Fractured cervical spine, dissected vertebral artery, and life-threatening stroke: A challenging case report and literature review

INTRODUCTION

Vertebral artery injury (VAI) following blunt trauma can lead to acute or delayed life-threatening posterior fossa ischemic stroke. Its management raises controversial issues and is still open to debate.

MATERIAL & METHOD

We report the case of a 48-year-old male who presented a life-threatening posterior circulation ischemic stroke, secondary to a vertebral artery dissection caused by a cervical spine fracture. This case was successfully managed through intravenous thrombolysis and endovascular thrombectomy followed by antiplatelet therapy and an anterior cervical discectomy and fusion. At the one-year follow-up, the patient had no persisting deficit and was back working as a policeman.

CONCLUSION

Rapid management of patients with dramatic clinical presentation can lead to full recovery. Implications include a systematic screening of blunt trauma VAI through computed tomography angiography when dealing with high-risk cervical spine fractures; patients harboring both a cervical spine fracture and a VAI must be transferred to a tertiary referral hospital able to deal both with strokes and cervical spine surgery to ensure responsiveness in case of stroke.

Primary intradural Extraosseous Ewing's sarcoma of the cauda equina: a Case Report and Literature Review

Intradural Extraosseous Ewing sarcoma (IEES) is an infrequent occurrence. We report a case of a 66-year-old male who presented with a 2-month history of low back pain and bilateral S1 sciatica, with acute sphincter dysfunction. Imaging studies revealed an intradural extramedullary lesion in the cauda equina spanning from level L4 to S1. The patient underwent partial removal of the intradural lesion. Histopathological examination showed the presence of small round cells, which were consistent with Ewing Sarcoma. The patient was then treated with targeted radiation therapy and chemotherapy. The rarity of IEES in this specific location underscores the significance of evaluating and managing patients with intradural spinal tumors with careful consideration of this diagnosis. To further investigate this condition, we conducted a thorough review of the literature on IEES involving the lumbar spine and cauda equina. Our analysis revealed that patients with this condition frequently exhibit rapidly progressive neurological symptoms likely attributed to hemorrhagic transformation. This characteristic may serve as a distinguishing factor from other lesion types, particularly benign ones. Our study provides a comprehensive summary that can offer direction for clinical management in comparable uncommon and novel cases.

Cirq® robotic assistance for percutaneous kyphoplasty of C1: report on feasibility

BACKGROUND

To report the feasibility and safety of C1 kyphoplasty using the Cirq® robotic assistance coupled to the AIRO® intraoperative computed tomography (iCT)-scan and BrainLab® navigation system.

METHODS

A 47-year-old woman with C1 osteolytic lesion responsible of intractable left-sided suboccipital pain was admitted. She underwent a percutaneous kyphoplasty of left lateral mass of C1 using Cirq® robotic assistance. She reported postoperative substantial pain relief. CT scan showed adequate filling of the osteolytic lesion without obvious leakage of cement.

CONCLUSION

Percutaneous kyphoplasty of C1 using Cirq® robotic assistance is a safe and effective alternative in selected patients with C1 lateral mass metastasis.

Anterolateral versus posterior minimally invasive lumbar interbody fusion surgery for spondylolisthesis: comparison of outcomes from a global, multicenter study at 12-months follow-up

BACKGROUND CONTEXT

Several minimally invasive lumbar interbody fusion techniques may be used as a treatment for spondylolisthesis to alleviate back and leg pain, improve function and provide stability to the spine. Surgeons may choose an anterolateral or posterior approach for the surgery however, there remains a lack of real-world evidence from comparative, prospective studies on effectiveness and safety with relatively large, geographically diverse samples and involving multiple surgical approaches.

PURPOSE

To test the hypothesis that anterolateral and posterior minimally invasive approaches are equally effective in treating patients with spondylolisthesis affecting one or two segments at 3-months follow-up and to report and compare patient reported outcomes and safety profiles between patients at 12-months post-surgery.

DESIGN

Prospective, multicenter, international, observational cohort study.

PATIENT SAMPLE

Patients with degenerative or isthmic spondylolisthesis who underwent 1- or 2-level minimally invasive lumbar interbody fusion.

OUTCOME MEASURES

Patient reported outcomes assessing disability (ODI), back pain (VAS), leg pain (VAS) and quality of life (EuroQol 5D-3L) at 4-weeks, 3-months and 12-months follow-up; adverse events up to 12-months; and fusion status at 12-months post-surgery using X-ray and/or CT-scan. The primary study outcome is improvement in ODI score at 3-months.

METHODS

Eligible patients from 26 sites across Europe, Latin America and Asia were consecutively enrolled. Surgeons with experience in minimally invasive lumbar interbody fusion procedures used, according to clinical judgement, either an anterolateral (ie, ALIF, DLIF, OLIF) or posterior (MIDLF, PLIF, TLIF) approach. Mean improvement in disability (ODI) was compared between groups using ANCOVA with baseline ODI score used as a covariate. Paired t-tests were used to examine change from baseline in PRO for both surgical approaches at each timepoint after surgery. A secondary ANCOVA using a propensity score as a covariate was used to test the robustness of conclusions drawn from the between group comparison.

RESULTS

Participants receiving an anterolateral approach (n=114) compared to those receiving a posterior approach (n=112) were younger (56.9 vs 62.0 years, p <.001), more likely to be employed (49.1% vs 25.0%, p<.001), have isthmic spondylolisthesis (38.6% vs 16.1%, p<.001) and less likely to only have central or lateral recess stenosis (44.9% vs 68.4%, p=.004). There were no statistically significant differences between the groups for gender, BMI, tobacco use, duration of conservative care, grade of spondylolisthesis, or the presence of stenosis. At 3-months follow-up there was no difference in the amount of improvement in ODI between the anterolateral and posterior groups (23.2 ± 21.3 vs 25.8 ± 19.5, p=.521). There were no clinically meaningful differences between the groups on mean improvement for back- and leg-pain, disability, or quality of life until the 12-months follow-up. Fusion rates of those assessed (n=158; 70% of the sample), were equivalent between groups (anterolateral, 72/88 [81.8%] fused vs posterior, 61/70 [87.1%] fused; p=.390).

CONCLUSIONS

Patients with degenerative lumbar disease and spondylolisthesis who underwent minimally invasive lumbar interbody fusion presented statistically significant and clinically meaningful improvements from baseline up to 12-months follow-up. There were no clinically relevant differences between patients operated on using an anterolateral or posterior approach.

