural extension, and post-operative complications. Careful pre-operative planning helps reduce the risk of complications. Pre-operative CT and MRI identify the hernia's location and size, calcifications, and intradural extension. The approach must provide adequate dural sac visualization with minimal manipulation of the cord. Non-anterior approaches are favoured if they provide at least equal exposure than anterior approach owing to higher risk of pulmonary morbidity associated with anterior approach. A transthoracic approach is recommended for central calcified herniated discs. A posterolateral approach is often suitable for non-calcified lateralized TDH. Thoracoscopic approaches are less invasive but have a substantial learning curve. Retropleural mini-thoracotomy is an acceptable alternative. Pre-operative identification of the pathological level is confirmed by intra-operative level check. Intra-operative cord monitoring is preferable but warrant further studies. Magnification and adequate lightening of the surgical field are paramount (microscope, thoracoscopy). Intra-operative CT scan with navigation is becoming increasingly popular since it provides real-time control on the decompression. Indications of fusion consist of pre-operative back pain, Scheuermann's disease, multilevel resection, wide vertebral body resection (> 50%), and herniation at thoracolumbar junction. Neurological deterioration, dural tear, and subarachnoid-pleural fistula are the most severe complications.

Conclusion: Further improvements are still warranted in thoracic spine surgery despite the advent of minimally invasive techniques. Intra-operative CT scan will probably enhance the safety of the TDH surgery.
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April 2019

Long-term functional and radiological outcomes of allograft hip prosthesis composite. A fourteen -year follow-up study.

Int Orthop 2017 07 3;41(7):1337-1345. Epub 2016 Dec 3.

Orthopaedic Department, Tumor and Spine Unit, Bicêtre University Hospital, AP-HP Paris, 78 rue du Général Leclerc, Le Kremlin-Bicêtre, France, F-94270.

Purpose: Allograft hip composite prosthesis (APC) is a type of reconstruction after resection of the proximal femur. This study aimed to assess long-term outcomes after an APC reconstruction.

Materials And Methods: Forty-six patients were retrospectively included (14 revision total hip replacements, 30 primary malignant bone tumors, two metastasis).

Results: The mean length of femoral bone resection was 16.4 cm (7 to 27). With a mean follow-up of 14.7 years (6.3 to 32.6), Postel-Merle d'Aubigné score was 15.7 (8 to 21), Musculoskeletal Tumor Society score at 23.1 or 77% (15 to 29), and abductor strength at 3.4 (2 to 5). Allograft resorption was minor for 20 patients (44.4%), moderate for 13 patients (28.9%), and severe for 12 patients (26.7%). Host-allograft shaft bone fusion was achieved in 37 cases (84.1%). Trochanteric fracture occurred in 26 cases (59.1%). Length of femoral resection, allograft bone resorption, and trochanteric fracture did not have an effect on functional outcomes. At ten years follow-up, overall revision-free and femoral stem survivals were 54.1 ± 0.8% and 81.4 ± 0.6% respectively. No parameter evaluated influenced the survivorship.

Conclusion: APC is a reliable reconstruction adapted for huge proximal femoral bone resections. Trochanteric fracture and allograft bone resorption do not seem to influence functional results.

Level Of Evidence: Level IV.
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July 2017

Interest of Denosumab for the Treatment of Giant-cells Tumors and Aneurysmal Bone Cysts of the Spine. About Nine Cases.

Spine (Phila Pa 1976) 2016 Jun;41(11):E654-E660

Orthopaedic Department, Tumor and Spine Unit, Bicêtre University Hospital, AP-HP Paris, JE 2494 Univ Paris-Sud Orsay, Le Kremlin-Bicêtre, France.

Study Design: A prospective cohort study.

Objective: The aim of this study was to evaluate the interest of denosumab in the treatment of spinal giant-cells tumors (GCTs) and aneurysmal bone cysts (ABCs).

Summary Of Background Data: To treat GCTs and ABCs, surgical resection remains the best treatment to limit local recurrence (LR) but constitutes an aggressive treatment with potential morbidity. Denosumab, a human antibody anti-RankL, inhibiting the differentiation of osteoclasts, could be an alternative treatment to avoid aggressive surgery.

Methods: Patients suffering from GCTs and ABCs of the spine were included. Patients received a monthly subcutaneous injection of denosumab (120 mg) during a minimum of 6 months either as a neoadjuvant or as an adjuvant therapy. In association with denosumab, an osteosynthesis was added in case of vertebral fracture and a laminectomy in case of spinal cord compression. Clinical and computed tomography (CT)-scan outcomes were analyzed.

