G. Lonjon

Terrorist attacks in Paris: Surgical trauma experience in a referral center

BACKGROUND On November 13th, 2015, terrorist bomb explosions and gunshots occurred in Paris, France, with 129 people immediately killed, and more than 300 being injured. This article describes the staff organization, surgical management, and patterns of injuries in casualties who were referred to the Teaching European Hospital Georges Pompidou. METHODS This study is a retrospective analysis of the pre-hospital response and the in-hospital response in our referral trauma center. Data for patient flow, resource use, patterns of injuries and outcomes were obtained by the review of electronic hospital records. RESULTS Forty-one patients were referred to our center, and 22 requiring surgery were hospitalized for>24h. From November 14th at 0:41 A.M. to November 15th at 1:10 A.M., 23 surgical interventions were performed on 22 casualties. Gunshot injuries and/or shrapnel wounds were found in 45%, fractures in 45%, head trauma in 4.5%, and abdominal injuries in 14%. Soft-tissue and musculoskeletal injuries predominated in 77% of cases, peripheral nerve injury was identified in 30%. The mortality rate was 0% at last follow up. CONCLUSION Rapid staff and logistical response, immediate access to operating rooms, and multidisciplinary surgical care delivery led to excellent short-term outcomes, with no in-hospital death and only one patient being still hospitalized 45days after the initial event.

Reliability and validity of the French-Canadian version of the scoliosis research society 22 questionnaire in France.

Study Design. Outcome study to determine the internal consistency, reproducibility, and concurrent validity of the French-Canadian version of the Scoliosis Research Society 22 (SRS-22 fcv) patient questionnaire in France. Objective. To determine whether the SRS-22 fcv can be used in a population from France. Summary of Background Data. The SRS-22 has been translated and validated in multiple countries, notably in the French-Canadian language in Quebec, Canada. Use of SRS-22 fcv seems appropriate for evaluating adolescent idiopathic scoliosis in France. However, French-Canadian French is noticeably different from the French spoken in France, and no study has investigated the use of a French-Canadian version of a health-quality questionnaire in another French population. Methods. The methods used for validating the SRS-22 fcv in Quebec were adopted for use with a group of 200 adolescents with idiopathic scoliosis and 60 healthy adolescents in France. Reliability and reproducibility were measured by the Cronbach &agr; and intraclass correlation coefficient (ICC), construct validity by factorial analysis, concurrent validity by the Short-Form of the survey, and discriminant validity by analysis of variance and multivariate linear regression. Results. In France, the SRS-22 fcv showed good global internal consistency (Cronbach &agr; = 0.87, intraclass correlation coefficient = 0.92), a coherent factorial structure, and high correlation coefficients between the SRS-22 fcv and Short-Form of the survey (P < 0.001). However, reliability and validity were slightly less than that for the instruments original validation and the validation of the SRS-22 fcv in Quebec. These differences could be explained by language and cultural differences. Conclusion. The SRS-22 fcv is relevant for use in France, but further development and validation of a specific French questionnaire remain necessary to improve the assessment of functional outcomes of adolescents with scoliosis in France. Level of Evidence: N/A

Assessment of the Radiation Exposure of Surgeons and Patients During a Lumbar Microdiskectomy and a Cervical Microdiskectomy: A French Prospective Multicenter Study

OBJECTIVE Cervical and lumbar disk herniations are the most frequently carried out procedures in spinal surgery. Often, a few snapshots during the procedure are necessary to validate the level or to position the implant. The objective of this study is to quantitatively estimate the radiation received by a spine surgeon and patient during a low-dose radiation procedure. METHODS We conducted a prospective multicenter study in France from November 2014 to April 2015. Four spine centers were monitored for radiation received by surgeons during interventions for lumbar disk herniation and cervical disk herniation. RESULTS A total of 134 patients were included. For lumbar disk herniation, the average exposure for the surgeon was 0.584 μSv on the chest, 5.291 μSv on the lens, and 9.295 μSv on the hands per procedure. For these procedures, the dose area product (DAP) was 94.2 ± 198.4 cGy·cm(2), and the fluoroscopic time was 10.2 ± 16.9 seconds. For a herniated cervical disk, the average exposure for the surgeon was 0.122 μSv on the chest, 3.106 μSv on the lens, and 7.143 μSv on the hands per procedure. For these procedures, the DAP was 35.7 ± 72.1 cGy·cm(2), and the fluoroscopic time was 19.7 ± 13.7 seconds. CONCLUSIONS Exposure to x-rays for surgeons and patients during surgery for lumbar disk herniation is higher than during surgery for cervical herniation disk. Our results show that radiation exposure to the spine surgeon is still far below the annual dose limits.

