Ahmad Eid

Fluoroscopy-based navigation system in spine surgery:

Abstract The variability in width, height, and spatial orientation of a spinal pedicle makes pedicle screw insertion a delicate operation. The aim of the current paper is to describe a computer-assisted surgical navigation system based on fluoroscopic X-ray image calibration and three-dimensional optical localizers in order to reduce radiation exposure while increasing accuracy and reliability of the surgical procedure for pedicle screw insertion. Instrumentation using transpedicular screw fixation was performed: in a first group, a conventional surgical procedure was carried out with 26 patients (138 screws); in a second group, a navigated surgical procedure (virtual fluoroscopy) was performed with 26 patients (140 screws). Evaluation of screw placement in every case was done by using plain X-rays and post-operative computer tomography scan. A 5 per cent cortex penetration (7 of 140 pedicle screws) occurred for the computer-assisted group. A 13 per cent penetration (18 of 138 pedicle screws) occurred for the non computer-assisted group. The radiation running time for each vertebra level (two screws) reached 3.5s on average in the computer-assisted group and 11.5s on average in the non computer-assisted group. The operative time for two screws on the same vertebra level reaches 10 min on average in the non computer-assisted group and 11.9 min on average in the computer-assisted group. The fluoroscopy-based (two-dimensional) navigation system for pedicle screw insertion is a safe and reliable procedure for surgery in the lower thoracic and lumbar spine.

Lésions neurologiques des fractures de l'anneau pelvien : À propos d'une série prospective continue de 50 lésions pelviennes postérieures opérées par vissage ilio-sacré

PURPOSE OF THE STUDY The purpose of this study was to analyze lesions to the lumbosacral plexus related to pelvic injury and its treatment. MATERIAL AND METHODS Forty-four patients presented 50 posterior osteoligamentary lesions of the pelvic girdle. All patients except eight had other injuries. Mean ISS was 27/75. Posterior lesions were: iliosacral disjunction (n=23), extra-foraminal fracture of the sacrum (n=4), transforaminal fracture (n=22), intra-foraminal fracture (n=1). Vertical posterior displacement was > 1 cm for 24 posterior lesions. Orthopedic reduction was performed at admission for all patients. Fluoroscopy-guided percutaneous lag screw fixation was performed in all cases, on the average eight days after the accident. Neurological involvement was evaluated at admission, after surgery, and at last follow-up. Data were recorded for skeletal muscles, lower limb dermatomes, tendon reflexes, and anal tone. Screw emplacement was checked on the CT-scan. Outcome was assessed subjectively with the Majeed score, a self-administered visual analog scale, and use of antalgesic drugs according to the WHO classification. RESULTS The neurological examination could not be performed for ten patients at admission. Postoperatively, there was a neurological deficit associated with 26 osteoligamentary lesions (23 lesions of the lumbosacral trunk, 14 lesions of the S1 spinal nerve, 3 lesions of the pudendal nerve, 12 lesions of the superior gluteal nerve, and 10 lesions of the femoral nerve). Patients with neurological involvement had experienced more severe trauma. The iliosacral screw was partially extra-osseous in thirteen cases, with an associated iatrogenic neurological deficit in seven. At mean follow-up of 20 Months (range 4-50) there persisted ten major sequelae including eight cases of hallux extensor deficit. DISCUSSION Neurological involvement is underestimated during the acute phase of trauma. After recovery, only the manifestations of major injuries persist. The prognosis is poor in the event of a stretched lumbosacral trunk or gluteal nerve due to iliosacral disjunction. Prognosis is good for nerve contusion due to sacral fracture because of early reduction. The femoral nerve is generally injured by compression due to a peri-fracture hematoma; recovery is the rule. Iliosacral screwing requires rigorous technique by a skilled and experienced surgeon. CONCLUSION About 52% of posterior osteoligamentary injuries are associated with neurological symptoms. After recovery, permanent deficit persists in 21.7%. The most common sequelae are hallux extensor and gluteus medius palsy due to stretching of the lumbosacral trunk.

Epiphyseal stapling of the proximal tibia for idiopathic genu valgum.