Results: Eight GCTs and one ABC were included. The mean age was 35 years (range: 22-55 yr). Five patients had neurologic deficit. All patients were operated: six osteosynthesis, one "en bloc" resection, four curettages, and two of them associated with an osteosynthesis. Average duration of denosumab therapy was 12.9 months (range: 3.2-24 months). Among them, four patients began denosumab 6 months at least before the surgery. With a mean follow-up of 19.3 months (range: 3.2-52.4 months), back pain and neurologic deficit improved for all patients. Systematic CT-scan at 6 months showed decrease of tumor size and bone consolidation. Regarding patients treated by neoadjuvant denosumab treatment, intraoperative histologic analysis showed an absence of giant cells and a maximum of 10% of alive tumor cells.

Conclusion: Denosumab allows bone formation and tumor regression with a maximum efficacy after 6 months of treatment without widely substituting surgery. Long-term results are mandatory to confirm the interest of denosumab and to evaluate LR when stopping denosumab.

Level Of Evidence: 3.
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June 2016

Interest of Laparoscopy for "En Bloc" Resection of Primary Malignant Sacral Tumors by Combined Approach: Comparative Study With Open Median Laparotomy.

Spine (Phila Pa 1976) 2015 Oct;40(19):1542-52

*Orthopaedic Department, Tumor and Spine Unit, Bicêtre University Hospital, AP-HP Paris, JE 2494 Univ Paris-Sud Orsay, F-01405, 78 Rue du Général Leclerc, Le Kremlin-Bicêtre 94270, France; and †General Surgery Department, Bicêtre University Hospital, AP-HP Paris, JE 2494 Univ Paris-Sud Orsay, F-01405, 78 Rue du Général Leclerc, Le Kremlin-Bicêtre 94270, France.

Study Design: Retrospective case-control study.

Objective: To compare laparoscopy with open median laparotomy for anterior approach in "en bloc" resection of primary malignant sacral tumors (PMST) in combined approach strategy.

Summary Of Background Data: Wide margin surgical resection is the "gold standard" treatment of PMST.

Methods: Two groups of patients suffering from PMST and operated for "en bloc" resection by combined approach (anterior and posterior) only differencing for the anterior approach were constituted: "laparoscopy" group (n = 11) and "laparotomy" group (n = 22). Intraoperative morbidity (blood loss, red blood cell transfusion (RBC transfusion), surgical procedure duration) and postoperative morbidity (surgical-site infection (SSI), perineal dysfunctions, local recurrence) were analyzed. Surgical margins were studied. Data of both groups were compared using nonparametric Mann-Whitney test for continuous data and Fisher test for categorical data. Overall survival (OS) and Disease-free survival (DFS) were analyzed by Kaplan-Meier method.

Results: Blood loss during anterior approach was less important in "laparoscopy" group 71.9 mL (range 0-400 mL) as compared with 2140 mL (range 0-9000 mL) for "laparotomy" group (P = 0.019). Blood loss during posterior approach was not different between the 2 groups. Total blood loss including anterior and posterior approach was inferior in "laparoscopy" group 2208 mL (range 230-4800 mL) versus 5385.7 mL (range 1400-11500 mL) for "laparotomy" group (P = 0.026). We reported significant difference on blood transfusion (3.7 RBC transfusions (range 0-8) for "laparoscopy group" versus 10.1 RBC transfusions (range 0-35) for "laparotomy" group (P = 0.025)). Surgical duration, quality of surgical margins, perineal dysfunctions and SSI were equivalent for both groups. At a follow-up of 36.6 months for "laparoscopy" group and 115.3 months for "laparotomy" group, OS and DFS were equivalent.

Conclusion: Use of laparoscopy for anterior approach decreases intraoperative blood loss and intraoperative RBC transfusion without increasing surgical duration, without altering the quality of surgical margins and without impairing long-term outcomes.

Level Of Evidence: 4.
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October 2015

Contrast enhanced ultrasound imaging for assessment of spinal cord blood flow in experimental spinal cord injury.

J Vis Exp 2015 May 7(99):e52536. Epub 2015 May 7.

Laboratoire d'étude de la microcirculation, Faculté de Médecine Paris Diderot Paris VII, U942; Department of orthopaedic surgery, Bicetre Universitary Hospital, Public Assistance of Paris Hospital;