Management of Spinal Metastasis by Minimally Invasive Surgical Techniques: Surgical Principles and Indications-A Literature Review

BACKGROUND

Spinal metastasis is becoming more frequent. This raises the topics of pain and neurological complications, which worsen the functional and survival prognosis of oncological population patients. Surgical treatment must be as complete as possible in order to decompress and stabilize without delaying the management of the oncological disease. Minimally invasive spine surgical techniques inflict less damage on the musculocutaneous plan than opened ones.

METHODS

Different minimally invasive techniques are proposed in this paper for the management of spinal metastasis. We used our experience, developed degenerative and traumatic pathologies, and referred to many authors, establishing a narrative review of our local practice.

RESULTS

Forty-eight articles were selected, and these allowed us to describe the different techniques: percutaneous methods such as vertebro/kyphoplasty, osteosynthesis, mini-open surgery, or that through a posterior or anterior approach. Also, some studies detail the contribution of new technologies, such as intraoperative CT scan and robotic assistance.

CONCLUSIONS

It seems essential to offer a lasting solution to a spinal problem, such as in the form of pain relief, stabilization, and decompression. Our department has embraced a multidisciplinary and multidimensional approach to MISS, incorporating cutting-edge technologies and evidence-based practices.

Factors influencing complications after 3-columns spinal osteotomies for fixed sagittal imbalance from multiple etiologies: a multicentric cohort study about 286 cases in 273 patients

PURPOSE

Spinal osteotomies performed to treat fixed spinal deformities are technically demanding and associated with a high complications rate. The main purpose of this study was to analyze complications and their risk factors in spinal osteotomies performed for fixed sagittal imbalance from multiple etiologies.

METHODS

The study consisted of a blinded retrospective analysis of prospectively collected data from a large multicenter cohort of patients who underwent 3-columns (3C) spinal osteotomy, between January 2010 and January 2017. Clinical and radiological data were compared pre- and post-operatively. Complications and their risk factors were analyzed.

RESULTS

Two hundred eighty-six 3C osteotomies were performed in 273 patients. At 1 year follow-up, both clinical (VAS pain, ODI and SRS-22 scores) and radiological (SVA, SSA, loss of lordosis and pelvic version) parameters were significantly improved (p < 0.001). A total of 164 patients (59.2%) experienced at least 1 complication (277 complications). Complications-free survival rates were only 30% at 5 years. Most of those were mechanical (35.2%), followed by general (17.6%), surgical site infection (17.2%) and neurological (10.9%). Pre-operative neurological status [RR = 2.3 (1.32-4.00)], operative time (+ 19% of risk each additional hour) and combined surgery [RR = 1.76 (1.08-2.04)] were assessed as risk factors for overall complication (p < 0.05). The use of patient-specific rods appeared to be significantly associated with less overall complications [RR = 0.5 (0.29-0.89)] (p = 0.02).

CONCLUSION

Spinal 3C osteotomies were efficient to improve both clinical and radiological parameters despite high rates of complication. Efforts should be made to reduce operative time which appears to be the strongest predictive risk factor for complication.

Synthesis, Characterization and Optical Properties of ZnO Nanoparticles Doped with Er and Yb

This paper discusses the structure, particle morphology, and optical properties of un-doped ZnO and ZnO doped with Er³⁺ and Yb³⁺ lanthanide ion nanoparticles (NPs) through a process denominated sol-gel-hydrothermal. According to the pattern of X-ray diffraction, ZnO:Er and ZnO:Yb is formed by a single-phase wurtzite structure with crystallites sized ~65 nm on average, and Er or Yb dopant ions in the hexagonal structure of ZnO, specifically in its distorted lattice sites. The results also suggest the possible role of oxygen vacancies or O^x- (defects) in the energy transfer from ZnO to the Er or Yb ions with a decrease of 3.18 eV and 3.19 eV in bandgap values to a red shift.

Surgery for spinal deformity in Parkinson's disease patients: What are we missing?

INTRODUCTION

Deformity associating coronal and sagittal malalignment can severely impair quality of life in Parkinson's disease (PD). Realignment using patient-specific rods (PSRs) is useful for achieving alignment goals.

METHODS

This was a retrospective single-center analysis of a prospectively maintained database of all PD patients who underwent surgery between January 2013 and January 2017. Clinical evaluation, preoperatively and at 1 year's follow-up, used the Oswestry Disability Index (ODI). Radiological evaluation used systematic preoperative and 1-year postoperative full-spine radiographs.

RESULTS

Twelve patients were included: 6 female, 6 male; mean age, 68.4 years. Mean follow-up was 40.8 months [range 12-70]. On average, 14 levels were fused [range 10-18]. Unplanned revision surgery was necessary for 8 patients at a mean 15.625 months after index surgery. Mean preoperative ODI score was 64% preoperatively [range 56-70] versus 52% [range 28-64] at 1 year's follow-up (P=0.004). Lumbar lordosis improved significantly, from -16.7° preoperatively to -41.4° at 1 year (P=0.006). Pelvic tilt was the least effectively corrected parameter, with a mean preoperative value of 31.6° vs. 27.8° at 1 year (P=0.19). Mean preoperative sagittal vertical axis was 149.7mm versus 73.6mm at 1 year (P=0.013). Mean preoperative coronal tilt was 68.2mm versus 22.9mm at 1 year (P=0.007).

CONCLUSION

Parkinson's disease is a degenerative disease frequently associated with major spine malalignment. The severity of the postural disorders in these patients needs special precautions to avoid complications.

Meningoencephalitis with refractory intracranial hypertension : Consider Decompressive craniectomy

BACKGROUND

The benefits of decompressive craniectomy (DC) have been demonstrated in malignant ischemic stroke and traumatic brain injuries with refractory intracranial hypertension (ICH) by randomized controlled trials. Some reports advocate the potential of DC in the context of ICH due to meningoencephalitis (ME) with focal cerebral edema but its interest remains controversial especially when there is diffuse cerebral edema. The aim of this study is to assess the benefits of DC in meningoencephalitis with malignant cerebral edema whether it is focal or diffuse.

METHODS

We report two cases successfully treated in our instution, plus we conducted a systematic literature review focused on cases of DC in ME in compliance with prisma guidelines.