Surgery in vertebral fracture: Epidemiology and functional and radiological results in a prospective series of 518 patients at 1 year's follow-up

INTRODUCTION Recent epidemiological data for spinal trauma in France are sparse. However, increased knowledge of sagittal balance and the development of minimally invasive techniques have greatly improved surgical management. OBJECTIVES To describe the epidemiology and management of traumatic vertebral fracture, and to analyze evolution and risk factors for poor functional outcome at 1 years follow-up. MATERIALS AND METHODS A prospective multicenter French cohort study was performed over a 6-month period in 2011, including all cases of vertebral fracture surgery. Data were collected by online questionnaire over the Internet. Demographic characteristics, lesion type and surgical procedures were collected. Clinical, functional and radiological assessment was carried out at 1 year. RESULTS Five hundred and eighteen patients, with a mean age of 47 years, were included. Sixty-seven percent of fractures involved the thoracic or lumbar segment. Thirty percent of patients had multiple fractures and 28% neurological impairment. A minimally invasive technique was performed in 20% of cases and neurological decompression in 25%. Dural tear was observed in 42 patients (8%). Seventy percent of patients were followed up at 1 year. Functionally, SF-36 scores decreased on all dimensions, significantly associated with age, persistent neurological deficit and previous spine imbalance. Thirty-eight percent of working patients had returned to work. Radiologically, sagittal balance was good in 74% of cases, with fracture consolidation in 70%. DISCUSSION Despite progress in management, spinal trauma was still a source of significant morbidity in 2011, with pronounced decrease in quality of life. Conserved sagittal balance appeared to be associated with better functional outcome.

Spinal cord compression due to undiagnosed thoracic meningioma following lumbar surgery in an elderly patient: A case report

As spinal surgery in elderly patients is becoming increasingly frequent, comorbidities likely to be decompensated after such procedures must be kept in mind. We report here the case of an 82-year-old woman who presented rapidly progressive spinal cord compression following lumbar surgery for radiculopathy. Investigations showed a thoracic intradural extramedullary compressive lesion, which after removal turned out to be a meningioma. We suggest that radiculopathy and non-specific degenerative modifications partially masked this lesion, and that lumbar surgery caused this acute neurological deterioration. Therefore, we advice caution in older patients among whom such ambiguous clinical presentation is frequent.

Survey of French spine surgeons reveals significant variability in spine trauma practices in 2013

BACKGROUND In France, attempts to define common ground during spine surgery meetings have revealed significant variability in clinical practices across different schools of surgery and the two specialities involved in spine surgery, namely, neurosurgery and orthopaedic surgery. OBJECTIVES To objectively characterise this variability by performing a survey based on a fictitious spine trauma case. Our working hypothesis was that significant variability existed in trauma practices and that this variability was related to a lack of strong scientific evidence in spine trauma care. METHODS We performed a cross-sectional survey based on a clinical vignette describing a 31-year-old male with an L1 burst fracture and neurologic symptoms (numbness). Surgeons received the vignette and a 14-item questionnaire on the management of this patient. For each question, surgeons had to choose among five possible answers. Differences in answers across surgeons were assessed using the Index of Qualitative Variability (IQV), in which 0 indicates no variability and 1 maximal variability. Surgeons also received a questionnaire about their demographics and surgical experience. RESULTS Of 405 invited spine surgeons, 200 responded to the survey. Five questions had an IQV greater than 0.9, seven an IQV between 0.5 and 0.9, and two an IQV lower than 0.5. Variability was greatest about the need for MRI (IQV=0.93), degree of urgency (IQV=0.93), need for fusion (IQV=0.92), need for post-operative bracing (IQV=0.91), and routine removal of instrumentation (IQV=0.94). Variability was lowest for questions about the need for surgery (IQV=0.42) and use of the posterior approach (IQV=0.36). Answers were influenced by surgeon specialty, age, experience level, and type of centre. CONCLUSION Clinical practice regarding spine trauma varies widely in France. Little published evidence is available on which to base recommendations that would diminish this variability.

Arthroscopic treatment in split depression-type tibial pilon fracture

Abstract Treatment of tibial pilon fractures is complicated and often very invasive. Partial fractures with a depressed component raise the question of the choice of surgical technique. Minimally invasive surgical reduction under arthroscopic guidance appears to be a promising alternative in this type of fracture. We describe a technique for arthroscopically assisted treatment of a split depression tibial pilon fracture.

