Publications by authors named "Gaby Kreichati"

20 Publications

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Reliability assessment of cervical spine parameters measured on full-body radiographs in asymptomatic subjects and patients with spinal deformity.

Orthop Traumatol Surg Res 2021 Jul 27:103026. Epub 2021 Jul 27.

Laboratory of Biomechanics and Medical Imaging, Faculty of Medicine, University of Saint-Joseph, Damascus Street, Beirut, Lebanon. Electronic address:

Background: Cervical spinal alignment is usually assessed on full-body radiographs allowing for the concomitant evaluation of possible compensatory mechanisms that may occur at any level in the setting of postural malalignment.

Hypothesis: Cervical parameters measured on full-body radiographs are reliable.

Patients And Methods: A total of 70 subjects were included and divided in 3 groups: asymptomatic adults (n=21), adolescents with idiopathic scoliosis (n=20), and adults with spinal deformity (n=29), for whom full-body low-dose biplanar radiographs were obtained. Eighteen cervical parameters including gaze and cervical curvature, upper cervical spine, global cervical alignment, thoraco-cervical and cervico-pelvic parameters were measured by 4 operators, three times each. The intraclass correlation coefficient (ICC) and the 95% confidence interval (95% CI) where calculated for each parameter and compared between the 3 groups.

Results: ICC and the 95% CI were similar between the 3 groups. The measured parameters showed a very high repeatability (ICC>0.8) except for C0-C2, which presented an average repeatability (ICC=0.57). The cSVA, CTPA, C2-SPi, cranial offset, T1-SPi, CBVA and cranial tilt had a 95% CI<2 (° or cm). The TIA, T1-CL and C0-C2 had a 95% CI>6°.

Discussion: The poor visibility of the foramen magnum, hard palate, C7, T1, and the sternum on radiographs could explain why certain parameters showed a higher measurement error. The assessment of these error margins is essential for an accurate evaluation of cervical spinal deformities and a proper therapeutic approach.

Level Of Evidence: III; retrospective analysis of prospectively collected data.
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July 2021

Clinical predictive model of lumbar curve Cobb angle below selective fusion for thoracic adolescent idiopathic scoliosis: a longitudinal multicenter descriptive study.

Eur J Orthop Surg Traumatol 2021 Jun 18. Epub 2021 Jun 18.

Pediatric Orthopaedic Surgery Unit, Lenval University Children's Hospital, Nice, France.

Purpose: To implement a clinically applicable, predictive model for the lumbar Cobb angle below a selective thoracic fusion in adolescent idiopathic scoliosis.

Methods: A series of 146 adolescents with Lenke 1 or 2 idiopathic scoliosis, surgically treated with posterior selective fusion, and minimum follow-up of 5 years (average 7) was analyzed. The cohort was divided in 2 groups: if lumbar Cobb angle at last follow-up was, respectively, ≥ or < 10°. A logistic regression-based prediction model (PredictMed) was implemented to identify variables associated with the group ≥ 10°. The guidelines of the TRIPOD statement were followed.

Results: Mean Cobb angle of thoracic main curve was 56° preoperatively and 25° at last follow-up. Mean lumbar Cobb angle was 33° (20; 59) preoperatively and 11° (0; 35) at last follow-up. 53 patients were in group ≥ 10°. The 2 groups had similar demographics, flexibility of both main and lumbar curves, and magnitude of the preoperative main curve, p > 0.1. From univariate analysis, mean magnitude of preoperative lumbar curves (35° vs. 30°), mean correction of main curve (65% vs. 58%), mean ratio of main curve/distal curve (1.9 vs. 1.6) and distribution of lumbar modifiers were statistically different between groups (p < 0.05). PredictMed identified the following variables significantly associated with the group ≥ 10°: main curve % correction at last follow-up (p = 0.01) and distal curve angle (p = 0.04) with a prediction accuracy of 71%.

Conclusion: The main modifiable factor influencing uninstrumented lumbar curve was the correction of main curve. The clinical model PredictMed showed an accuracy of 71% in prediction of lumbar Cobb angle ≥ 10° at last follow-up.

Level Of Evidence Iv: Longitudinal comparative study.
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June 2021

Gait kinematic alterations in subjects with adult spinal deformity and their radiological determinants.

Gait Posture 2021 07 4;88:203-209. Epub 2021 Jun 4.