Reduced spinal cord blood flow (SCBF) (i.e., ischemia) plays a key role in traumatic spinal cord injury (SCI) pathophysiology and is accordingly an important target for neuroprotective therapies. Although several techniques have been described to assess SCBF, they all have significant limitations. To overcome the latter, we propose the use of real-time contrast enhanced ultrasound imaging (CEU). Here we describe the application of this technique in a rat contusion model of SCI. A jugular catheter is first implanted for the repeated injection of contrast agent, a sodium chloride solution of sulphur hexafluoride encapsulated microbubbles. The spine is then stabilized with a custom-made 3D-frame and the spinal cord dura mater is exposed by a laminectomy at ThIX-ThXII. The ultrasound probe is then positioned at the posterior aspect of the dura mater (coated with ultrasound gel). To assess baseline SCBF, a single intravenous injection (400 µl) of contrast agent is applied to record its passage through the intact spinal cord microvasculature. A weight-drop device is subsequently used to generate a reproducible experimental contusion model of SCI. Contrast agent is re-injected 15 min following the injury to assess post-SCI SCBF changes. CEU allows for real time and in-vivo assessment of SCBF changes following SCI. In the uninjured animal, ultrasound imaging showed uneven blood flow along the intact spinal cord. Furthermore, 15 min post-SCI, there was critical ischemia at the level of the epicenter while SCBF remained preserved in the more remote intact areas. In the regions adjacent to the epicenter (both rostral and caudal), SCBF was significantly reduced. This corresponds to the previously described "ischemic penumbra zone". This tool is of major interest for assessing the effects of therapies aimed at limiting ischemia and the resulting tissue necrosis subsequent to SCI.
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May 2015

Predicting sagittal deformity after surgery for intramedullary tumors.

J Neurosurg Spine 2014 Sep 27;21(3):342-7. Epub 2014 Jun 27.

Service de neurochirurgie and.

Object: Spinal deformity after surgery for intramedullary tumors is a potentially serious complication that may require subsequent fusion. The aim of this study was to determine whether there were risk factors that could be used to predict postoperative sagittal deformity.

Methods: The authors conducted a retrospective study of patients harboring an intramedullary tumor who had undergone surgery at a single center between 1985 and 2011. The main outcome of interest was the difference, at the last follow-up, between post- and preoperative measures of the Cobb angle formed by the superior and inferior limits of the laminectomy (ΔCobb).

Results: Sixty-three patients were eligible for inclusion in the study. The mean sagittal deformity, measured as described above, was 15.9° (range 0°-77°) at a mean follow-up of 85.4 months (range 4-240 months). Univariate analysis showed increased sagittal deformity in patients 30 years old or younger (21.9° vs 13.7°, p = 0.04), undergoing a laminectomy involving 4 or more levels (19.3° vs 12.1°, p = 0.04), and undergoing a laminectomy that included a spinal junction (20.8° vs 12.4°, p = 0.02). Multivariate analysis showed that only age (p = 0.01) and the number of spinal levels involved in the laminectomy (p = 0.014) were significant and independent predictors of postoperative sagittal deformity. The linear regression equation drawn from this model allows one to quantitatively predict sagittal deformity for any follow-up time point after surgery.

Conclusions: Authors of this study developed a statistical tool that could be used to plan surgery and follow-up as regards the risk of sagittal spinal deformity in patients undergoing surgery for intramedullary tumors.
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September 2014

"En bloc" resection of sacral chordomas by combined anterior and posterior surgical approach: a monocentric retrospective review about 29 cases.

Eur Spine J 2014 Sep 28;23(9):1940-8. Epub 2014 Jan 28.

Orthopaedic Department, Tumor and Spine Unit, Bicêtre University Hospital, AP-HP Paris, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France,

Purpose: "En bloc" resection of sacral chordomas (SC) with wide margins is statistically linked with a decrease of local recurrence (LR). Nevertheless, surgery potentially leads to complications and neurological deficits. The effectiveness of radiotherapy (RT) and chemotherapy (CT) remains controversial. The aim of the study was to evaluate the margins of tumor resection, the morbidity of "En bloc" resection of SC by combined anterior and posterior surgical approach and to look for predictive factors on survival and LR.

Methods: We performed sacrococcygectomy by surgical combined approach in 29 SC between 1985 and 2012. We analyzed overall survival and survival to LR with survival analysis using Kaplan-Meier method. Complications and morbidity were reported.

Results: The mean follow-up was of 77.9 months (0-241 months). We found 18 (62.1%) postoperative infections and 7 (24.1%) wound dehiscences. Eighteen patients had tumor wide margins (62.1%), 6 marginal (20.7%) and 4 intralesional (13.8%). Seven patients had a LR (24.1%). OS rate was 84.4% at 5 and 10 years, survival rate with LR was 64 and 56%, respectively, after 5 and 10 years. Quality of margins (p = 0.106), tumor volume (p = 0.103), postoperative RT (p = 0.245) and postoperative local infection (p = 0.754) did not have effect on LR.

Conclusion: "En bloc" resection by combined surgical approach seems to be a relevant alternative especially for SC invading the high sacrum above S3. Nevertheless, it yet remains the problem of postoperative infection. Systematic Adjuvant RT might allow better control on LR in association with surgery.
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September 2014

Effect of norepinephrine on spinal cord blood flow and parenchymal hemorrhage size in acute-phase experimental spinal cord injury.

Eur Spine J 2014 Mar 14;23(3):658-65. Epub 2013 Nov 14.