RESULTS

the first patient is a 36-years-old woman who suffered from fulminant pneumococcal meningoencephalitis (ME) with refractory ICH following a transphenoidal removal of pituitary adenoma. The second patient is a 20-years-old man suffering from neuromeningeal cryptococcosis with refractory ICH. In both cases DC led to major clinical improvement with a GOS-E 8 at one year. These results are consistent with the literature review which reports a favorable outcome in 85% of cases.

CONCLUSIONS

DC appears to be a promising therapeutic option in cases of ME with refractory ICH. Thus, reliable criteria will have to be defined to guide us in our practice in emergency cases where DC has not been part of the therapeutic arsenal yet.

High level of HIV drug resistance informs dolutegravir roll-out and optimized NRTI backbone strategy in Mozambique

Background

HIV drug resistance (HIV-DR) is rising in sub-Saharan Africa in both ART-naive and ART-experienced patients.

Objectives

To estimate the level of acquired DR (ADR) and pre-treatment DR (PDR) across selected urban and rural sites in Southern Africa, in Mozambique.

Methods

We conducted two cross-sectional surveys among adult HIV patients (October 2017–18) assessing ADR and PDR. In the (ADR) survey, those on NNRTI-based first-line ART for ≥6 months were recruited (three sites). In the PDR survey, those ART-naive or experienced with ≥3 months of treatment interruption prior were enrolled (eight sites).

Results

Among 1113 ADR survey participants 83% were receiving tenofovir (TDF)/lamivudine (3TC)/efavirenz (EFV). The median time on ART was 4.5 years (Maputo) and 3.2 years (Tete), 8.3% (95% CI 6.2%-10.6%, Maputo) and 15.5% (Tete) had a VL ≥ 1000 copies/mL, among whom 66% and 76.4% had NNRTI+NRTI resistance, and 52.8% and 66.7% had 3TC+TDF-DR. Among those on TDF regimens, 31.1% (Maputo) and 42.2% (Tete) were still TDF susceptible, whereas 24.4% and 11.5% had TDF+zidovudine (ZDV)-DR. Among those on ZDV regimens, 25% and 54.5% had TDF+ZDV-DR. The PDR survey included 735 participants: NNRTI-PDR was 16.8% (12.0–22.6) (Maputo) and 31.2% (26.2–36.6) (Tete), with a higher proportion (≥50%) among those previously on ART affected by PDR.

Conclusions

In Mozambique, viral failure was driven by NNRTI and NRTI resistance, with NRTI DR affecting backbone options. NNRTI-PDR levels surpassed the WHO 10% ‘alert’ threshold. Replacing NNRTI first-line drugs is urgent, as is frequent viral load monitoring and resistance surveillance. Changing NRTI backbones when switching to second-line regimens may need reconsideration.

Meningiomas in patients with long-term exposition to progestins: Characteristics and outcome

OBJECTIVE

The aim of this study was to describe progestin-associated meningiomas' characteristics, outcome and management.

MATERIAL AND METHODS

We included 53 patients operated on and/or followed in the department for meningioma with progestin intake longer than one year and with recent drug discontinuation.

RESULTS

Cyproterone acetate (CPA), nomegestrol acetate (NomA), and chlormadinone acetate (ChlA) were involved in most cases. Mean duration of progestin drugs intake was 17.5 years. Tumors were multiple in 66% of cases and were located in the anterior and the medial skull base in 71% of cases. Transitional subtype represented 16/25 tumors; 19 meningiomas were WHO grade I and 6 were grade II. The rate of transitional subtype and skull base location was significantly higher compared to matched operated meningioma general population. No difference was observed given WHO classification. But Ki67 proliferation index tends to be lower and 5/6 of the WHO grade II meningiomas were classified as WHO grade II because of brain invasion. Strong progesterone receptors expression was observed in most cases. After progestin discontinuation, a spontaneous visual recovery was observed in 6/10 patients. Under CPA (n=24) and ChlA/NomA (n=11), tumor volume decreased in 71% and 18% of patients, was stabilized in 25% and 64% of patients, and increased in 4% and 18% of patients, respectively. Volume outcome was related to meningioma location.

CONCLUSIONS

Outcome at progestins discontinuation is favorable but different comparing CPA versus ChlA-NomA and comparing tumor location. Long-term follow-up is required. In most cases, simple observation is recommended and surgery should be avoided.

Nocardia farcinica cerebral abscess: A systematic review of treatment strategies

PURPOSE

Nocardia farcinica is an opportunistic pathogen causing mainly pneumonia in immunocompromised patients, complicated in almost one-third of the cases by a thick-walled multiloculated cerebral abscess which induces significant morbidity and mortality. This review aims to assess the optimal treatment strategy for N. farcinica cerebral abscess.

METHODS

Report of a case. Medline database was used to conduct a systematic review from inception to January 2020 looking for English-language articles focused on N. farcinica cerebral abscess, in accordance with the PRISMA guidelines.

RESULTS

The research yielded 54 articles for a total of 58 patients. N. farcinica cerebral abscess displayed three different neuroimaging patterns: a single multiloculated abscess in half of the cases, multiple cerebral abscesses, or a small paraventricular abscess with meningitis. The patients who benefited from surgical excision of the abscess showed a trend towards a lower risk of surgical revision (8% versus 31%, P=0.06) and a lower mortality rate (8% versus 23%, P=0.18) than patients who benefited from needle aspiration. Twenty-two percent of the patients benefited from microbiological documentation from another site with a mortality rate of 23%.

CONCLUSION

Urgent multimodal MRI is necessary in face with clinical suspicion of cerebral nocardiosis. In case of single or multiple small cerebral abscesses, microbiological documentation can be obtained with puncture of pseudotumoral visceral lesions. In case of large or symptomatic cerebral abscess, an aggressive surgical excision seems a reliable option and can be preferred over needle aspiration. Long-term antibiotic therapy with cotrimoxazole is necessary thereafter.

Robotic Assistance for Minimally Invasive Cervical Pedicle Instrumentation: Report on Feasibility and Safety

BACKGROUND

Accurate screw placement remains challenging, especially in the cervical spine. We present our first experience of minimally invasive posterior cervical and upper thoracic pedicle screw fixation in the lower cervical spine.

METHODS

This study reports a case series of patients, undergoing posterior percutaneous pedicle fixation using Cirq robotic assistance coupled to the Airo intraoperative computed tomography scan and Brainlab navigation system. Routine computed tomography was performed on postoperative day 2 to evaluate pedicle screw placement. The effective dose was calculated.

