Purpose of the study: Conventional treatment for recurrent lumbar disc herniation is repeated discectomy. Other methods such as fusion, ligamentoplasty or implantation of a discal prosthesis are sometimes proposed but all increase morbidity. The purpose of this work was to ascertain the efficacy of isolated repeated radicular release for the treatment of recurrent discal herniation.

Material and methods: Thirty-four patients underwent surgery for recurrent discal herniation. Repeated radicular release was used in all patients included in this analysis who completed a self-administered questionnaire at last follow-up to assess the final functional outcome.

Results: The cohort included 13 women and 21 men, mean age at surgery 45 years. Mean time from first discectomy to revision surgery for recurrence was 55 months. At the time of the review, four patients had died, all four from cancer. None of these patients had undergone a revision procedure on the lumbar spine. One patient was lost to follow-up so 85% of the cohort was analyzed with 60 months average follow-up. A dural tear occurred during the proscedure in six patients (17%. Five patients (14.7%) required revision surgery, one for deep infection, four for recurrent or persistent lumboradiculalgia (recurrent discal herniation, isthmic fracture, lateral stenosis associated with inflammatory discopathy). The rate of revision for painful failure was 11.4%. The final outcome could be assessed for 25 patients and was satisfactory for 22/25 (88%). The self-administered questionnaire revealed 65% average improvement with more than half of the patients reported better than 80% improvement. Ten patients (40%) complained of lumbar pain and a third had residual, generally intermittent, radiculalgia. Eighteen of 25 patients resumed their work at a comparable level after six months on average; 84% of the patient would accept the same operation again.

Discussion: In terms of morbidity and rate of revision, the results are comparable to reports in the literature. Repeated release does not increase the risk of a new recurrence.

Conclusion: This work enabled us to demonstrate that in the large majority of patients repeated discectomy provides satisfactory functional outcome with little morbidity.

Purpose of the study: Injury to the infrapatellar branches of the medial saphenous vein are incriminated in disorder of the anterior aspect of the knee after bone-tendon-bone ligamentoplasty procedures. We have demonstrated in an anatomic study the usefulness of a minimal two-way approach for harvesting the patellar transplant in order to preserve the nerve branches. The purpose of this clinical study was to evaluate the feasibility of this method and its impact on the sensitivity of the anterior aspect of the knee after ligamentoplasty in comparison with the usual harvesting technique.

Material and methods: This non-randomized prospective controlled contemporary study included 47 consecutive patients. The graft was harvested via two vertical incisions, one on the apex of the patella, the other on the eminence of the anterior tibial tuberosity. After harvesting the patellar splint, discision of the patellar tendon fibers was performed subcutaneously to the tibial tuberosity. Before removing the graft via the tibial incision with a forceps inserted via the inferior incision without injuring the peritendon. A tibial piece was then harvested. The ligamentoplasty was performed as usual using two anterolateral and anteromedial arthroscopic portals. The tibial tunnel was drilled first on the tibial tuberosity. These 47 knees were compared with 34 knees where the conventional approach was used (control group). We assess: harvesting time, width of the tendon transplant, quality of the graft, requirement to convert to conventional harvesting technique. Patients were reviewed at six weeks, three months and six months to assess anterior pain, dysesthesia, surface area of hypo or anesthesia and at six months kneeling problem.

Results: Conversion was not necessary for any of the knees. Mean harvesting time was 17 minutes (control group ten minutes). A good quality graft was obtained in all cases. Thirty-five patients were reviewed at six months. No sensorial disorders were noted in 18 patients. Sensorial disorders were noted in 17 patients (permanent hypoesthesia in the control group). None of the patients presented anesthesia. The mean surface area presenting a sensorial disorder was 13.6 cm² at six weeks (37.8 cm² in the control group) and 8.85 cm² at six months (23.4 cm² in the control group). Mean gain compared with the control group was 62%. There were two cases of anterior pain at six months and no case of dysesthesia. Sixteen patients could kneel normally (none in the control group); kneeling was not possible in one patient.

Discussion: The infrapatellar branches of the medial saphenous nerve are often injured when harvesting a bone-tendon-bone graft for ligamentoplasty. Anterior disorders would in part be correlated with the degree of sensorial impairment on the anterior aspect of the knee. The subcutaneous harvesting technique presented here with two minimal incisions appears to be an attractive alternative.