Faculty of Medicine, University of Saint-Joseph in Beirut, Lebanon; Institut de Biomécanique Humaine Georges Charpak, Arts et Métiers ParisTech, Paris, France. Electronic address:

Background: Adults with spinal deformity (ASD) are known to have postural malalignment affecting their quality of life. Classical evaluation and follow-up are usually based on full-body static radiographs and health related quality of life questionnaires. Despite being an essential daily life activity, formal gait assessment lacks in clinical practice.

Research Question: What are the main alterations in gait kinematics of ASD and their radiological determinants?

Methods: 52 ASD and 63 control subjects underwent full-body 3D gait analysis with calculation of joint kinematics and full-body biplanar X-rays with calculation of 3D postural parameters. Kinematics and postural parameters were compared between groups. Determinants of gait alterations among postural radiographic parameters were explored.

Results: ASD had increased sagittal vertical axis (SVA:34 ± 59 vs -5 ± 20 mm), pelvic tilt (PT:19 ± 13 vs 11 ± 6°) and frontal Cobb (25 ± 21 vs 4 ± 6°) compared to controls (all p < 0.001). ASD displayed decrease walking speed (0.9 ± 0.3 vs 1.2 ± 0.2 m/s), step length (0.58 ± 0.11 vs 0.64 ± 0.07 m) and increased single support (0.45 ± 0.05 vs 0.42 ± 0.04 s). ASD walked with decreased hip extension in stance (-3 ± 10 vs -7 ± 8°), increased knee flexion at initial contact and in stance (10 ± 11 vs 5 ± 10° and 19 ± 7 vs 16 ± 8° respectively), and decreased knee flexion/extension ROM (55 ± 9 vs 59 ± 7°). ASD had increased trunk flexion (12 ± 12 vs 6 ± 11°) and reduced dynamic lumbar lordosis (-11 ± 12 vs -15 ± 7°, all p < 0.001). Sagittal knee ROM, walking speed and step length were negatively determined by SVA; lack of lumbar lordosis during gait was negatively determined by radiological lumbar lordosis.

Significance: Static compensations in ASD persist during gait, where they exhibit a flexed attitude at the trunk, hips and knees, reduced hip and knee mobility and loss of dynamic lordosis. ASD walked at a slower pace with increased single and double support times that might contribute to their gait stability. These dynamic discrepancies were strongly related to static sagittal malalignment.
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July 2021

Toward understanding the underlying mechanisms of pelvic tilt reserve in adult spinal deformity: the role of the 3D hip orientation.

Eur Spine J 2021 Sep 27;30(9):2495-2503. Epub 2021 Feb 27.

Laboratory of Biomechanics and Medical Imaging, Faculty of Medicine, University of Saint-Joseph, Beirut, Lebanon.

Purpose: To explore 3D hip orientation in standing position in subjects with adult spinal deformity (ASD) presenting with different levels of compensatory mechanisms.

Methods: Subjects with ASD (n = 159) and controls (n = 68) underwent full-body biplanar X-rays with the calculation of 3D spinopelvic, postural and hip parameters. ASD subjects were grouped as ASD with knee flexion (ASD-KF) if they compensated by flexing their knees (knee flexion ≥ 5°), and ASD with knee extension (ASD-KE) otherwise (knee flexion < 5°). Spinopelvic, postural and hip parameters were compared between the three groups. Univariate and multivariate analyses were then computed between spinopelvic and hip parameters.

Results: ASD-KF had higher SVA (67 ± 66 mm vs. 2 ± 33 mm and 11 ± 21 mm), PT (27 ± 14° vs. 18 ± 9° and 11 ± 7°) and PI-LL mismatch (20 ± 26° vs - 1 ± 18° and - 13 ± 10°) when compared to ASD-KE and controls (all p < 0.05). ASD-KF also had a more tilted (34 ± 11° vs. 28 ± 9° and 26 ± 7°), anteverted (24 ± 6° vs. 20 ± 5° and 18 ± 4°) and abducted (59 ± 6° vs. 57 ± 4° and 56 ± 4°) acetabulum, with a higher posterior coverage (100 ± 6° vs. 97 ± 7° for ASD-KE) when compared to ASD-KE and controls (all p < 0.05). The main determinants of acetabular tilt, acetabular abduction and anterior acetabular coverage were PT, SVA and LL (adjusted R [0.12; 0.5]).

Conclusions: ASD subjects compensating with knee flexion have altered hip orientation, characterized by increased posterior coverage (acetabular anteversion, tilt and posterior coverage) and decreased anterior coverage which can together lead to posterior femoro-acetabular impingement, thus limiting pelvic retroversion. This underlying mechanism could be potentially involved in the hip-spine syndrome.
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September 2021

A new classification for coronal malalignment in adult spinal deformity: a validation and the role of lateral bending radiographs.