RESULTS

Between February 2020 and December 2020, 7 patients (4 men and 3 women) were treated. The mean age was 58.8 years (range, 29-75 years). Fixation was performed with a cannulated PASS OCT Reconstruction System (Medicrea). Overall, 28 screws were placed within cervical and upper thoracic pedicles. According to the Neo and Heary classification, 85.7% were rated as acceptable and 14.3% as poor. The radiation dose received by the patient was 9.1 mSv (range, 7.7-10.6 mSv). The radiation dose received by the surgical staff was 0 mSv. The postoperative course was excellent.

CONCLUSIONS

Posterior miniopen fixation using Cirq robotic assistance coupled with an intraoperative computed tomography navigation system is a major innovation that can improve the accuracy of pedicle screw positioning, with acceptable patient radiation and reduced surgical team exposure.

PICA injury secondary to anterior odontoid screw fixation: Case report of an exceptional complication

BACKGROUND

Odontoid fracture is a common injury in the upper cervical spine that can sometimes be managed by anterior odontoid screw fixation.

CASE DESCRIPTION

We report the first case of iatrogenic postero-inferior cerebellar artery (PICA) injury while performing anterior odontoid screw fixation for a type II odontoid fracture in a 22-year-old man. Fisher grade 4 subarachnoid hemorrhage secondary to iatrogenic pseudoaneurysm formation was managed by the endovascular neuroradiologist. Odontoid fracture was then managed posteriorly using Harm's technique. Postoperative 12-month follow-up revealed good clinical and radiological results. CT scan showed fusion. Complete exclusion of the pseudo aneurysm with a mild stroke in the inferior left cerebellar hemisphere were noted on the MRI. There were no cerebellar ataxia or swallowing disorders.

CONCLUSION

To the best of our knowledge, this is the first case report of iatrogenic PICA injury in anterior odontoid screw fixation. The patient was well managed in our institution within a multidisciplinary team. We recommend that surgical management of odontoid fractures should be performed in expert centres.

Post-operative complications in cranial and spine neurosurgery: a prospective observational study

BACKGROUND

Post-operative complications do occur in all neurosurgical departments, but the way they are defined, and their true incidence vary a lot. The aim of the present study is to objectively assess the morbidity and mortality related to all neurosurgical procedures performed in our department and provide insight on their main causes and identify key factors to reduce their incidence.

METHODS

Data were retrieved from a prospectively-maintained database regarding all patients undergoing a cranial or spinal neurosurgical procedure between November 2016 and April 2016 in the neurosurgical department in Timone University Hospital (APHMMarseille). Patients undergoing a functional, pediatric or interventional neuroradiological procedures were not included.

RESULTS

The medical records of a total number of 963 patients were analyzed. A postoperative complication occurred in 208 patients (21.6%) including 115 (26.6%) in the cranial surgery group and 93 (17.5%) in the spinal surgery group. A complication occurred 1.5 more frequently in the cranial than in the spinal surgery group. Cranial surgery is 1.5 times more at risk of complications than spinal surgery (p=0.007). Preoperative comorbidities (ASA score > 3 to 4) were significantly associated with the occurrence of complications (p<.001). In the cranial group, procedures performed in an emergency setting were 1.8 times more at risk of complications than scheduled surgeries (p<.001). Conversely, in the spine group, scheduled surgeries were 1.4 times less at risk than emergency procedures (p=0.04). The main complication in both groups was found to be post-operative infection, with an incidence of 9.3% and 11.1% for cranial and spinal surgery respectively. Post-operative mortality reached 4.9% and 1.7% and the average length of stay was 12 and 11 days respectively.

CONCLUSIONS

The incidence of complication in our series was found to be relatively high with predominantly infection as the main cause of postoperative complications. Reinforcing good practice measures at every step should help to significantly decrease our complication rate.

C1-C2 Injury: Factors influencing mortality, outcome, and fracture healing

BACKGROUND

C1-C2 injury represents 25-40% of cervical injuries and predominantly occurs in the geriatric population.

METHODS

A prospective multicentre study was conducted under the aegis of the french spine surgery society (SFCR) investigating the impact of age, comorbidities, lesion type, and treatment option on mortality, complications, and fusion rates.

RESULTS

A total of 417 patients were recruited from 11 participating centres. The mean ± SD age was 66.6 ± 22 years, and there were 228 men (55%); 5.4% presented a neurological deficit at initial presentation. The most frequent traumatic lesion was C2 fracture (n = 308). Overall mortality was 8.4%; it was 2.3% among those aged ≤ 60 years, 5.0% 61-80 years, and 16.0% > 80 years (p < 0.001). Regarding complications, 17.8% of patients ≤ 70 years of age presented with ≥ 1 complication versus 32.3% > 70 years (p = 0.0009). The type of fracture did not condition the onset of complications and/or mortality (p > 0.05). The presence of a comorbidity was associated with a risk factor for both death (p = 0.0001) and general complication (p = 0.008). Age and comorbidities were found to be independently associated with death (p < 0.005). The frequency of pseudoarthrosis ranged from 0 to 12.5% up to 70 years of age and then constantly and progressively increased to reach 58.6% after 90 years of age.

CONCLUSIONS

C1-C2 injury represents a serious concern, possibly life-threatening, especially in the elderly. We found a major impact of age and comorbidities on mortality, complications, and pseudarthrosis; injury pattern or treatment option seem to have a minimal effect.

Transfalcine approach for the resection of a bilateral falx meningioma: Technical nuances and review of literature

The tendency to reduce invasive surgeries is gaining more adepts, and the primary goal in meningioma surgery is the maximal safe resection. Falx meningioma is common location for intracranial meningioma, and according to their deep localization, falx meningioma represents a neurosurgical challenge. The objective of the study is to report the feasibility of a transfalcine nontumor dominant side approach for a bilateral falx meningioma. We report a technical note about the surgical approach of a 44-year-old female suffering from an evolutive meningioma of the middle third of the falx. According to the venous drainage anatomy, and the tumor conformation, a contralateral transfalcine approach was done. We described with details this surgical approach, and a reflection about transfalcine approach is proposed, which is a variant of the interhemispheric approach. It permits a good exposure of the medial surface of the contralateral hemisphere thanks to a falx incision. Moreover, a literature review is proposed about 278 articles with a special emphasis on transfalcine approach in meningioma surgery. We report an original minimal invasive approach for an intracranial meningioma, with a complete resection (Simpson I) without any technical complication. This contralateral transfalcine approach brings new technical nuances for the resection of falx or midline intracranial tumors.