Conclusion: Our study confirmed the feasibility of this harvesting technique which significantly reduces the surface area of sensorial disorders and avoids most kneeling problems.

Purpose of the study: The posterior paraspinal approach to the lumbar spine was initially described and promoted by Wiltse for posterolateral arthrodesis of the lumbosacral junction in patients with spondylolisthesis. Despite technical improvements proposed by Wiltse, the muscular cleavage is still poorly localized in the sacrospinalis muscle. The purpose of this work was to provide a more accurate anatomic description of this spinal approach and to describe anatomic landmarks to facilitate execution of the procedure.

Material and methods: Fifty anatomic specimens were dissected (27 male and 23 female cadavers); 33 had been embalmed. The anatomy study used a bilateral approach to the spine. The exact anatomic localization of the muscle cleavage was noted. Measures were taken in relation to the mid line of the L4 spinatus process.

Results: In all specimens, the muscle cleavage lay between the multifidus and longissimus heads of the sacrospinalis muscle. A fibrous partition was noted in 88 of the 100 specimens. The mean distance from the mid line to the cleavage line was 4.04 cm (range 2.4–7.0 cm). The surface of the sacrospinalis muscle presented fine perforating arteries and veins in all specimens, directly in line with the cleavage plane. In 12 cases, a major posterior sensorial branch of the L3 nerve running to the skin was identified in the cranial portion of the approach.

Discussion: The muscle cleavage plane appears to be easy to localize for the paraspinal approach to the lumbosacral junction. Opening the aponeurosis of the latissimus dorsi near the mid line enables visualization of the perforating vessels in line with the anatomic cleavage plane of the sacrospinalis muscle. In our experience, this plane is situated on average 4 cm from the mid line. Hemostasis of these vessels is acceptable since the sacrospinalis muscle has a rich supply of anastomosed vessels. Care must be taken to avoid injury to the posterior sensorial branch of the L3 nerve which runs along the plane of the muscle cleavage.

Conclusion: In our opinion, this minimally hemorrhagic approach is perfectly adapted to non-instrumented fusion of the lumbosacral junction, particularly for spondylolisthesis in children and adults. Precise knowledge of the anatomy of this approach is a necessary prerequisite for successful execution.

Purpose of the study: Experimentally, posterolateral fusion only allows incomplete control of flexion/extension, rotation and lateral inclination. This defect of posterolateral fusion is most marked with there is a wide anterior gap. For certain authors, this situation justifies use of intersomatic arthrodesis. The purpose of this work was to evaluate, within a spinal segment immobilized by posterolateral fusion, the changes observed in disc height and the possible clinical and radiographic impact of a change in disc height.

Material and methods: This was a retrospective analysis of a consecutive series of patients who underwent posterolateral fusion from January 1999 through December 2003 performed in addition to radicular release for degenerative spondylolisthesis were included. Functional symptoms were noted using: VAS, Beaujon function scale, Beaujon self-administered questionnaire, satisfaction scale, GHA28 anxiety/depression scale, and SF36 quality of life questionnaire. Spineview® was applied at the olisthesic level (disc height, listhesis, anglulation), at adjacent levels, for pelvic parameters, sagittal tilt, and vertebral motion on stress views. We searched for a correlation between the consequences of changes in these variables was and the functional outcome as well as the quality of the fusion. The effect of variations in the following preoperative variables was studied with multivariate analysis: disc height, intervetebral angulaion, listhesis, vertebral motion, sagittal balance, use of osteosynthesis or not.

Results: Forty patients were reviewed with a mean follow-up of 38 months (range 15–70 months). Decreased disc height at the olithesic level was associated with local kyphosis. The level above tended towards lordosis while the level below towards kyphosis. These variations had no effect on the final functional outcome.

Discussion: No formal argument could be found in the literature favoring the use of intersomatic arthrodesis to complete posterolateral fusion for the treatment of degenerative spondylisthesis. Disc height is lost after isolated posterolateral fusion with a risk of local kyphosis and persistent intervertebral motion, but these effects do not appear to influence the functional outcome nor the rate of fusion. More than disc height, it would appear that sagittal balance should be preserved to improve functional outcome.

Conclusion: This study enabled us to observe, as is reported in the literature, decreased disc height after posterolateral fusion for degenerative spondylolisthesis. However, there appears to be no correlation between this decreased disc height and the functional outcome. More than disc height, sagittal balance appears to be the determining factor.