Eur Spine J 2020 09 25;29(9):2287-2294. Epub 2020 Jun 25.

Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Place Amélie Raba-Léon, 33076, Bordeaux, France.

Purpose: Coronal malalignment (CM) causes pain, impairment of function and cosmetic problems for adult spinal deformity (ASD) patients in addition to sagittal malalignment. Certain types of CM are at risk of insufficient re-alignment after correction. However, CM has received minimal attention in the literature compared to sagittal malalignment. The purpose was to establish reliability for our recently published classification system of CM in ASD among spine surgeons.

Methods: Fifteen readers were assigned 28 cases for classification, who represented CM with reference to their full-length standing anteroposterior and lateral radiographs. The assignment was repeated 2 weeks later, then a third assignment was done with reference to additional side bending radiographs (SBRs). Intra-, inter-rater reliability and contribution of SBRs were determined.

Results: Intra-rater reliability was calculated as 0.95, 0.86 and 0.73 for main curve types, subtypes with first modifier, and subtypes with two modifiers respectively. Inter-rater reliability averaged 0.91, 0.75 and 0.52. No differences in intra-rater reliability were shown between the four expert elaborators of the classification and other readers. SBRs helped to increase the concordance rate of second modifiers or changed to appropriate grading in cases graded type A in first modifier.

Conclusions: Adequate intra- and inter-rater reliability was shown in the Obeid-CM classification with reference to full spine anteroposterior and lateral radiographs. While side bending radiographs did not improve the classification reliability, they contributed to a better understanding in certain cases. Surgeons should consider both the sagittal and coronal planes, and this system may allow better surgical decision making for CM.
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September 2020

Is There Still a Place for Convex Hemiepiphysiodesis in Congenital Scoliosis in Young Children? A Long-Term Follow-up.

Global Spine J 2020 Jun 23;10(4):406-411. Epub 2019 Jun 23.

Hôtel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon.

Study Design: Retrospective cohort.

Objectives: To evaluate the long-term effect of convex growth arrest (CGA) on coronal deformity correction in congenital scoliosis.

Methods: Twenty-two patients with congenital scoliosis operated by 1-staged double approach hemiephysiodesis by bone grafting of the convex side without instrumentation are included. Eighteen curves had an isolated hemivertebra while 4 curves had congenital bar. Subgroup analysis was performed according to age at surgery (3 years cutoff), type of malformation (hemivertebra vs congenital bar), and severity of curve (35° cutoff).

Results: Patients' mean age at surgery was 3 years (range 0.5-8 years), with a mean frontal Cobb angle of 40.59°. Mean follow-up is 10.7 years (range 5.5-25 years). Overall results showed mean frontal Cobb angle reduction of 35.47% (40.59° to 27.41°). Detailed analysis showed that 15 curves had a mean correction of 51.8%, 5 stabilized and 2 had a mean aggravation of 25.11%. Subgroup analysis revealed that patients operated ≤3 years of age had mean cobb angle correction of 43.1% versus 21.49% in patients operated >3 years ( = .140). Mean correction of 44.5% was gained in curves with isolated hemivertebra compared with 1.3% in curves with congenital bar ( = .004). A 58.17% mean correction was reached in curves ≤35° versus 23.68% in curves >35° ( = .032).

Conclusions: A limited convex hemiepiphysiodesis still has a place in congenital scoliosis care when it is performed in patients ≤3 years old, with curves ≤35°, and with isolated hemivertebra. It spares patients the risks of vertebral resection and instrumentation, while fusing the same number of levels.
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June 2020

Influence of spino-pelvic and postural alignment parameters on gait kinematics.

Gait Posture 2020 02 24;76:318-326. Epub 2019 Dec 24.

Faculty of Medicine, University of Saint-Joseph, Beirut, Lebanon; Institut de Biomécanique Humaine Georges Charpak, Arts et Métiers ParisTech, Paris, France. Electronic address:

Introduction: Postural alignment is altered with spine deformities that might occur with age. Alteration of spino-pelvic and postural alignment parameters are known to affect daily life activities such as gait. It is still unknown how spino-pelvic and postural alignment parameters are related to gait kinematics.

Research Question: To assess the relationships between spino-pelvic/postural alignment parameters and gait kinematics in asymptomatic adults.