Cirq® Robotic Assistance for Minimally Invasive C1-C2 Posterior Instrumentation: Report on Feasibility and Safety

BACKGROUND

Accurate screw placement remains very challenging especially in the upper cervical spine.

OBJECTIVE

To present our first experience of a percutaneous posterior C1-C2 fixation for a traumatic fracture.

METHODS

This is a case report of a non-neurological patient, harboring a type II odontoid fracture. She underwent a posterior percutaneous fixation using Cirq® Robotic Assistance coupled to the AIRO® intraoperative computed tomography (iCT)-scan and BrainLab® navigation system (all by BrainLab AG). Routine CT was performed on postoperative day 2 to evaluate pedicle screw placement. The effective dose was calculated.

RESULTS

The C1-C2 posterior percutaneous fixation was performed with cannulated VERTEX® Reconstruction System (Medtronic). Overall, 4 screws were placed. All of them were rated as acceptable (100%). Radiation dose received by the patient was 4.13 mSv. Radiation dose received by the surgical staff was 0 mSv. Postoperative course was excellent.

CONCLUSION

Posterior percutaneous fixation using Cirq® Robotic Assistance coupled with iCT navigation system is a major innovation that can improve pedicle screw positioning's accuracy with acceptable patient radiation and reduced surgical team exposure.

Surgical site infection following surgery for spinal deformity: About 102 patients

INTRODUCTION

Complex spinal surgery is known to be at risk of complications. Surgical site infection is a serious complication in spine surgery and its frequency is significantly increased in adult spinal deformity correction. The aim of this study is to identify patients' characteristics and risk factors of surgical site infection (SSI) following an osteotomy.

METHODS

This is a single-center retrospective study of patients who underwent an osteotomy between January 2015 and December 2017. Surgical site infection diagnosis was based upon patient's clinical evidence of infection, biologic parameters, microbiological criteria and/or image findings.

RESULTS

In total, 102 patients were eligible and 70 were women (68.6%). Mean age was 65 years old (27-83 years) and mean body mass index (BMI) was 26.14kg.m^-2 (18.4-44.1). Eleven patients were in the SSI group and 91 in the No-SSI group. The mean Schwab grade was 1.5 (1-4) in the SSI group vs. 1.4 (1-5) in the No-SSI group (P=0.435). The mean operative time was on 201.9 minutes (67-377). Mean length of stay was 20.6 days (10-73) in the SSI group vs. 15 days (5-44) in the No-SSI group (P=0.041). Favorable outcome was found in 10 patients (90.9%) in the SSI group.

CONCLUSION

Correction surgery for adult spinal deformity with osteotomies carries a high risk of complications specially SSI. Identification of risk factors, prevention and medical management of SSI should be well assessed.

Use of artificial intelligence to estimate population health indicators in France

Background

The use of artificial intelligence is increasing to estimate and predict health outcomes from large data sets. The main objectives were to develop two algorithms using machine learning techniques to identify new cases of diabetes (case study I) and to classify type 1 and type 2 (case study II) in France.

Methods

We selected the training data set from a cohort study linked with French national Health database (i.e., SNDS). Two final datasets were used to achieve each objective. A supervised machine learning method including eight following steps was developed: the selection of the data set, case definition, coding and standardization of variables, split data into training and test data sets, variable selection, training, validation and selection of the model. We planned to apply the trained models on the SNDS to estimate the incidence of diabetes and the prevalence of type 1/2 diabetes.

Results

For the case study I, 23/3468 and for case study II, 14/3481 SNDS variables were selected based on an optimal balance between variance explained and using the ReliefExp algorithm. We trained four models using different classification algorithms on the training data set. The Linear Discriminant Analysis model performed best in both case studies. The models were assessed on the test datasets and achieved a specificity of 67% and a sensitivity of 62% in case study I, and a specificity of 97 % and sensitivity of 100% in case study II. The case study II model was applied to the SNDS and estimated the prevalence of type 1 diabetes in 2016 in France of 0.3% and for type 2, 4.4%. The case study model I was not applied to the SNDS.

Conclusions

The case study II model to estimate the prevalence of type 1/2 diabetes has good performance and will be used in routine surveillance. The case study I model to identify new cases of diabetes showed a poor performance due to missing necessary information on determinants of diabetes and will need to be improved for further research.

The interest of intraoperative scanner coupled to neuronavigation in traumatic or oncologic fractures of the cervical and upper thoracic spine requiring vertebral body height restoring procedures

OBJECT

In recent years, the classical vertebroplasty has tended to be replaced by vertebral augmentation procedures. This article discusses the reliability of vertebral augmentation procedures using balloon kyphoplasty or a spine jack system, with intraoperative CT scan control coupled with the neuronavigation system as a treatment option for cervical and upper thoracic spine lesions.

METHODS

In our neurosurgical department, in the past two years, 11 patients underwent either a kyphoplasty or a vertebral augmentation by a Spine Jack via a transpedicular route, under perioperative 3D imaging, for a total of 15 cervical/upper thoracic lesions. For these patients, we evaluated the clinical symptoms before and after surgery, the intraoperative and postoperative complications as well as the radiation exposure and the duration of their hospitalisation.

RESULTS

We noted for all of the patients an improvement of the mean Karnofsky index, which improved from 50 to 80, and of the VAS that decreased from a mean of 75 to 15, as they were clearly alleviated after the operation. The radiation was lower for patients that were treated for 2 or more vertebrae, and much lower for the medical staff. The intraoperative complications rate (4 cement leakages for 15 vertebrae, 26%), was low and completely asymptomatic in all cases. The radiological follow-up examinations were satisfactory for all the patients.

CONCLUSIONS

Our results suggest that percutaneous transpedicular vertebral augmentation techniques using intraoperative CT scan are a viable treatment for secondary lesions or traumatic compression fractures of the cervical and upper thoracic spine.

French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury

OBJECTIVES

To update the French guidelines on the management of trauma patients with spinal cord injury or suspected spinal cord injury.

