Journal of Spine

It is known that cervical spine involvement occurs in over half of patients with rheumatoid arthritis (RA). This involvement is over 70% in Tunisia. The majority of our patients are seen at Ranawat’s stage III with spinal cord injury. We report a series of 28 patients treated in our institution for RA with atlantoaxial dislocation with several degrees of spinal cord injury (Ranawat’s stage II and III). Even though overshadowed by major impairments related to severe peripheral joint disease, 60% of our patients presented a good functional result at the average of 10 years follow up.

The next step in expanding the indications of percutaneous endoscopic lumbar discectomy is management of lumbar canal stenosis via endoscopic approach. Technical advances in the endoscopic instruments especially endodrill [burr], and endoscopic punch are allowing the spine surgeons to take on the challenge of lumbar decompression by the most minimally invasive approach possible. But the procedure is still in developmental phases with indications limited to selective cases. We wish to present a technical report and brief discussion about the current application of endoscopy in lumbar canal stenosis.

Introduction: The goal of immobilization is to transform the entire body of the patient into a single mass so it can withstand the stress of the rescue without further damage. The traumatized patients must be immobilized on spine stretchers to ensure complete immobilization of their spine. The world’s best selling stretcher of this type is the Ferno Scoop Exl65. The Northwall Innovation’s Skidboard is a stretcher that does not require the collar and can be dragged on the ground.

Material and Methods: We compared the stress to the spine during the loading and transport steps with both the Skidboard and the Exl65 stretchers. We collected data from electronic devices placed on the patient’s suit and helmet. Each sensor inside the suit and helmet showed values on the three Cartesian axes during all manoeuvers. We repeatedly simulated the rescue of a fallen rider and performed rescue operations both by lifting and transporting the patient on the Exl65 stretcher and by loading the patient on the Skidboard and dragging it on the ground, in a variety of scenarios.

Results: In general, the Skidboard creates less energy than the Exl65. The Skidboard ensures correct immobilization of the cervical spine during the entire rescue process, unlike the Exl65 that does not immobilize the cervical spine when the patient is wearing a helmet. The rest of the spine, even if tied on the Exl65, is more subject to pitching and especially rolling on the Exl65 as opposed to the Skidboard. The stresses dragging Skidboard are physically more noisy and we were expecting the body to absorb the vibrations and turn it into injury, but it is not so. Probably because the fastening system of the Skidboard makes the body an integral block with the stretcher, and the energy developed by skidding is dissipated in other forms, without injury to the spine. The Exl65 seems to vibrate slightly during the transport, however the operators perform instinctive ergonomic and compensatory acts that generate energy on the patient, although tied to the stretcher. The Skidboard does not only discharge less energy on patient than the Exl65, but also greatly reduces the severity of the fall of the patient from the stretcher because only a portion of the body is elevated a few centimeters above the ground.

Conclusion: Data show that the stress to the patient using Skidboard is not greater than with another stretcher during the transport on flat ground. The system of dragging a stretcher seems to be a valid system to rescue traumatized and non-traumatized patients. In fact, it does not deliver greater energy than lifting and transporting on other stretchers. The author declares no conflicts of interests.

Posterolateral lumbar fusions have been successfully used to surgically treat mechanical back pain, low grade spondylolisthesis and other degenerative spinal conditions. The addition of biological grafts to augment available autologous bone has further improved fusion rates, yet, some of these biologics have been found to cause deleterious post-operative clinical situations and sometimes are used in an off-label manner. A biological alternative that provides equivalent fusion rates with a similar, or lower, risk profile is desirable. In this study, we report on fusion rates associated with the use of an allogeneic growth factor (OsteoAMP) to assist with lumbar spinal arthrodesis with and without augmentation with bone marrow aspirate as compared to rhBMP-2 used with and without the allogeneic growth factor. Patients having posterolateral lumbar fusion were evaluated for fusions at clinically relevant time points. A total of 302 patients (146 growth factor with BMA, 81 growth factor without BMA, 50 rhBMP-2 alone, 25 rhBMP-2 with allogeneic growth factor) were retrospectively reviewed. The growth factor with BMA group had approximately an 88% fusion rate by 12 months and 99% by 24 months. The growth factor non- BMA group had a fusion rate of 35% by 12 months and exceeding 98% at the 2 year follow up. The OsteoAMP augmented rhBMP-2 group had fusion rates of 33% at 12 months and 100% at 24 months, while the rhBMP-2 alone group only attained a 14% fusion rate at 12 months and a 32% fusion rate at 24 months. The allogeneic growth factor appears to provide a viable option to assist with the development of posterolateral spinal arthrodesis. Longer follow up and increased patient sample size is needed to further confirm these initial results.

Background: Sacroiliac (SI) joint pain conservative treatments show poor outcomes. Hypothesis: surgical treatment will show better results.