Methods: 134 asymptomatic subjects (aged 18-59 years) underwent 3D gait analysis, from which kinematics of the pelvis and lower limbs were extracted in the 3 planes. Subjects then underwent full-body biplanar X-rays, from which skeletal 3D reconstructions and spino-pelvic and postural alignment parameters were obtained such as sagittal vertical axis (SVA), center of auditory meatus to hip axis plumbline (CAM-HA), thoracic kyphosis (TK) and radiologic pelvic tilt (rPT). In order to assess the influence of spino-pelvic and postural alignment parameters on gait kinematics a univariate followed by a multivariate analysis were performed.

Results: SVA was related to knee flexion during loading response (β = 0.268); CAM-HA to ROM pelvic obliquity (β = -0.19); rPT to mean pelvic tilt (β = -0.185) and ROM pelvic obliquity (β = -0.297); TK to ROM hip flexion/extension in stance (β = -0.17), mean foot progression in stance (β = -0.329), walking speed (β = -0.19), foot off (β = 0.223) and step length (β = -0.181).

Significance: This study showed that increasing SVA, CAM-HA, TK and rPT, which is known to occur in adults with spinal deformities, could alter gait kinematics. Increases in these parameters, even in asymptomatic subjects, were related to a retroverted pelvis during gait, a reduced pelvic obliquity and hip flexion/extension mobility, an increased knee flexion during loading response as well as an increase in external foot progression angle. This was associated with a decrease in the walking pace: reduced speed, step length and longer stance phase.
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February 2020

Cervical Hyperextension Deformity After Sagittal Balance Correction in Patient with Congenital Limb-Girdle Myopathy: Surgical Technique and Review of Literature.

World Neurosurg 2019 Mar 9;123:265-271. Epub 2018 Nov 9.

Department of Neurosurgery, Hotel Dieu de France Hospital, Beirut, Lebanon. Electronic address:

Background: There is no gold standard surgical treatment for cervical hyperextension deformity, especially in case of muscular dystrophy. Special considerations and caution should be taken as they carry a high risk of early mortality and spinal cord injury. Only a few case reports are available in the literature.

Case Description: We report a case of surgical correction of an iatrogenic cervical hyperextension deformity following sagittal balance correction in a patient with congenital limb-girdle myopathy. The patient was successfully treated by posterior cervical release and fusion after verification of the range of motion, reducibility of the deformity, and absence of any positional spinal cord compression with dynamic radiographic examination and preoperative magnetic resonance imaging in the desired postoperative position.

Conclusions: We suggest posterior cervical release and fusion in case of a radiologically and clinically reducible cervical hyperextension deformity under both motor and sensory spinal evoked potential monitoring. In cases of longstanding, rigid, nonreducible cervical hyperextension, laminectomy and concomitant duroplasty could be considered.
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March 2019

Cervical and postural strategies for maintaining horizontal gaze in asymptomatic adults.

Eur Spine J 2018 11 7;27(11):2700-2709. Epub 2018 Sep 7.

Faculty of Medicine, University of Saint-Joseph, Beirut, Lebanon.

Purpose: To investigate the different cervical strategies for maintaining horizontal gaze in asymptomatic subjects.

Methods: One hundred and forty-four asymptomatic adults filled the SF-36 quality of life questionnaire and underwent full-body biplanar radiographs. Chin brow vertical angle (CBVA) and postural and cervical parameters were measured. Subjects were grouped according to cervical spine curvature (C2-C7 angle): kyphotic (< - 5°), straight [- 5°, 5°], lordotic (> 5°). Demographics, SF-36 component scores and CBVA were compared between groups. All other parameters were compared between groups, while controlling for confounding factors (ANCOVA). A correlation test was conducted between all cervical parameters.

Results: 32% of subjects had kyphotic (- 12° ± 7°), 27% straight (0° ± 3°) and 41% lordotic (12° ± 7°) cervical spines. While demographic and SF-36 data did not differ between groups, CBVA differed between lordotic and kyphotic groups (2° vs. 6.5°, p = 0.002). Sagittal vertical axis (SVA) and thoracic kyphosis (TK) were lower in the kyphotic group (SVA: K = - 26 ± 20 mm vs. L = - 2 ± 21 mm, p < 0.001; TK: K = 40° ± 6° vs. L = 51° ± 8°, p < 0.001). C2 slope (K = 29° ± 6° vs. L = 18° ± 6°, p < 0.001), C0-C2 (K = 42° ± 8° vs. L = 30° ± 8°, p < 0.001) and C1-C2 (K = 33° ± 6° vs. L = 28° ± 6°, p = 0.004) were higher in the kyphotic group. Significant correlations were found between almost all cervical parameters and C2-C7 angle.