"Microcirculation, Bioénergétique, Inflammation et Insuffisance Circulatoire Aiguë", Equipe Universitaire 3509 Paris VII-Paris XI-Paris XIII, Paris, France,

Purpose: In the acute phase of spinal cord injury (SCI), ischemia and parenchymal hemorrhage are believed to worsen the primary lesions induced by mechanical trauma. To minimize ischemia, keeping the mean arterial blood pressure above 85 mmHg for at least 1 week is recommended, and norepinephrine is frequently administered to achieve this goal. However, no experimental study has assessed the effect of norepinephrine on spinal cord blood flow (SCBF) and parenchymal hemorrhage size. We have assessed the effect of norepinephrine on SCBF and parenchymal hemorrhage size within the first hour after experimental SCI.

Methods: A total of 38 animals were included in four groups according to whether SCI was induced and norepinephrine injected. SCI was induced at level Th10 by dropping a 10-g weight from a height of 10 cm. Each experiment lasted 60 min. Norepinephrine was started 15 min after the trauma. SCBF was measured in the ischemic penumbra zone surrounding the trauma epicenter using contrast-enhanced ultrasonography. Hemorrhage size was measured repeatedly on parasagittal B-mode ultrasonography slices.

Results: SCI was associated with significant decreases in SCBF (P = 0.0002). Norepinephrine infusion did not significantly modify SCBF. Parenchymal hemorrhage size was significantly greater in the animals given norepinephrine (P = 0.0002).

Conclusion: In the rat, after a severe SCI at the Th10 level, injection of norepinephrine 15 min after SCI does not modify SCBF and increases the size of the parenchymal hemorrhage.
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March 2014

Criteria for the appropriate treatment of osteoporotic vertebral compression fractures.

Pain Physician 2013 Sep-Oct;16(5):E519-30

Interventional Radiology, Villa Maria Hospital, Turin, Italy; St Georges Hospital, London, United Kingdom; Department for Spine Surgery and Traumatology, Orthopaedische Fachklinik Schwarzach, Schwarzach/Munich, Germany; Bicetre University Hospital, AP-HP.

Background: The heterogeneity of patients with osteoporotic vertebral compression fractures (VCF) necessitates a tailored approach of balancing the benefits and limitations of available treatments. Current guidelines are divergent, sometimes contradictory, and often insufficiently detailed to guide practice decisions.

Objectives: This study aimed at establishing treatment recommendations at the patient-specific level.

Study Design: Using the RAND/UCLA Appropriateness Method (RAM), the appropriateness of different treatment options for osteoporotic VCFs was assessed.

Setting: The assessment was conducted by a European multidisciplinary panel of 12 experts.

Methods: The appropriateness of non-surgical management (NSM), vertebroplasty (VP), and balloon kyphoplasty (BKP) was determined for 128 hypothetical patient profiles. These were unique combinations of clinical factors considered relevant to treatment choice (time since fracture, MRI findings, impact and evolution of symptoms, spinal deformity, ongoing fracture process, and pulmonary dysfunction). After 2 individual rating rounds and plenary meetings, appropriateness statements (appropriate, inappropriate, and uncertain) were calculated for all clinical scenarios.

Results: Disagreement dropped from 31% in the first round to 7% in the second round. Appropriateness outcomes showed specific patterns for the 3 treatments. For three-quarters of the profiles, only one treatment was considered appropriate: NSM 25%, VP 6%, and BKP 45%. NSM was usually appropriate in patients with a negative MRI or a positive MRI without other unfavorable conditions (poor outcomes for the other variables). VP was usually appropriate in patients with a positive MRI, time since fracture ≥ 6 weeks, and no spinal deformity. BKP was recommended for all patients with an ongoing fracture process, and also in most patients with a positive MRI and ≥ 1 other unfavorable factor.

Limitations: The prevalence of the patient profiles in daily practice is yet unknown.

Conclusion: The panel results may help to support treatment choice in the heterogeneous population of patients with osteoporotic VCF.
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May 2014

Rat model of spinal cord injury preserving dura mater integrity and allowing measurements of cerebrospinal fluid pressure and spinal cord blood flow.

Eur Spine J 2013 Aug 19;22(8):1810-9. Epub 2013 Mar 19.

Equipe universitaire 3509 Paris VII-Paris XI-Paris XIII, Microcirculation, Bioénergétique, Inflammation et Insuffisance circulatoire aiguë, Paris Diderot-Paris VII University, Paris, France.

Purposes: Cerebrospinal fluid (CSF) pressure elevation may worsen spinal cord ischaemia after spinal cord injury (SCI). We developed a rat model to investigate relationships between CSF pressure and spinal cord blood flow (SCBF).

Methods: Male Wistar rats had SCI induced at Th10 (n = 7) or a sham operation (n = 10). SCBF was measured using laser-Doppler and CSF pressure via a sacral catheter. Dural integrity was assessed using subdural methylene-blue injection (n = 5) and myelography (n = 5).