Patients and methods: Prospective series: 24 patients undergoing SI fusion after failure of medical treatment and showing temporary relief with SI infiltration. Period: Nov 2009-July 2013. Gender: 9/15. 11 cases bilaterally (all ). Age: 32-71 years (mean 47.4 years). Height: 161-178 cm (mean 168.2 cm). Weight: 56-84 kg (mean 68.4 kg). Etiology: 12 degenerative/spontaneous, 7 fall on buttocks, 3 coincident with lumbar disc and 2 with lumbar posterolateral fusion. Exclusion criteria: ankylosing spondylitis, osteitis condensans ilii, sacro-iliac joint arthropaty. Demographics, analgesics and NSAID’s consumption, incidence and severity of complications, clinical outcome using a visual analog scale (VAS) for pain, Oswestry Disability Index (ODI) and time to returning to work were collected postoperatively at 1, 3 and 6 months, and then at six months interval until last follow-up.

Results: Follow-up: 1-4.5 years (mean 23.3 months). No intra-operative or post-operative major complications. No blood transfusions. Patients stayed over-night, and discharged next morning. No crutches used. Time to returning to work: 47.4 days (range 30-67 days). Post-op: marked reduction in VAS and analgesic consumption (preop 8.7, post-op 1 month 3.2, 3 months 2.8, 6 months post-op 2.1, 12 months 1.7, 18 months 1.7, 2 years 1.9, 2½ years 1.8, 3 years 2.0, at 3½ years 2.1, 4 years 2.1 and 4½ 2.1). Mean ODI scores improved from 54.1 preoperatively to 23.9, 21.2, 20.4 and 14.3 at 1, 3, 6 and 12 months postoperatively, and 15.1, 15.5 15.8, 16.0, 16.1, 16.3 and 16.3 at 1½, 2, 2½, 3, 3½, 4 and 4½ years (p<.001). 1 year post-op 22/24 patients would undergo the procedure again.

Conclusion: Percutaneous SI joint arthrodesis is effective and safe to treat chronic SI joint pain.

The effects of treatment of scoliosis in neurofibromatosis type 1 are less satisfactory than other scoliotic types due to the particular pathogenesis and clinical characteristics. Surgical treatment usually included 360 degrees fusion with instrumentation, but optimal strategies are different according to the degree of deformity. High incidence of pseudarthrosis, extensive bleeding and curve progression even after solid spinal fusion are also major concerns of neurofibromatosis type 1 associated spinal deformity surgery. With advance of technology, cobalt-chrome rod with dural rod technique, tranexamic acid, recombinant human bone morphogenetic protein-2 and electrophysiologic monitoring were used in neurofibromatosis deformity surgery to get better outcome. Searching from PubMed, we reviewed overall about neurofibromatosis spine deformity surgery.

Objective: To examine the validity of using cadaveric spines of deer or boars for biomechanical experiments as substitutes for the cadaveric spine of humans. Materials and Methods: Five specimens of the L3-4 functional spinal unit of human cadavers, mature deer and mature boars were prepared according to 3 models: 1) normal model, 2) injured model and 3) pedicle screw fixation model and they were evaluated in 8-direction bending and 2-direction rotation tests. The mean ROM in bending and rotation tests of each specimen and the rate of relative change of ROM were calculated. Results: Flexibility of cadaveric spine of deer and boars was slightly higher than that of cadaveric spine of humans in the bending and rotation tests, but the rates of relative change of ROM in the rotational and bending tests were similar across species. Conclusions: It is reasonable to use cadaveric spines of deer and boars as a model of the human cadaveric spine in biomechanical experiments.

Introduction: An insufficiency fracture is a type of non-traumatic fracture caused by bone fragility that most commonly occurs in the pelvis and lower extremities. Although sacral insufficiency fracture is not uncommon, its diagnosis is often delayed or missed. We here report the case of SIF with rheumatoid arthritis that occurred during the pre-operative waiting time for total hip arthroplasty.

Case presentation: A 57-year-old woman with rheumatoid arthritis presented with sacral insufficiency fracture that occurred during the pre-operative waiting time for total hip arthroplasty. During the four months after the onset of the sacral insufficiency fracture, her pubis, ischium and acetabulum fractured and deformity of her left hip joint gradually progressed. Total hip arthroplasty was performed using bone grafting onto the acetabulum from the autogenous femoral head. The findings upon clinical examination and the patient’s assessment of function were excellent at the time of the most recent follow-up.

Conclusion: When total hip arthoplasty is performed in patients with severe osteoporosis or insufficiency fracture of the acetabulum, it is essential to avoid additional pelvic factures at the time of setting the acetabular cup component. Moreover, as a total hip arthoplasty might itself be a predisposing causative factor of pelvic insufficiency fracture, recurrence of insufficiency fractures should be monitored in those patients with the history. Aggressive intervention for osteoporosis might be necessary to prevent insufficiency fracture development.