Detorsion night-time bracing for the treatment of early onset idiopathic scoliosis

BACKGROUND Management for early onset scoliosis has recently changed, with the development of new surgical procedures. However, multiple surgeries are often required and high complication rates are still reported. Conservative management remains an alternative, serial casting achieving excellent results in young children. Better compliance and improvement over natural history have been reported with night-time bracing in adolescent idiopathic scoliosis (AIS), but this treatment has never been reported in early onset idiopathic scoliosis (EIOS). METHODS All patients treated for progressive EOIS by detorsion night-time bracing (DNB), and meeting the Scoliosis Research Society (SRS) criteria for brace studies were reviewed. Recommendations were given to wear the DNB 8h/night and no restriction was given regarding sports activities. Radiological parameters were compared between referral and latest follow-up. Based on the SRS criteria defined for AIS, a similar classification was used as follows to analyze the course of the curves: success group: patients with a progression of 5° or less; unsuccess group (progression or failure): patients with a progression>5°, patients with curves exceeding 45° at maturity, or who have had recommendation for/undergone surgery, or patients who changed orthopaedic treatment, or who were lost to follow-up. RESULTS Thirty-three patients were included (21 girls and 12 boys), with a median Cobb angle of 31° (Q1-Q3: 22-40). Age at brace initiation averaged 50months (Q1-Q3: 25-60). Median follow-up was 102-months (Q1-Q3: 63-125). Fifteen patients (45.5%) had reached skeletal maturity at last follow-up. The success rate was 67% (22 patients), with a median Cobb angle reduction of 15° (P<0.001). Four patients stopped DNB due to an important regression. Eleven patients were in the unsuccessful group (33%). Only one had surgery. All patients remained balanced in the frontal plane and normokyphotic. Initial curve magnitude and age at brace initiation appeared to be important prognostic factors. CONCLUSIONS DNB is an effective conservative treatment, which can be considered a delaying tactic in the management of EOIS. This brace offers potential psychosocial and compliance benefits, and allows unconstrained spinal and chest wall growth, resulting in normokyphosis at maturity. LEVEL OF EVIDENCE Therapeutic study (retrospective consecutive case series): Level IV.

Indication Variability in Degenerative Lumbar Spine Surgery: A Four-nation Survey

Study Design. Electronic survey. Objective. The aim of this study was to identify the international nuances in surgical treatment patterns for severals lumbar degenerative conditions, specifically, to identify differences in responses in each country groupand different treatment trends across countries. Summary of Background Data. Significant variations in treatment of lumbar degenerative conditions exist among spine surgeons, related to the lack of established consensus in the literature. Methods. An online survey with preformulated answers was submitted to 52 orthopedic surgeons, 50 neurosurgeons from four different countries (United States, France, Spain, and Germany) regarding five vignette-cases. Cases included: multilevel stenosis, monolevel stenosis, lytic spondylolisthesis, isthmic lysis, and degenerative scoliosis. The variability for each country was calculated according to the Index of Qualitative Variation (IQV = 0: no variability and 1: maximal variability). We used Fleiss kappa (range: from −1, poor agreement, to 1, almost perfect agreement) for assessing the reliability of agreement between the participants concerning specialties, countries, and age groups. Results. For the two stenosis cases, US surgeons were more likely to propose decompression (IQV multilevel = 0.47 and monolevel = 0.32) comparing with European countries more heterogeneous (all IQV >0.70) and more frequently proposing fusion. As regards degenerative scoliosis, all attitudes were extremely heterogeneous with IQV >0.8. Fusion for isthmic spondylolisthesis was more consensual (all IQV <0.63), but attitudes were more heterogeneous for isthmic lysis (IQV ranged from 0.48 to 0.76) with anterior approach proposed in France (37%) and United States (19.2%). The overall interrater agreement was equally slight not only for neurosurgeons (Fleiss Kappa = 0.04) and orthopedic surgeons (Kappa = 0.13), but also for countries (Kappa <0.13) and age groups (Kappa <0.1). Conclusion. In this study, we found substantial agreement for some spinal conditions but a high variability in some others: intranational and international variations were observed, reflecting the lack of literature consensus. Level of Evidence: 2

Surgical treatment of thoracic spine fractures. Outcomes on 50 patients at 23 months follow-up.

PURPOSE The morphological and biomechanical features of the thoracic spine, together with its close proximity to the spinal cord, set it apart from other spinal segments. Management of thoracic spine injuries consists of achieving a reduction and an immediate and long-lasting stabilization of the spine while constantly protecting the central and peripheral nervous system. The aim of this study was to determine the best treatment for surgical thoracic spine fractures. MATERIALS AND METHODS We studied the baseline characteristics of 68 patients admitted to our neurosurgical department for one or several thoracic spine fractures between 2008 and 2010. We analysed on this group of patient the surgical management, complications and functional outcomes. We detailed the 2-years radiological outcome on 50 patients (23 months mean follow-up). RESULTS The majority of patients underwent an extensive posterior arthrodesis bridging, on average, 5.3 vertebrae. The median time between diagnosis and surgery was 2 days and the median length of stay in hospital was 13.5 days. About 94% of hooks and 80% of pedicle screws were considered stable. Mean values of reduction and correction loss were similar (about 4.5°). We concluded to the superiority of extensive procedures and of pedicle screws fixation for the reduction and the maintenance of the correction by the end of follow-up. Functional data indicated daily discomfort and moderate pain. CONCLUSION A prospective study comparing the different procedures and instrumentations is needed to better define guidelines for the management of thoracic spine injuries. LEVEL OF EVIDENCE Level IV.