Results: The SCI group had significantly lower SCBF (p < 0.0001) and higher CSF pressure (p < 0.0001) values compared to the sham-operated group. Sixty minutes after SCI or sham operation, CSF pressure was 8.6 ± 0.4 mmHg in the SCI group versus 5.5 ± 0.5 mmHg in the sham-operated group. No dural tears were found after SCI.

Conclusion: Our rat model allows SCBF and CSF pressure measurements after induced SCI. After SCI, CSF pressure significantly increases.
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August 2013

Percutaneous treatment of subarachnoid-pleural fistula with Onyx.

J Neurosurg Spine 2013 Apr 22;18(4):378-81. Epub 2013 Feb 22.

Service de Neurochirurgie, Hôpital Bicêtre, Groupe Hospitalo-Universitaire Paris-Sud, Université Paris-Sud, Paris, France.

Subarachnoid-pleural fistula is a well-described complication after anterior surgery for thoracic disc herniation, but is difficult to treat by means of traditional chest and lumbar drains due to interference by positive ventilation pressures that may keep the fistula open and prevent proper closure. Current treatment strategies include surgical repair, which is technically challenging, and noninvasive positive pressure ventilation, which can take several weeks to be effective. In this report, the authors describe a novel treatment for subarachnoid-pleural fistula using percutaneous obliteration with Onyx. Surgery for removal of a T7-8 disc herniation associated with ossification of the posterior longitudinal ligament was performed in a 56-year-old woman via an anterior transthoracic transpleural approach. Ten days after surgery, she presented with diplopia due to a subarachnoid-pleural fistula that was confirmed by CT myelography. Percutaneous injection of Onyx was performed under local anesthesia. Postprocedure CT showed complete obliteration of the fistula with no adverse events. A CT scan obtained 1 month later showed complete resolution of the pleural effusion. Neurological examination at 3 months postsurgery was normal. Clinical and radiological follow-up at 1 year showed complete recovery and no sign of fistula recurrence. Percutaneous treatment for subarachnoid-pleural fistula is an easy, safe, and effective strategy and can therefore be proposed as a first-line option for this challenging complication.
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April 2013

Real-time and spatial quantification using contrast-enhanced ultrasonography of spinal cord perfusion during experimental spinal cord injury.

Spine (Phila Pa 1976) 2012 Oct;37(22):E1376-82

Equipe Universitaire 3509, Paris VII-Paris XI-Paris XIII, Paris, France.

Study Design: Experimental study in male Wistar rats.

Objective: To quantify temporal and spatial changes simultaneously in spinal cord blood flow and hemorrhage during the first hour after spinal cord injury (SCI), using contrast-enhanced ultrasonography (CEU).

Summary Of Background Data: Post-traumatic ischemia and hemorrhage worsen the primary lesions induced by SCI. Previous studies did not simultaneously assess temporal and spatial changes in spinal cord blood flow.

Methods: SCI was induced at Th10 in 12 animals, which were compared with 11 sham-operated controls. Spinal cord blood flow was measured in 7 adjacent regions of interest and in the sum of these 7 regions. Blood flow was quantified using CEU with intravenous microbubble injection. Spinal cord hemorrhage was measured on conventional B-mode sonogram slices.

Results: CEU allowed us to measure the temporal and spatial changes in spinal cord blood flow in both groups. In the SCI group, spinal cord blood flow was significantly decreased in the global region of interest (P = 0.0016), at the impact site (epicenter), and in the 4 regions surrounding the epicenter, compared with the sham group. The blood flow decrease was maximum at the epicenter. No statistically significant differences between the sham groups were found for the most rostral and caudal regions of interest. Hemorrhage size increased significantly with time (P < 0.0001), from 30.3 mm(2) (±2) after 5 minutes to 39.6 mm(2) (±2.3) after 60 minutes.

Conclusion: CEU seems reliable for quantifying temporal and spatial changes in spinal cord blood flow. After SCI, bleeding occurs in the spinal cord parenchyma and increases significantly throughout the first hour.
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October 2012

Long-term outcomes of en bloc resection of non-small cell lung cancer invading the thoracic inlet and spine.

Ann Thorac Surg 2011 Sep;92(3):1024-30; discussion 1030

Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Le Plessis Robinson, France.

Background: The purpose of this study was to determine whether en bloc resection of non-small cell lung cancer (NSCLC) invading the thoracic inlet (TI) and spine can provide good long-term outcomes.

Methods: We studied 54 consecutive patients treated with en bloc resection of NSCLC invading the TI and spine between 1992 and 2009 at our center. There were 36 men and 18 women with a mean age of 51 years (range, 37 to 71 years). Tumor resection involved at least 2 vertebral levels. We divided the patients into 3 groups based on whether vertebral invasion involved the transverse process only, the intervertebral foramina, requiring hemivertebrectomies with spinal fixation, or the vertebral body, requiring total vertebral body resection with spinal fixation.