Conclusions: Subjects with cervical kyphosis presented with more posterior global alignment and lower TK than subjects with lordosis. In order to maintain horizontal gaze, subjects with cervical kyphosis presented with a more lordotic upper cervical spine than subjects with cervical lordosis. Subjects with straight cervical curvature presented with an intermediate sagittal alignment. These slides can be retrieved under Electronic Supplementary Material.
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November 2018

Are the sagittal cervical radiographic modifiers of the Ames-ISSG classification specific to adult cervical deformity?

J Neurosurg Spine 2018 Nov;29(5):483-490

1Faculty of Medicine and.

OBJECTIVEThe Ames-International Spine Study Group (ISSG) classification has recently been proposed as a tool for adult cervical deformity evaluation. This classification includes three radiographic cervical sagittal modifiers that have not been evaluated in asymptomatic adults. The aim of this study was to determine whether the sagittal radiographic modifiers described in the Ames-ISSG cervical classification are encountered in asymptomatic adults without alteration of health-related quality of life (HRQOL).METHODSThe authors conducted a cross-sectional study of subjects with an age ≥ 18 years and no cervical or back-related complaints or history of orthopedic surgery. All subjects underwent full-body biplanar radiographs with the measurement of cervical, segmental, and global alignment and completed the SF-36 HRQOL questionnaire. Subjects were classified according to the sagittal radiographic modifiers (chin-brow vertical angle [CBVA], mismatch between T1 slope and cervical lordosis [TS-CL], and C2-7 sagittal vertical axis [cSVA]) of the Ames-ISSG classification for cervical deformity, which also includes a qualitative descriptor of cervical deformity, the modified Japanese Orthopaedic Association (mJOA) myelopathy score, and the Scoliosis Research Society (SRS)-Schwab classification for spinal deformity assessment. Characteristics of the subjects classified by the different modifier grades were compared.RESULTSOne hundred forty-one asymptomatic subjects (ages 18-59 years, 71 females) were enrolled in the study. Twenty-seven (19.1%) and 61 (43.3%) subjects were classified as grade 1 in terms of the TS-CL and CBVA modifiers, respectively. Ninety-eight (69.5%) and 4 (2.8%) were grade 2 for these same respective modifiers. One hundred thirty-six (96.5%) subjects had at least one modifier at grade 1 or 2. There was a significant relationship between patient age and grades of TS-CL (p < 0.001, Cramer's V [CV] = 0.32) and CBVA (p = 0.04, CV = 0.22) modifiers. The HRQOL, global alignment, and segmental alignment parameters were similar among the subjects with different modifier grades (p > 0.05).CONCLUSIONSThe CBVA and TS-CL radiographic modifiers of the Ames-ISSG classification do not seem to be specific to subjects with cervical deformities and can occur in asymptomatic subjects without alteration in HRQOL.
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November 2018

Etiology, Evaluation, and Treatment of Failed Back Surgery Syndrome.

Asian Spine J 2018 Jun 4;12(3):574-585. Epub 2018 Jun 4.

Department of Orthopedic Surgery, Hôtel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon.

The study aimed to review the etiology of failed back surgery syndrome (FBSS) and to propose a treatment algorithm based on a systematic review of the current literature and individual experience. FBSS is a term that groups the conditions with recurring low back pain after spine surgery with or without a radicular component. Since the information on FBSS incidence is limited, data needs to be retrieved from old studies. It is generally accepted that its incidence ranges between 10% and 40% after lumbar laminectomy with or without fusion. Although the etiology of FBSS is not completely understood, it is possibly multifactorial, and the causative factors may be categorized into preoperative, operative, and postoperative factors. The evaluation of patients with FBSS symptoms should ideally initiate with reviewing the patients' clinical history (observing "red flags"), followed by a detailed clinical examination and imaging (whole-body X-ray, magnetic resonance imaging, and computed tomography). FBSS is a complex and difficult pathology, and its accurate diagnosis is of utmost importance. Its management should be multidisciplinary, and special attention should be provided to cases of recurrent disc herniation and postoperative spinal imbalance.
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June 2018

Posterior-only versus combined anterior/posterior fusion in Scheuermann disease: a large retrospective study.

Eur Spine J 2018 09 19;27(9):2322-2330. Epub 2018 May 19.

Groupe Hospitalier Paris Saint-Joseph, 185, rue Raymond Losserand, 75014, Paris, France.

Purpose: The literature shows controversies concerning surgical treatment of Scheuermann's kyphosis between posterior-only fixation and combined anterior/posterior fusion. The aim of this study is to compare the clinical and radiological results and the rate of complications between these two techniques.