DESIGN

A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

The committee studied twelve questions: (1) What are the indications and arrangements for spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few days in hospital? (4) What is the best way to manage these patients to improve their long-term prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® Methodology.

RESULTS

The experts' work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/-) and 12 have a low level of evidence (GRADE 2+/-). For 5 recommendations, the GRADE method could not be applied, resulting in expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations.

CONCLUSIONS

There was significant agreement among experts on strong recommendations to improve practices for the management of patients with spinal cord injury.

Is the type 2 diabetes epidemic plateauing in France? A nationwide population-based study

AIM

Nationwide data on the evolution of diabetes incidence and prevalence are scarce in France. For this reason, our objectives were to determine type 2 diabetes prevalence and incidence rates between 2010 and 2017, stratified by gender, age and region, and to assess annual time trends over the study period in adults aged≥45 years.

METHODS

Diabetes cases in the National Health Data System (SNDS), which covers the entire French population (66 million people), were identified through a validated algorithm. Gender- and age-specific prevalence and incidence rates were estimated. Negative binomial models, adjusted for gender, age and region, were used to assess annual time trends for prevalence and incidence throughout the study period.

RESULTS

During 2017, 3,144,225 diabetes cases aged≥45 years were identified. Over the study period, prevalence increased slightly (men from 11.5% to 12.1%, women from 7.9% to 8.4%) whereas incidence decreased (men from 11 to 9.7, women from 7.2 to 6.2 per 1000 person-years). In only four groups did prevalence rates decrease: men aged 45-65 years; women aged 45-60 years; women in Reunion; and women in Martinique. An increasing annual time trend was observed for prevalence (men: +0.9% [95% CI: +0.7%, +1%]; women: +0.4% [95% CI: +0.2%, +0.6%]) with a decreasing annual time trend for incidence in both genders (men: -2.6% [95% CI: -3.1%, -2.0%]; women: -3.9% [95% CI: -4.5%, -3.4%]).

CONCLUSION

Further efforts towards diabetes prevention are required to ensure that incidence rates in France continue to diminish, as the disorder continues to represent an important public-health burden.

Minimally invasive posterior fixation and anterior debridement-fusion for thoracolumbar spondylodiscitis: A 40-case series and review of the literature

INTRODUCTION

Pyogenic spondylodiscitis is a rare disease, but incidence is increasing. Reported failure rates following conservative management range from 12% to 18%. The purpose of this study was to determine the safety and efficacy of posterior percutaneous pedicle screw fixation combined with anterior debridement and fusion (ADF) for infective spondylodiscitis in the thoracic and/or lumbar spine.

METHODS

The retrospective study cohort comprised all patients without neurological deficit who underwent minimally invasive posterior and anterior surgery between April 2008 and April 2016 for thoracic and/or lumbar spondylodiscitis.

RESULTS

Forty patients were eligible (16 female: 40%). The lumbar region was affected in 31 cases (77.5%). Source of infection was identified in only 22 cases (55%) and bacteriological identification was obtained in 32 cases (80%). Mean hospital stay was 14.8 days (range, 6-39 days). Complete recovery was achieved in 39 patients (97.5%) at 3 months' follow-up. Mean preoperative local kyphosis angle was 16.1^o, versus 14^o at 1-year (P>0.05). 36 patients (90%) had at least 1 year's follow-up, and fusion was obtained for all these cases.

CONCLUSION

Two-stage minimally invasive surgery is effective and safe for the treatment of single or two-level thoracolumbar spondylodiscitis. It could be an alternative to conventional open surgery or conservative treatment.

Correction to: Outcomes of surgical treatments of spinal metastases: a prospective study

The correct name of F. Saihlan should be F. Sailhan.

Effect on the Chemical, Structural and Magnetic Characteristics on Fe-Doped SrTiO³

SrTiO³ nanopowders doped with various percentages of Fe (0, 1, 3, and 5 mol%) was synthesized, determining its chemical and structural properties using X-ray diffraction and X-ray photoelectron spectroscopy. The magnetic properties of the samples were studied using hysteresis curves obtained by an alternating gradient magnetometer. Theoretical calculations within the framework of the density functional theory are also performed to support experimental data. The results indicated that Fe incorporated into de SrTiO³ structure induced intrinsic magnetic properties, which increase as the Fe percentage increase. At 5 mol% of Fe in the sample showed a single-domain state, typical of a ferromagnetic material capable for information storage. This latter result would be due to the reduction of oxygen vacancies as more Fe was added and to the presence of Fe²⁺ and Fe³⁺ ions reinforced the magnetic behaviour of the compound.

Does the hip positioning matter for oblique lumbar interbody fusion approach? A morphometric study

PURPOSE

To evaluate whether left hip positioning widened the access corridor using oblique lateral interbody fusion (OLIF) approach during right lateral decubitus (RLD).

METHODS

Ten healthy adult volunteers underwent a T2 lumbosacral MRI (1.5 T) in the supine position, RLD position with left hip in extension and then in flexion. L2-L3 to L5-S1 disc spaces were identified. At each level, left psoas surface (in cm²), access corridor (in mm) and vessel movement were calculated in the three positions. Paired t test was used for comparison.

RESULTS

The mean surface of the left psoas ranged from 7.83 to 17.19 cm² in the three positions (p > 0.05). From L2-3 to L4-5, in RLD, when the left hip shifted from extension to flexion, nor the access corridor nor vessel movements were significantly different. When the volunteers shifted from supine to RLD position with hip in extension, arteries moved 3.66-5.61 mm to the right (p < 0.05 at L2-3, L3-4 and L5-S1), while the venous structures moved 0.92-4.96 mm (p < 0.05 at L2-3) to the right. When the position shifted from supine to RLD with hip in flexion, the arterial structures moved 0.47-4.88 mm (p < 0.05 at L2-3 and L3-4) to the right, while the venous structures moved - 0.94 to 4.13 mm (p < 0.05 at L2-3 and L3-4) to the right.

CONCLUSION

Hip positioning was not associated with a significant widening of the surgical corridor. To perform OLIF, we advocate for RLD position with left hip in extension to move away the vascular structures and reduce the psoas volume. These slides can be retrieved under Electronic Supplementary Material.

Outcomes of surgical treatments of spinal metastases: a prospective study

BACKGROUND

Owing to recent advances in cancer therapy, updated data are required for clinicians counselling patients on treatment of spinal metastases.

OBJECTIVE

To analyse the outcomes of surgical treatments of spinal metastases.