PurposeThe purpose of this study is to evaluate the clinical and radiological outcomes of hemiepiphysiodesis with a single medial staple of the proximal tibia in idiopathic genu valgum angular correction.MethodsA retrospective review was performed identifying nine adolescents (18 knees) treated for idiopathic adolescent genu valgum by means of a bilateral hemiepiphysiodesis with a single staple of the proximal tibia. The intermalleolar distance (IMD) and hip–knee–ankle angle were measured at skeletal maturity.ResultsThe IMD and hip–knee–ankle angle were reduced in all patients at skeletal maturity.ConclusionHemiepiphysiodesis with a single medial staple of the proximal tibia seems to be a reliable and safe alternative method to achieve correction of an idiopathic genu valgum.

Computer-assisted versus manual spine surgery: clinical report

Clinical evaluation of a computer-assisted spine surgery system is presented. 40 pedicle screws have been inserted in lumbar and thoracic vertebrae in different types of disorder including scoliosis, spondylolisthesis, and iatrogenic or degenerative instability. 20 screws were inserted with a computer-assisted system while 20 were inserted manually. Surgery was followed by post-operative X-ray and CT examination, on which measurements of screw position relative to pedicle could be done. Comparison between the two groups show that the computer-assisted technique is much more accurate and safe than manual insertion.

Growth tethering devices for idiopathic scoliosis

Adolescent idiopathic scoliosis is a 3D spine deformity that worsens during the whole growth. The treatments available are bracing during the whole growth to avoid progression of the deformity and surgical fusion of the spine at skeletal maturity for the most severe curves. Recent advances in flexible spinal implants have given rise to new expectations in the management of progressive scoliosis with growth modulation without fusion. For the first time, treatment allows us to expect a correction of progressive curves without fusion. This review discusses the recent developments in the field of spinal growth modulation techniques and discusses the pros and cons of the medical devices used in this indication.

A New Paradigm for the Management of Thoracolumbar Pediatric Spine Traumas.

Objectives The transient breath holding sign (TBHS) is a clinical sign often associated with magnetic resonance imaging (MRI) spine traumatic lesions. The aims of this study were to prospectively evaluate the TBHS in the detection of thoracolumbar lesions in a large cohort of children and to establish a comprehensive strategy on the use of MRI in spine traumas in children. Study Design All conscious 5- to 16-year-old patients admitted for a spine trauma in our institution were prospectively included in the study. All patients were asked for the TBHS and underwent a full spine MRI. Sensitivity and specificity of the TBHS were derived from the confusion matrix. All MRI lesions were analyzed and classified. Results One hundred ninety-eight patients were included. The sensitivity of the TBHS was 92%, the specificity was 83%, the positive predictive value was 83%, and the negative predictive value was 91%. The x-rays missed 67% of the vertebrae injured in the MRI. The MRI lesions consisted in an upper end plate injury, in the sagittal plane only, in 90% of the cases. The vertebral canal and the spinal cord were never injured. Conclusions This study confirms that the TBHS is a relevant clinical tool that should be added in the routine questionnaire after any trauma at admission. Magnetic resonance imaging should be restricted to patients with a TBHS positive at admission. A single T2 Short T1 Inversion Recovery (STIR) sagittal sequence seems sufficient to make the diagnosis and could replace the use of standard x-rays in pediatric spine traumas.

A thoracic spinal bone giant cell tumor in a skeletally immature girl. A case report and literature review

PurposeGiant cell tumors (GCT) are benign primary bone tumors, locally aggressive, affecting in long bones in young adults during the third decade. It is rare to experience this lesion in skeletally immature patients. GCT are related to a risk of local recurrence and malignant transformation.MethodWe report a rare case of a giant cell tumor of the thoracic spine in a skeletally immature girl presenting with a painful right scoliosis.ResultsMRI, CT scan, and bone scintigraphy were discordant and the percutaneous biopsy non-contributive.ConclusionA marginal “en bloc” resection was performed and revealed the GCT. Based on a literature review, the diagnosis and the surgical management of this case are discussed.