Methods: We performed a multicentric retrospective review of 131 patients who underwent primary fusion for Scheuermann's kyphosis divided into two groups: 67 patients operated via posterior approach only and 64 operated via combined anterior/posterior approach. Classical clinical, surgical and radiological data were collected. A descriptive and statistical analysis was performed between the two groups to evaluate the influence of the surgical procedure on the rate of complications, the functional results and radiological correction.

Results: The average age was 23 and the average kyphosis was 77 degrees. The mean follow-up was 4.2 years (range 0.1-27.3). There was no difference regarding demographic data, preoperative radiographic data and length of fusion between the two groups. Functional results were good in 81% of cases. Kyphosis correction was on average 15° and the correction of the compensatory lumbar lordosis was 20°. The correction was stable at final follow-up. There was no difference between the two groups in terms of functional results, the complications rate and radiological correction.

Conclusion: Surgery for Scheuermann's kyphosis gives good and stable functional and radiological results. Given the fact that the two surgical strategies give the same results, it appears that the anterior/posterior fusion technique to treat Scheuermann's kyphosis should be reserved for major deformations. These slides can be retrieved under Electronic Supplementary Material.
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September 2018

Roussouly's sagittal spino-pelvic morphotypes as determinants of gait in asymptomatic adult subjects.

Gait Posture 2017 05 22;54:27-33. Epub 2017 Feb 22.

Laboratory of Biomechanics and Medical Imaging, Faculty of Medicine, University of Saint-Joseph, Beirut, Lebanon; Hôtel-Dieu de France Hospital, University of Saint-Joseph, Beirut, Lebanon.

Sagittal alignment is known to greatly vary between asymptomatic adult subjects; however, there are no studies on the possible effect of these differences on gait. The aim of this study is to investigate whether asymptomatic adults with different Roussouly sagittal alignment morphotypes walk differently. Ninety-one asymptomatic young adults (46M & 45W), aged 21.6±2.2years underwent 3D gait analysis and full body biplanar X-rays with three-dimensional (3D) reconstructions of their spines and pelvises and generation of sagittal alignment parameters. Subjects were divided according to Roussouly's sagittal alignment classification. Sagittal alignment and kinematic parameters were compared between Roussouly types. 17 subjects were classified as type 2, 47 as type 3, 26 as type 4 but only 1 as type 1. Type 2 subjects had significantly more mean pelvic retroversion (less mean pelvic tilt) during gait compared to type 3 and 4 subjects (type 2: 8.2°; type 3:11.2°, type 4: 11.3°) and significantly larger ROM pelvic obliquity compared to type 4 subjects (type 2: 11.0°; type 4: 9.1°). Type 2 subjects also had significantly larger maximal hip extension during stance compared to subjects of types 3 and 4 (type 2: -11.9°; type 3: -8.8°; type 4: -7.9°) and a larger ROM of ankle plantar/dorsiflexion compared to type 4 subjects (type 2: 31.1°; type 4: 27.9°). Subjects with type 2 sagittal alignment were shown to have a gait pattern involving both increased hip extension and pelvic retroversion which could predispose to posterior femoroacetabular impingement and consequently osteoarthritis.
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May 2017

Vertebral Augmentation: State of the Art.

Asian Spine J 2016 Apr 15;10(2):370-6. Epub 2016 Apr 15.

Department of Spine Surgery, Mount Lebanon University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.

Osteoporotic vertebral compression fractures (OVF) are an increasing public health problem. Cement augmentation (vertebroplasty of kyphoplasty) helps stabilize painful OVF refractory to medical treatment. This stabilization is thought to improve pain and functional outcome. Vertebroplasty consists of injecting cement into a fractured vertebra using a percutaneous transpedicular approach. Balloon kyphoplasty uses an inflatable balloon prior to injecting the cement. Although kyphoplasty is associated with significant improvement of local kyphosis and less cement leakage, this does not result in long-term clinical and functional improvement. Moreover, vertebroplasty is favored by some due to the high cost of kyphoplasty. The injection of cement increases the stiffness of the fracture vertebrae. This can lead, in theory, to adjacent OVF. However, many studies found no increase of subsequent fracture when comparing medical treatment to cement augmentation. Kyphoplasty can have a protective effect due to restoration of sagittal balance.
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April 2016

Aneurysmal Bone Cyst of the Cervical Spine in Children: A Review and a Focus on Available Treatment Options.

J Pediatr Orthop 2015 Oct-Nov;35(7):693-702

Departments of *Orthopedic Surgery §Neurosurgery, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon †Department of Pediatric Orthopedics, CHU Caen, Caen ‡AH-HP, Service d'Orthopédie et Traumatologie pédiatrique, hôpital Necker-enfants malades, Paris, France.