METHODS

Prospective and multicentric study that included consecutively patients operated on for spinal metastases between January 2016 and January 2017. Overall survival was calculated with the Kaplan-Meier method. Cox proportional hazard model was used to calculate hazard ratio (HR) analysing mortality risk according to preoperative Karnofsky performance status (KPS), mobility level and neurological status.

RESULTS

A total of 252 patients were included (145 males, 107 females) aged a mean 63.3 years. Median survival was 450 days. Primary cancer sites were lung (21%) and breast (19%). Multiple spinal metastases involved 122 patients (48%). Concomitant skeletal and visceral metastases were noted in 90 patients (36%). Main procedure was laminectomy and posterior fixation (57%). Overall, pain and mobility level were improved postoperatively. Most patients had normal preoperative motor function (50%) and remained so postoperatively. Patients "bedbound" on admission were the less likely to recover. In-hospital death rate was 2.4% (three disease progression, one septic shock, one pneumonia, one pulmonary embolism). Complication rate was 33%, deep wound infection was the most frequent aetiology. Higher mortality was observed in patients with poorest preoperative KPS (KPS 0-40%, HR = 3.1, p < 0.001) and mobility level ("bedbound", HR = 2.16, p < 0.001). Survival seemed also to be linked to preoperative neurological function.

CONCLUSION

Surgical treatments helped maintain reasonable condition for patients with spinal metastases. Intervention should be offered before patients' condition worsen to ensure better outcomes.

Antibacterial Activities of Copper Nanoparticles in Hybrid Microspheres

Active hybrid microspheres were prepared by blending aqueous solutions of gelatine and chitosan with different concentrations of copper nanoparticles (0) (CuNPs) using emulsion-based crosslinking synthesis to obtain hybrid microspheres. The incorporation of CuNPs slightly affected the physical and chemical properties of the films. Microscopic surface structure (SEM), energy dispersive X-ray (EDX) spectroscopy and X-ray diffraction (XRD) analysis confirmed the presence of elemental copper and the crystalline structure of the CuNPs in the hybrid matrix. The surface properties of CuNPs were studied by XPS analyses. The antimicrobial activity of CuNPs coated with chitosan (QO)/gelatine (GE) compared to the QO/GE matrix alone was investigated, using the agar diffusion and culture medium methods in Mueller-Hinton. The evaluation was performed using the Gram-negative bacterium E. coli and the Gram positive bacterium E. faecalis. The investigated microspheres showed antimicrobial activity. Hybrid microspheres with 40 mg of Cu, evaluated in liquid medium, inhibited the growth of E. coli by 56% and of E. faecalis by 40% compared to the matrix hybridised alone; in solid medium, the inhibition was 2.5-fold and 2.6-fold, respectively. Thus, these microspheres are a promising material for applications with medical uses.

Patient and healthcare professional satisfaction with 3D imaging new technologies for medical purposes

BACKGROUND AND OBJECTIVES

Advances in the field of three-dimensional scanning have enabled the development of instruments that can generate images that are useful in medicine. On the other hand, satisfaction studies are becoming increasingly important in the evaluation of quality in healthcare. We aimed to evaluate patients' and professionals' satisfaction with the use of a three-dimensional scanner applied to chest wall malformations.

MATERIAL AND METHODS

In the framework of a study to validate the results of three-dimensional scanning technology, we developed questionnaires to measure satisfaction among patients and professionals. We analyzed the results with descriptive statistics.

RESULTS

We included 42 patients and 10 professionals. Patients rated the speed and harmlessness positively; the mean overall level of satisfaction was 4.71 on a scale from 1 to 5. Among professionals, the level of satisfaction was lower, especially with regards to the treatment of the image; the mean overall level of satisfaction was 3.1.

CONCLUSIONS

Patients rated 3D scanning technology highly, but professionals were less satisfied due to the difficulty of treating the images and lack of familiarity with the system. For this technology to reach its maximum potential, it must be simplified and more widely disseminated.

Management of two cavernous sinus dural arteriovenous fistulae by direct microsurgical approach and catheterization of the superior ophthalmic vein

BACKGROUND

In case of cavernous sinus dural arteriovenous fistula, transvenous embolization of the cavernous sinus via the inferior petrosal sinus is generally sufficient. However, when inferior petrosal sinus access is challenging, various alternative approaches have been reported, with corresponding difficulties and risks.

CASE REPORTS

We report the management of two cases of life-threatening cavernous sinus dural arteriovenous fistula revealed by a typical cavernous sinus syndrome. Conventional approaches were unsuccessful, and a direct microsurgical approach was performed, with catheterization of the superior ophthalmic vein. This combined approach safely accessed the cavernous sinus, and obtained complete occlusion of the fistulae by Onyx® embolization.

CONCLUSIONS

This procedure could be an interesting alternative option in the treatment of cavernous sinus dural arteriovenous fistula when conventional approaches are not possible.

Osteocutaneous free transfer of vascularized fibula in cervico-thoracic spinal reconstruction with filling of an esophageal fistula: A case report

The case under review is a 60-year-old patient with a vertebral plasmocytoma treated by cervico-thoracic fusion 2 years previously. He presented a thoracic spinal septic non-union complicated by esophagospinal fistula. We performed vascularized fibula transplant with cutaneous pad to fill the esophageal fistula. Control CT at day 5 confirmed vascular anastomosis permeability and bone transplant position. Osseointegration was achieved at 18 months postoperatively. The patient was alive 3 years after the last procedure (5 years after tumorectomy). A systematic review of the literature on spinal reconstruction by vascularized fibula transplant showed the diversity of surgical techniques available. In view of the multiplicity of possible organ and soft tissue defects involving the spine, reminders are provided of the different approaches and recipient vessels in this type of reconstruction depending on location.

Circumferential minimally invasive approach for low-grade isthmic spondylolisthesis: A clinical and radiological study of 43 patients

INTRODUCTION

Circumferential fusion for lumbar low-grade isthmic spondylolisthesis (LGIS) provides the best spinal stability and highest fusion rates. The aim of this study is to investigate results of minimal invasive management of LGIS and correlations between Intervertebral Foramen Surface (IFS) and other parameters.

