I. Hovorka

Short device fixation and early mobilization for burst fractures of the thoracolumbar junction

The authors present a retrospective study based on a homogeneous series of 34 patients with burst fractures of the thoracolumbar junction, fixed using Cotrel-Dubousset instrumentation. These patients under-went instrumentation using a short construct of hooks and screws gripping the two vertebrae above the lesion (2HS) and screws and hooks gripping the first vertebra below the lesion (1SH). This construct was therefore called “2HS-1SH”. In order to evaluate just the material resistance after getting up, only the patients who were upright on the 4th day without a body cast and with no secondary anterior osteosynthesis were included in this study. Four patients showed some neurological symptoms on admission but recovery was so quick that they could be included in this study. Mean follow-up was 4 years 1 month (range 3 years 1 month and 6 years 2 months). Vertebral and regional kyphosis angles were measured preoperatively, postoperatively and at the final follow-up. Functional recovery and complications were analyzed. Mean vertebral kyphosis was 21.2° preoperatively, 3.8° postoperatively and 5.3° at the final follow-up. Regional kyphosis angles were respectively 19.2, 0.2, and 2.7°. We had two cases of deep suppuration, one early and the other late. None of the patients required analgesics for more than 6 months after the operation. Patients returned to work after 5 months on average. The authors concluded that fixation by screw-and-hook constructs is an effective way to stabilize thoracolumbar junction burst fractures.

Five years’ experience of retroperitoneal lumbar and thoracolumbar surgery

Abstract Retroperitoneal videoscopic spine surgery has been developed in our department since 1994. It has been used not only at the lumbar, but also at the thoracolumbar and lumbosacral level. Thirty-eight patients have been operated on. We have performed 12 thoracolumbar approaches, 23 lumbar approaches, and 3 retroperitoneal lumbosacral approaches. In every case, a video-assisted technique has been employed. These techniques have been used for anterior grafting in 18 cases of fracture, for corporectomy and grafting with or without anterior osteosynthesis in 6 cases of malunion, for cage implantation or isolated grafting in ¶10 cases of degenerative disc disease, and for the treatment of 4 cases of spondylodiscitis. Results were satisfactory for every type of pathology. The complications related to the approach were the same as those seen with open surgery; however, the videoscopic approach seems to us less invasive, with cosmetic benefit, less blood loss, and more rapid recovery. A video-assisted technique appears to be a good compromise between videoscopic technique and open surgery. With the development of these techniques, few indications remain for open anterior surgery on the lumbar spine in our opinion.

New possibilities in L2–L5 lumbar arthrodesis using a lateral retroperitoneal approach assisted by laparoscopy: preliminary results

Four patients underwent lumbar interbody fusion, performed via a video-assisted retroperitoneal laparoscopic approach, complementary to posterior osteosynthesis at the L2–L3, L3–L4 and/or L4–L5 level. In three cases the interventions were for lumbar fractures, and in one case for microcristalline arthritis. After surgical training on human cadavers and several porcine operative sessions, retroperitoneal lateral approaches on the left side were performed by the authors without CO2 insufflation, assisted by videoscopy. The fusion process was monitored by fluoroscopy. It is possible to perform this technique cranially above L2 or caudally below L5. Minimal blood loss was observed. Average time for these interventions was 127 min. Interbody fusion was achieved in the first, second and fourth cases; the outcome in the third case at the final check-up, 6 months after operation, was uncertain. The first patients had a complication of ureteral wound, which was certainly caused by insufficient experience with the new technique. The authors hope to extend the application of this technique to other procedures as they become more experienced.

Vidéo-discectomie lombaire. Résultats d'une série prospective continue.

PURPOSE OF THE STUDY We report results obtained in a prospective consecutive cohort of patients undergoing videoscopy-guided discectomy using the Destandau technique. MATERIAL AND METHODS Between June 1998 and August 2000, 40 patients underwent videoscopy-guided discectomy. There were 24 males and 16 females, mean age 43 years (24-78 years). Eleven patients had associated lumbar stenosis. Outcome was reviewed by an independent investigator. Mean follow-up was 19 months (12-67). RESULTS One patient required reoperation to establish proof of infection. Three patients required revision for open extended decompression which did not reveal any case of remaining hernia fragment or postoperative hematoma. All three of these patients had lumbar stenosis. At last follow-up 36 patients had not required revision surgery. Mean hospital stay was 3.3 days. The Waddel score was excellent or good for 91% of patients and the Prolo score was excellent or good for 84%. Mean improvement compared with the preoperative status was 65%, as assessed by the Oswestry score. DISCUSSION AND CONCLUSIONS Lumbar videodiscectomy provides satisfactory functional results equivalent to those of microdiscectomy. The advantages of this technique are the precise control of the operation and the good hemostasis made possible by the optical magnification. Low cost is another advantage since the procedure only requires a standard arthroscopic column and standard spinal surgery instruments. Associated stenosis is a relative contraindication for this minimally invasive technique.Resume Le but de cette etude prospective continue etait d’evaluer les resultats de la cure de hernie discale lombaire sous controle videoscopique selon la technique de Destandau. Quarante patients ont ete operes selon cette technique sur une periode allant de juin 1998 a aout 2000. Il s’agissait de 24 hommes et de 16 femmes, d’âge moyen 43 ans (extremes : 24 et 78 ans). Onze patients presentaient une stenose associee du canal rachidien. Tous les patients ont ete suivis et revus en consultation par un examinateur different de l’operateur. Le recul moyen etait de 19 mois (extremes : 12 et 27 mois). Un patient a ete repris pour infection profonde. Trois patients ont ete reoperes d’une decompression elargie, sans recidive ou hematome retrouve. Ces 3 patients presentaient tous un canal lombaire etroit associe. Les resultats fonctionnels ont ete evalues sur les 36 patients non reoperes. La duree moyenne d’hospitalisation etait de 3,3 jours (2 a 5 jours). Quatre-vingt-onze pour cent des patients presentaient un bon et tres bon resultat selon le score de Waddell, et 84 % selon le score de Prolo. Le score d’Oswestry a montre en moyenne 65 % d’amelioration. Une correlation significative a ete trouvee entre la frequence des reprises chirurgicales et la presence d’un canal lombaire etroit. L’accident du travail et la fragilite psychologique des patients ont ete pejoratifs pour les resultats. La video-discectomie lombaire donne des resultats fonctionnels satisfaisants, equivalents a ceux de la microdiscectomie. Les avantages de cette technique sont le controle precis du geste operatoire et de l’hemostase, permis par le grossissement optique de l’image. Un second avantage est le faible cout du fait de l’utilisation d’une colonne d’arthroscopie standard et d’instruments classiques de chirurgie rachidienne. L’association d’un canal lombaire etroit constitue une contre-indication relative a cette technique « mini-invasive ».