Objective: To present a series of pediatric cervical spine (CS) aneurysmal bone cysts (ABC), to review the literature, and to propose a treatment algorithm.

Material: We present a series of 4 cases of ABC and review the literature using PubMed, EMBASE, and Google scholar.

Results: Only 51 cases are documented. The mean age at diagnosis is 11.5 years, and there is a small female predominance (F:M ratio=1.6). Most of ABC occurs in the upper CS (41%), are located in the posterior component (75%), and extends in 40% of the vertebral body. A single treatment modality was used in 56.9%, whereas combination of surgery with other treatment modalities was used in the rest. Of the total number of cases, 56.8% were managed with marginal resection, and instrumentation was used in 80%. Mean follow-up was 72.5 months, with the majority of patients disease free. Pain is the most common symptom present at the latest follow-up.

Conclusions: ABC of the spine is a pediatric tumor occurring rarely in the CS. Treatment options vary from simple curettage to total resection with or without instrumentation. Recurrence after surgery is highest after curettage alone. The main indications for surgery are rapid progression, despite intracystic injection, and/or the presence of neurological signs or symptoms.
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May 2016

[Predictors of osteoarticular problems in a cohort of computer users in Lebanon: about 810 employees].

J Med Liban 2013 Jul-Sep;61(3):161-9

Centre hospitalier universitaire Hôtel-Dieu de France.

Objective: The aim of the study is the analysis of osteoarticular problems (OAP) occurring in a group of computer users (CU) in search of correlation between symptoms and different etiological factors.

Material And Method: Questionnaire of 31 items dealing with personal data, the activity of the CU, stress, the occurrence of osteoarticular problems during the last month (Oaplm) and last twelve months (Oaptm) and a checklist of 17 items covering the physical characteristics of the workplace.

Results: DESCRIPTIVE ANALYSIS * 810 respondents of mean age 36 +/- 9 years and predominantly female (69%) *

Features: seniority at the workplace (12.5 +/- 9 years), pace of work (825 +/- 1.5 hours/day and 5.5 +/- 1 days/ week), number of breaks (13 +/- 1.04/d), duration of breaks (35 min +/- 25/d), 44.5% in sports activities, work stress in 92% of participants * OAP described:--Osteoarticular problems last month (62%), neck pain (68%), shoulder (46%) and lumbar spine (62%) pain. Tingling hands (40%). Headache (55.5%). Temporomandibular disorders (18.5%)--Osteoarticular problems the last twelve months (46%). UNIVARIATE ANALYSIS: Detection of risk factors * RISK FACTORS and Oaplm relationship: female, weight gain, secretary, stress, pain during labor and work stoppages withp < 0.05 * RISK FACTORS and Oaptm relationship: the position of secretary, stress, pain at work, work stop-pages for Oaplm withp < 0.05 * Protection factor: sports more than one time per week. MULTIVARIATE ANALYSIS: Oaplm occurrent factors: weight gain, Oaptm withp < 0.05. Protection factor: well designed workstation * Oaptm occurrent factors: age, stress and Oaplm with p < 0.05.

Conclusion: Significant prevalence of osteoarticular problems in Lebanese computer users.

Risk Factors: age, Oaptm, weight gain, stress, work-break cycle not respected and poor layout of the workstation. Ergonomic interventions are necessary and indispensable to reduce the cost of occupational diseases related to the CU, and ensure good mental and physical health.
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February 2014

Tumoral calcinosis of the cervical spine and its association with Caffey disease in a 4-month-old boy: case report and review of the literature.

J Pediatr Orthop B 2012 May;21(3):286-91

Hotel-Dieu de France Hospital, Saint Joseph University, Boulevard Alfred Naccache, Ashrafieh, Beirut, Lebanon.

Tumoral calcinosis (TC) is a rare condition involving large joints and rarely the spine. It is characterized by calcification and swelling of periarticular tissues. Caffey disease (CD) is defined by recurrent episodes of painful soft tissue swelling and cortical thickening of the underlying bones. It is a self-limited disease that occurs in the first year of life. We report the first association of CD and TC of the cervical spine in a 4-month-old boy. We suggest that TC occurred as a consequence of the repetitive reparative process that takes place in CD, adding the latter to the list of diseases that may secondarily produce TC.
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May 2012

Anterior spinal artery syndrome after percutaneous vertebroplasty.

Spine J 2011 Aug 10;11(8):e5-8. Epub 2011 Aug 10.