METHODS

We retrospectively reviewed cases of 43 patients who underwent a minimally invasive circumferential fusion (Anterior lumbar interbody fusion followed by percutaneous posterior pedicle screw fixation) for LGIS between January 2010 and December 2014 in our institution. Inclusion criteria were one-level (L4-L5 or L5-S1) LGIS with low back and/or radicular pain. Pre- and postoperative radiographic evaluations were performed at 6, 12 and 24months. Measurements (Percentage of anterior displacement, degree of slip angle, height of the intervertebral space and the IFS) were obtained using Surgimap^®.

RESULTS

Nineteen patients (44.2%) were males. Mean age was 43 years old (19-72years). The mean follow-up of the series was 18.3months (3-72months). Mean preoperative Visual Analogy Scale (VAS) for low back pain decreased from 70mm to 20mm and from 80mm to 10mm as to radicular pain. Anterior displacement was reduced from 18% to 7% (p<0.01), degree of slippage were increased from 9.8° to 15.2° (p<0.01), intervertebral height was restored from 4.4mm to 8.5mm (p<0.01) and increase of the IFS was calculated 48.8%.

CONCLUSION

One stage circumferential fixation for adults' LGIS without decompression, allows restoration of intervertebral height permitting good reduction of the slippage, an increasing of the IFS and liberation of nerve roots.

Factors involved in the late failure of endoscopic treatment of vesicoureteral reflux

INTRODUCTION

The short-term results of endoscopic treatment of vesicoureteral reflux (VUR) are excellent. Over time, however, a number of patients have been identified for whom VUR reappeared after being resolved with this technique. The aim of this study was to analyse the factors related to this event.

MATERIAL AND METHODS

A retrospective, analytical, case-control study included 395 ureteral units with primary VUR treated successfully at our centre, with a minimum follow-up of 3 years. We identified cases in which VUR reappeared and analysed the demographic variables, those related to VUR (grade, laterality, initial study) and those related to the operation (materials used).

RESULTS

We identified 77 ureteral units with recurrence in the 395 included units (19.5%). The recurrence rate was 29.7% for the patients treated with dextranomer/hyaluronic acid (Dx/HA), 20.2% for those treated with polydimethylsiloxane (MP) and 12.2% for polytetrafluoroethylene (PTFE). The onset of recurrence rose to 35% for patients treated before 1 year of age and those with gradeV VUR. Urinary dysfunction symptoms also increased the recurrence rate to 34.9%.

CONCLUSION

The use of resorbable dextranomer/hyaluronic acid material was related to recurrence in the endoscopic treatment of VUR. The high-grade reflux and treatment at an early age, as well as the presence of urinary dysfunction, are also factors associated with recurrence.

Multiple neurosurgical treatments for different members of the same family with Currarino syndrome

INTRODUCTION

Currarino's syndrome (CS) is an autosomal dominant disorder of embryonic development causing a rare malformating syndrome characterized by a triad of an anorectal malformations, presacral mass (most commonly an anterior sacral meningocele) and sacral bony defects. Mutations of the HLXB9 gene have been identified in most CS cases, but a precise genotype-phenotype correlation has not been described so far. Family screening is obligatory. The diagnosis is usually made during childhood and rarely in adulthood. In this context, imaging, and especially MRI plays a major role in the diagnosis of this syndrome. Surgical management is provided by pediatric surgeons or neurosurgeons.

FAMILIAL CASE REPORT

Here, we present a family case report with CS requiring different neurosurgical management. The son, a 3-year-old boy, developed a tethered spinal cord syndrome associated to a lipoma of the filum terminale, a sacro-coccygeal teratoma and an anal adhesion. A combined surgical approach permitted a good evolution on the urinary and digestive functions despite a persistent fecal incontinence. The 2-year-old daughter presented with a cyst of the thyreoglossal tract infected and fistulized to the skin. She was also followed for a very small lipoma of the filum terminale that required a neurosurgical approach. The father, 44-year-old, manifested functional digestive and urinary disorders caused by a giant anterior sacral meningocele. The ligation of the neck of the cyst and aspiration of the liquid inside in full through a posterior partial approach permit a complete collapse of the cyst with an instantly satisfactory clinical outcome.

CONCLUSION

In these cases, cooperation between pediatric surgeons and neurosurgeons was crucial. The follow-up of these patients should be done in a spina bifida clinic. A geneticist evaluation must be offered to the patient in the case of a CS as well as a clinical evaluation of the relatives (parents, siblings).

A New Minimally Invasive Technique for Primary Unstable C2 Spondylolysis in an 8-Year-Old Child: A Case Report and Review of the Literature

BACKGROUND

Posterior arch defect of C2 with an unstable spondylolysis is a rare condition mostly occurring within children. Its management is still controversial.

CASE DESCRIPTION

We report in this article the first minimally invasive surgery (MIS) technique for this condition in an 8-year-old boy. A primary unstable C2 spondylolysis was diagnosed on the exploration of episodic paresthesia of upper limbs associated with headache lasting for several months. The surgical technique consisted in a direct pars repair through an MIS approach: METRx tubular retractor system (Medtronic Sofamor Danek, Memphis, Tennessee, USA), intraoperative C-arm fluoroscopy, surgical microscope, endoscopic spine instrument, and high-speed drill were required. Muscles were split and retracted. One-year postoperative course was excellent.

CONCLUSIONS

After reviewing the past literature of this pathology, we discuss the minimally invasive posterior approach of the upper cervical spine. It is the first case, to our knowledge, describing direct minimally invasive repair for bilateral primary C2 pars defect in a child. Image guidance and surgical microscope help safe and effective screw placement.

Adjacent level spondylodiscitis in a patient with thoracic spondylodiscitis: A case report and review of the literature

INTRODUCTION

Adjacent level spondylodiscitis (ALS) after primary surgery for thoracic spondylodiscitis is a very rare condition.

CASE REPORT

We report the case of a 76-year-old man with this pathology. A first posterior minimally invasive approach combined with anterior approach to the thoracic spine was safely performed for thoracic spondylodiscitis. More than a year later, exploration of recurrent symptoms with ¹⁸FDG PET scan helped to diagnose ALS. Further surgery was performed. At 3-year follow-up examination showed no recurrence of the infection.

DISCUSSION

ALS should be suspected during recurrent symptoms after spinal fusion surgery. Evaluation should be based on the results of ¹⁸FDG PET scan and surgery.

CONCLUSION

Bacterial and histopathological analyses combined with an increase of spine fixation and adapted antimicrobial therapy are a safe management for ALS.