Results: Induction chemotherapy was given to 27 (50%) patients including 3 who also received induction radiotherapy. Nine (17%) patients were in the transverse process group, 42 (78%) in the intervertebral foramina group, and 3 (6%) in the vertebral body group. Resection involved the subclavian artery in 19 (35%) patients. Complete resection was achieved in 49 (91%) patients. There were no perioperative deaths or residual neurologic impairments. Recurrence occurred in 31 (57%) patients and was local (n=6), systemic (n=24), or both (n=1). Local recurrence was more common in patients with N2-3 disease (p=0.0008) and subclavian artery involvement (p=0.031). There was a nonsignificant increase in local recurrence in patients with positive resection margins (40% vs 10%, p=0.058). The 1-, 5-, and 10-year survival rates were 82%, 31%, and 31%, respectively. The 1-, 5- and 10-year disease-free survival rates were 63%, 28%, and 28%, respectively. Five patients are alive and free of disease 10 years after surgery. By multivariate analysis, factors that independently affected survival were incomplete (R1) resection (p=0.006; odds ratio 67; 95% confidence interval 1.5 to 11.3) and subclavian artery involvement (p=0.037; odds ratio 0.46; 95% confidence interval 0.2 to 0.9).

Conclusions: Good long-term survival can be achieved in highly selected patients with NSCLC invading the TI and spine, provided complete en bloc resection is performed.
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September 2011

Preoperative imaging study of the spinal cord vascularization: interest and limits in spine resection for primary tumors.

Eur J Radiol 2011 Jan 18;77(1):26-33. Epub 2010 Dec 18.

Hôpital Universitaire de Bicetre, AP-HP, Bicetre F-94270, Université Paris-Sud, Department of Orthopaedic Surgery, Le Kremlin-Bicetre, France.

The necessicity to localize the anterior spinal arteries before anterior approach of the spine stays controversial by orthopaedic surgeons. On the other hand the surgical treatment of thoracoabdominal aneurisms routinely sacrifices many segmental arteries pairs without spinal arteries localization. This, associated with spinal cord protection, results to few neurological complication. However, during vertebrectomies, the roots ligation completely interrupts the spinal cord blood supply at this level. In our experience the spinal arteries localization was systematically done before ninety-eight spine resections. In five cases an anterior radiculomedullary artery was ligated (four anterior radiculomedullary and one great anterior radiculomedullary arteries) without neurological complication, in two cases of extended resection (more than four levels) a neurological complication occurred. No spinal artery was identified at the resection level and the neurological complications were resolutive and did not seem related to definitive vascular problem. These accomplishments lead to discuss the importance of spinal arteries localization and preservation in this surgery. The discovery of an anterior radiculomedullary artery is not a contraindication to en-bloc vertebrectomy at this level, nevertheless in the case of great anterior radiculomedullary artery (Adamkiewicz) the surgical indication must be seriously debated. In fact, this case and those where multilevel resections (more than three levels) are indicated seem the most dangerous situations and the use of the different means of spinal cord protection could be indicated to decrease neurological risk. So before spine resection the spinal arteries localization could improve patient information and give more deciding factors for planning treatment.
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January 2011

Biological and mechanical consequences of transient intervertebral disc bending.

Eur Spine J 2007 Nov 16;16(11):1899-906. Epub 2007 Aug 16.

Orthopaedic Surgery, University of California, 533 Parnassus Avenue, San Francisco, CA 94143-0514, USA.

Degenerative mechanisms for the intervertebral disc are unclear, particularly those associated with cumulative trauma. This research focuses on how mechanical loading at levels below those known to cause acute trauma can lead to cellular injury. Mouse-tail discs were subjected to static bending for 1 week, then allowed to recover unloaded for 3 weeks and 3 months. Discs were analyzed using histology, in situ hybridization (collagen and aggrecan gene expression), TUNEL assay for apoptotic cell death, and biomechanics. The bent discs demonstrated loss of annular cellularity on the concave (compressed) side, while the nucleus and convex annulus appeared normal. Chondrocyte-like cells were apparent within the inner, concave annulus on the recovered discs, with evidence of proliferation at the annulus/endplate interface. However, annular architecture and biomechanical properties for the recovered discs were not different from controls, suggesting that restoration of physiologic tissue stress prevents the inner annular degradation noted in previous compression-induced degeneration models. These data demonstrate that cellular injury can be induced by transient compressive stress, and that recellularization is slow in this avascular tissue. Taken together, this suggests that cellular damage accumulation may be an important injury mechanism that is distinct from acute mechanical failure.
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November 2007

Spinal surgery and ophthalmic complications: a French survey with review of 17 cases.