Congenital lumbar kyphosis with skin ulceration and osteomyelitis in a myelomeningocele child: a case report

IntroductionKyphosis is a frequent problem in children with spina bifida, and this deformity may cause different complications as respiratory insufficiency, bowel dysfunction, and skin ulcers.Case reportWe report on a 13-year-old myelomeningocele male with a lumbar kyphoscoliosis associated to a septic skin ulceration that resulted in an acute sepsis. An X-ray revealed a kyphosis of 110° and a scoliosis of 25° between T9 and L5. The wound and blood cultures showed Staphylococcus aureus colonization, and an appropriate antibiotic therapy was started. An MRI showed a wedged vertebra at T12, a laminae defects from T8 to the sacrum, and a spondylitis at T12-L1. Ulcer resection and kyphectomy from T12 to L3 were performed “en bloc,” and the spine was instrumented fromT7 to S1. After the surgery, the kyphosis was corrected to 10°, and the scoliosis was corrected to 0°. At an 18-month follow-up, a solid bony fusion was obtained, and no recurrence of skin ulcer was reported.ConclusionAntibiotherapy associated to one-step “en-bloc” surgical debridement and kyphectomy should be considered as a valid option to eradicate the infection and to correct the spine deformity in kyphosis due to myelomeningocele associated to septic skin ulcer and spondylitis.

Pièges diagnostiques de la traumatologie du coude de l’enfant ☆ ☆☆

Elbow injuries are frequent but occult fractures are difficult to diagnose on x-rays. However, any delay in the diagnosis may severely impair the prognosis of some fractures. Simple tips may help the clinician read x-rays properly and avoid the classical pitfalls of elbow injuries in children. The chronology of appearance of ossification nuclei around the elbow is important to distinguish normal features from abnormality. Drawing simple geometric constructions on the x-rays may clarify most occult elbow fractures in children.

56 Fracture pertrochantérienne du sujet âgé de plus de 75 ans. Étude prospective randomisée d’une cohorte de 65 patients comparant l’ostéosynthèse et la reconstruction prothétique.

Cette etude comparait un groupe de 35 patients traites par prothese intermediaire de reconstruction non cimentee avec un groupe de 30 patients traites par osteosynthese de type vis-clou. Il s’agissait d’une etude prospective randomisee en simple aveugle incluant des sujets de plus de 75 ans, presentant une fracture de type 31-A1.3, 31-A2 ou 31-A3 de la classification AO. Le protocole d’etude a ete soumis a l’avis du CCPPRB. Les deux groupes etaient significativement identiques pour l’âge, le sexe, le cote fracture, le mecanisme de la chute, l’index osteopenique de Singh, le type de fracture, le lieu de vie initial, la comorbidite, le score ASA, le score d’autonomie de Katz, le Mini Mental Test Abrege, la marche, le score de mobilite, le delai d’hospitalisation et d’intervention et l’hemoglobine preoperatoire. Il n’y avait pas de difference significative pour le type d’anesthesie, les pertes sanguines globales, la reprise de l’appui, la duree d’hospitalisation et le lieu de sortie. La duree moyenne d’intervention etait differente avec 45 minutes pour la prothese et 30 minutes pour l’osteosynthese. Le saignement peroperatoire etait different avec 381 ml pour la prothese et 110 ml pour l’osteosynthese. Au recul moyen 16 mois (extremes de 1 a 30 mois), la mortalite etait differente avec 37 % pour le groupe prothese contre 26 % pour le groupe osteosynthese. Des complications specifiques ont ete rencontrees 2 fois dans chaque groupe avec necessite de reprise chirurgicale. Le score de mobilite etait different a 6 mois, avec une perte de la mobilite autonome dans 87 % des cas du groupe prothese contre une perte de 67 % des cas du groupe osteosynthese. La marche se faisait avec deambulateur dans 59 % des cas du groupe prothese contre 33 % des cas du groupe osteosynthese, a 1,5 mois. La perte de l’autonomie pour l’activite de la vie quotidienne (Katz A et B) etait identique dans les 2 groupes a 1,5 mois. L’implant prothetique non cimente utilise dans cette etude en traumatologie du sujet âge procure une bonne stabilite primaire avec un appui immediat. Cependant, le choix de l’osteosynthese conduit, a 16 mois a au moins d’aussi bons resultats fonctionnel que le choix de la prothese ; peut-etre par mobilisation secondaire de l’implant femoral dans le fut femoral osteoporotique.