Department of Orthopedic Surgery, Hotel Dieu de France University Hospital, Achrafiye, Alfred naccach St, Beirut, Lebanon.

Background Context: Vertebroplasty is commonly performed for the management of pain associated with benign compression fractures, multiple myelomas, lymphomas, vertebral metastatic lesions, and hemangiomas. We describe a severe complication associated with this procedure; only one previous case has been reported in the literature.

Objective: To report a case of anterior spinal cord syndrome caused by a direct cement leakage in the arterial vessels after vertebroplasty.

Methods: A 20-year-old man who has been diagnosed with multifocal Ewing sarcoma for 5 months suffered from severe and chronic inflammatory polyarthralgia in the left knee, pelvis, and the low back. The imaging studies, X-ray and computed tomography scan, showed the presence of pathologic fractures of T8 and L1 vertebrae. There was no retropulsion of bony fragment in the vertebral canal. A percutaneous vertebroplasty of T8 and L1 level was performed.

Results: Immediately after the procedure, the patient experienced a total paralysis and loss of sensitivity to pain and temperature in both lower limbs; however, deep pressure sensation and two-point discrimination below the umbilicus were preserved. Computed tomography scans showed no leakage of polymethylmethacrylate of T8 and L1 vertebral bodies, with opacification of the right intercostal artery at the L1 level and a segment of the anterior spinal artery at the T10-L1 level.

Conclusions: Although percutaneous vertebroplasty has many benefits, including its simplicity and relative safety, it could lead to serious complications. The current case demonstrates the direct leakage of cement within the anterior spinal artery leading to an irreversible paralysis. The clinicians should be aware of such complications to happen and explain it to their patients.
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August 2011

Herniated intervertebral disc associated with a lumbar spine dislocation as a cause of cauda equina syndrome: a case report.

Eur Spine J 2006 Jun 14;15(6):1015-8. Epub 2006 Apr 14.

Orthopaedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon.

To report a case of Cauda Equina syndrome with the completion of the paralysis after the reduction of a L4L5 dislocation due to a herniated disc. Although several articles have described a post-traumatic disc herniation in the cervical spinal canal, this is not well known in the lumbar region. A 30-year-old man was admitted to the emergency room with blunt trauma to the chest and abdomen with multiple contusions plus a dislocation of L4-L5 with an incomplete neurological injury. After an emergency open reduction and instrumentation of the dislocation, the patient developed a complete cauda equina syndrome that has resulted from an additional compression of the dural sac by a herniated disc. In a dislocation of the lumbar spine, MRI study is mandatory to check the state of the spinal canal prior to surgical reduction. A posterior approach is sufficient for reduction of the vertebral displacement, however an intra-canal exploration for bony or disc material should be systematically done.
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June 2006

[The particularities of the adult Scheuermann's disease: study about 45 patients].

J Med Liban 2004 Jan-Mar;52(1):19-24

Service de Médecine physique, CHU Hôtel-Dieu de France, Beyrouth, Liban.

Objective: Our aim was to find out which factors favor the occurrence of pain in adult patients with Scheuermann's disease--a juvenile manifestation of osteochondrosis of the spine, to study the clinical and radiological signs, the role of rehabilitation and the means to avoid the recurrence of pain.

Patients And Methods: Descriptive and retrospective study about 45 adults treated by rehabilitation. A data sheet listed the patient's occupation, current practice of sport, antecedents (violent sport, traumatism, pain), presence of a family form, motive of consultation, clinical and paraclinical examinations and immediate and long-term results of rehabilitation.

Results: Average age 35 years (18 to 65), male predominance (1.8:1), occupational risk factors: 16%; only 24% practiced sports currently.

Antecedents: sports 49%, spinal column traumatism 13%, dorsal and lumbar pain during adolescence 16%. Consultation motive: abnormal posture 4% and pain 96%. According to the examination: abnormal spinal column in 80% of cases. According to radiography, our patients were divided into 49% who were carriers of growth vertebral dystrophy and 51% who were carriers of the real Scheuermann's disease. The immediate results of rehabilitation were satisfactory, 75% of the results were very good and good. Between six months and four years, 70% of the results were very satisfactory. Exercises were observed in only 11% of the cases, and stopped after two months on average.

Conclusion: Scheuermann's disease in adults is a different entity from that of the teenager for the major manifestation is pain and not aesthetic quality. The patient's occupation is rather sedentary; sport is beneficial. The functional rehabilitation is the basic treatment and recourse to surgery or dorso-lumbar braces is rare.
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May 2005