J Spinal Disord Tech 2007 Jun;20(4):302-7

Department of Orthopaedic Surgery, University Hospital Pierre Zobda Quitman, Fort de France, Martinique, France.

Objectives: Ocular complications after spine surgery are incompletely understood and are not as rare as implied by recent publications. In 13 out of 15 published case reports, ocular complications are attributed mainly to compression. But in 66 cases reported in 4 series in the literature, compression seems to play a role in less than 10 cases. However, 3 out of the 4 series lack sufficient detail to support this mechanism clearly. Our objectives were to identify the mechanisms and specific risk factors associated with this devastating complication, to help in prevention.

Methods: A 2-page survey was sent to all French orthopedic centers specializing in spine surgery (28 centers) requesting information regarding any patients who had experienced visual deficits after spine surgery. Respondents were asked to identify presence of commonly cited preoperative risk factors, including ophthalmologic diagnosis and local signs (eyelid or conjunctival edema, periorbital numbness, or paresthesia) and intraoperative risks, such as positioning of the head, to clarify the possible mechanisms. Seventeen patients were thus included.

Results: Two main mechanisms were identified. First, ocular compression (9 cases) characterized by a unilateral definitive blindness with local signs due to a central retinal artery occlusion. Second, internal carotid thromboembolism (4 cases) associated with head rotation toward the ipsilateral side, causing an ischemic optic neuropathy with a unilateral partial and potentially regressive visual loss.

Conclusions: The authors propose 2 preventive measures: modification of horseshoe-shaped headrest and precautions with lateral rotation of the head in patients with carotid atheroma.
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June 2007

Traumatic dislocation of the lumbosacral junction diagnosis, anatomical classification and surgical strategy.

Injury 2007 Feb 18;38(2):169-81. Epub 2006 Sep 18.

Department of Paediatric Orthopaedics, Armand Trousseau Hospital, Université Pierre et Marie Curie Paris VI, F 75571 Paris, Cedex 12, France.

Purpose Of The Study: Traumatic lumbosacral dislocation is a rare lesion often characterised by a fracture dislocation of L5-S1 articular facets associated with anterior L5 slipping. Because of its rarity, the surgical strategy of lumbosacral traumatic dislocation remains controversial. We report the most important series of traumatic lumbosacral dislocation. The cases of six men and five women are presented. We discuss the diagnosis and surgical treatment options regarding the different type of lesions. A moderate anterior slipping of L5 over S1 was present in eight cases. The lesion was a bilateral lumbosacral fracture dislocation in eight cases, a pure lateral dislocation in two cases and a unilateral rotatory dislocation in one case. Patients were multiple-trauma patients in eight cases. A radicular deficit was present in two cases. All patients were treated surgically with a posterior osteosynthesis and fusion. A circumferential fusion was made in six cases. In four cases, the anterior fusion was made during the posterior approach. The postoperative course was favorable in all the cases. One patient necessitated secondarily an iterative posterior lumbosacral fixation and anterior fibular bone graft because of a lumbosacral pseudarthrosis. Traumatic dislocation of the lumbosacral junction is a rare and severe spinal fracture which occurs in patients after high energy trauma and could be initially misdiagnosed. We devised a new classification based on anatomical lesions. Treatment is always surgical, requiring reduction, osteosynthesis, and fusion. In case of L5 anterior slipping, it is crucial to assess the L5S1 disc by MRI or surgical exploration for disc disruption. In such case, we recommend to perform circumferential fusion to prevent lumbosacral pseudarthrodesis.
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February 2007

Anatomical feasibility of using the ninth, 10th, and 11th intercostal nerves for the treatment of neurological deficits after damage to the spinal cord.

J Neurosurg Spine 2006 Mar;4(3):225-32

Ecole de Chirurgie de l'Assistance Publique des Hôpitaux de Paris, France.

Object: The topographic anatomy of the lower intercostal nerves is less well known than that of the upper ones, except for the 12th intercostal nerve. It is possible to use the lower intercostal nerves to perform a neurotization of the lumbar roots. The authors studied the anatomy of the ninth, 10th, and 11th intercostal nerves to obtain descriptive and topographic anatomical data to aid in establishing optimal conditions for harvesting.

Methods: The ninth, 10th, and 11th intercostal nerves of 50 cadavers were dissected. The proximal part of the nerve in the posterior intercostal space (ISC) was exposed through a posterior approach. The lateral ICS was exposed through a lateral approach, under the latissimus dorsi, which made it possible to harvest the intercostal nerves using a stripping technique. A histological study was conducted on 10 pigs to evaluate the risk of nerve lesions during the stripping procedure.

Conclusions: The proximal course of the nerve in the posterior ICS was the same in all cases. The mean total length of the intercostal nerves harvested was 17.96 cm for the ninth, 17.14 cm for the 10th, and 15.94 cm for the 11th intercostal nerve. The harvested nerve length was sufficient in 297 of the 300 cases to perform lumbar root neurotization. The histological study showed no difference between the "open" and the "stripping" techniques regarding the risk of histological lesions in harvested nerves.
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March 2006

The Wiltse paraspinal approach to the lumbar spine revisited: an anatomic study.

Clin Orthop Relat Res 2006 Apr;445:175-80

Ecole de Chirurgie de l'Assistance Publique des Hopitaux de Paris, Paris, France.

The paraspinal posterior approach to the lumbar spine initially was described for spinal fusion, particularly for treatment of lumbosacral spondylolisthesis. Despite the technical details described by Wiltse et al, the exact location of the sacrospinalis muscle that must be split remains unclear. We sought to clarify the anatomic description of the paraspinal posterior approach to the lumbar spine, and to provide topographic landmarks for facilitating this surgical approach. Fifty cadavers were dissected using an anatomic transmuscular paraspinal approach. The level of the natural cleavage plane between the multifidus and the longissimus parts of the sacrospinalis muscle was noted, and measurements were taken between this level and the midline at the level of the spinous process of L4. A natural cleavage plane between the multifidus and the longissimus parts of the sacrospinalis muscle was present in all specimens. There was a fibrous separation between the two muscular parts in 88 of 100 cases. The mean distance between the level of the cleavage plane and the midline was 4.04 cm (range, 2.4-7 cm). Small arteries and veins were present at the level of the cleavage plane in all specimens. These vascular landmarks make it easier to locate the muscular cleavage plane and reach the articular and transverse processes during the paraspinal approach.
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April 2006

Traumatic lateral lumbosacral dislocation: one case and review of literature.

J Spinal Disord Tech 2005 Jun;18(3):286-9

Department of Orthopaedic Surgery, Kremlin-Bicêtre Hospital, Paris-Sud University, Le Kremlin-Bicêtre, France.

Objective: Lateral traumatic lumbosacral dislocation is a rare and severe lesion of the lumbosacral junction. Only one case has been reported in the literature. We report a new case of pure lateral lumbosacral dislocation.

Methods: A 27-year-old man had an isolated pure lateral traumatic dislocation of the lumbosacral junction after a motorcycle accident. The diagnosis and the therapeutic course are analyzed and discussed.

Results: Traumatic lumbosacral dislocation usually occurs in patient with multiple traumas. Generally, in the case of complete fracture-dislocation, on lateral radiographs one can observe the L5 vertebra slippage over the sacrum, resulting from an associated severe disc disruption. This feature was not seen in our patient. Surgical treatment consisted of an open reduction of the dislocation, stabilization with posterior instrumentation, and a lumbosacral arthrodesis by posterolateral grafting. In cases of pure lateral dislocation, short instrumentation can be recommended, extending from L5 to S1. Addition of an interbody fusion should be considered when the L5-S1 disc is disrupted, which is responsible for the anterior slippage of L5 over S1. Disc disruption can be evoked on preoperative magnetic resonance imaging (MRI) and intraoperatively by exploring the spinal canal.

Conclusions: Pure lumbosacral dislocation with a lateral translation seemed to have no disc disruption as observed in complete fracture dislocation. Nevertheless, we recommend looking for an L5-S1 disc disruption either on preoperative MRI or during surgical exploration.
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June 2005

Fracture of the posterior margin of the lumbar spine: case report after an acute, unique, and severe trauma.

Spine (Phila Pa 1976) 2004 Dec;29(24):E565-7

Department of Orthopaedic and Traumatologic Surgery, University Hospital of Bicêtre, France.

Study Design: Case report.

Objective: We report a case of a posterior margin fracture in the lumbar spine after an acute, unique, and severe trauma with neurologic deficiency in a nonathlete adolescent with no history of lumbar pain. A literature review did not uncover a similar case.

Summary Of Background Data: Fracture of the posterior margin of lumbar vertebral body is not a common injury. It usually occurs in adolescent and young adults and has been always reported after sports-related microtraumatisms. Symptoms are mainly back pain and radicular pain. Neurologic deficiency is rare.

Results And Conclusion: An acute and severe spine trauma in a nonathlete adolescent with no previous history of lumbar pain can lead to posterior vertebra margin fracture. Neurologic deficiency may appear, and it can be directly related to the posterior displacement of bone fragment or to a compressive peridural hematoma. Radiographs and computed tomograph scans are used for diagnosis. Magnetic resonance imaging is accurate to visualize disc space and for the diagnosis of peridural hematoma. Treatment is surgical and consists of laminectomy, hematoma drainage, and excision of bone fragment. Discectomy and arthrodesis are to be considered in relation to age, magnetic resonance imaging findings, and type of bone lesions.
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December 2004