Purpose of the study: It is currently accepted (particularly since the work by Katz et al.) that a number of factors can potentially influence the functional outcome obtained after surgical treatment of lumbar canal stenosis (LCS). Among these factors are comorbid conditions and the notion of perceived health appear to be predominant. Little work has however been focused on the influence of these same factors on the qualitative and quantitative expression of functional impairment expressed by patients before their treatment. This possible link might have an intrinsic impact on the assessment of the outcome obtained after medical or surgical treatment of LCS. We wanted to examine this question.

Material and methods: Two hundred twenty patients referred to our orthopaedic surgery consultations were included in this prospective observation study, irrespective of the type f treatment eventually proposed (medical or surgical) or the type of lumbar stenosis. Patients who had had prior spinal surgery and those treated for LCS due to spinal deformity were excluded. The degree of the functional symptoms was determined with the SF36 and a self-administered questionnaire specifically designed and validated for the evaluation of LCS. Comorbidity factors were studied individually and with the following scores: the ASA score, the FCI (Functional Comorbidity Index), the CIRS (Cumulative Illness Rating Scale, and the ICED (Index of co-existent Diseases). Univariate and multivariate analysis was used to search for correlations between expressed functional impairment and comorbid factors.

Results: Expression of a functional impairment was significantly associated with a high number of comorbidity factors. This correlation was tighter when there was no additional compressive discal factor and when the functional neurological symptoms were longstanding. The type of comorbid factor analysed did not have an impact on these results

Conclusion: The presence of comorbid factors is significantly associated with more severe expression of functional impairment related to LCS. This effect could also influence the functional outcome after treatment of LCS and should be taken into consideration.

Purpose of the study: Surgical strategy for the treatment of pyogenic spondylodiscitis remains a controversial issue, mainly because of the low incidence. This retrospective review was undertaken to clarify current practices.

Material and methods: Nineteen patients (11 male, 6 female)with pyogenic spondylodiscitis underwent surgery from 2003 to 208. Mean age at surgery was 62.7 years (41–100). The localisation was cervical (n=6), thoracic (n=8) and lumbar (n=3). Motor deficit was present preoperatively in 13 patients. There were no cases of complete paralysis. The indication for surgery was aggravation of the neurological deficit in 14 patients and kyphosic deformity in three. The release was achieved via an anterior access for the cervical cases and via a posterior access for the thoracic and lumbar cases. The circumferential procedure achieved complete bilateral arthrectomy. In all cases the instrumented fusion was followed by postoperative immobilisation for three months. Antibiotics were also given for three months. Functional and radiographic outcome were assessed at last follow-up.

Results: Mean follow-up was months (12–26 months). There were no clinical or biological signs of recurrent infection despite implantation of osteosynthesis material. Irrespective of the delay to treatment, the 13 patients with a preoperative deficit presented signs of recovery. Eight of them recovered completely and the five others had a motor deficit rated at 4/5. Radiographically, there were no fusion failures at last follow-up. Two patients had revision surgery: one for recurrent tetraparesia due to a postoperative epidural haematoma, the other to achieve impaction of the graft in the vertebral body.

Discussion: – This series emphasises the clinical impact of surgical treatment of pyogenic spondylodiscitis. Surgery enables a certain degree of neurological recover achieved by wide decompression. It enables bone fusion despite instrumentation in this complex septic situation.

Purpose of the study: Although the iliac autograft is the gold standard for single-level intervertebral fusion, complications and morbidity related to autologous graft harvesting from the iliac crest remain a point of concern. Bone morphogenic protein (BMP) has proven advantages for fusion of the intersomatic and posterolateral graft. This study compared the efficacy and tolerance of OP-1 compared with an autologous graft in patients with symptomatic spondylolisthesis. This study reports the preliminary results of a prospective randomised controlled trial comparing OP-1 with an iliac autologous graft for instrumented single-level posterolateral fusion for arthrodesis of grade 1 spondylolisthesis.

Material and methods: Lamino-arthrectomy associated with a posteriolateral instrumented arthrodesis with an iliac autologous graft or a mixture of OP-1 and local autologous graft material was performed in 27 patients with spondylolisthesis leading to lumboradiculalgia or neurogenic claudication. The final outcome was time to fusion at one year on the scanner and plain x-rays. The Oswestry score and pain at the harvesting site as well as side effects were also noted.

Results: The cohort included 27 patients. Three were excluded from the analysis, leaving 24 patients assessed at one year. The demographic data were comparable for the two groups regarding mean age (64 years versus 69 years for the OP-1 group). At one year, ten radiographically certain fusions were noted in the control group and eight in the OP-1 group. Two nonunions and one doubtful fusion were noted in the control group compared with three doubtful fusions in the OP-1 group. The mean Oswestry score was comparable in the two groups. The mean score in the control group improved from 49.5 to 28.5 compared with 45.9 to 29.7 in the OP-1 group. There was no secondary effect attributable to use of OP-1. There were no cases of systemic toxicity, nor heterotopic calcification or restenosis for the 11 patients in the OP-1 group.

Conclusion: A fusion rate of 73% without secondary effects attributable to OP-1 was observed in this preliminary study. This study allows the conclusion that this technique is reliable, safe and, in terms of fusion, a valid alternative to autologous iliac crest graft. The main advantage resulting from the use of OP-1 is to avoid the morbidity linked with harvesting the iliac graft.

Generally, the sacroiliac joint is not considered accessible for arthroscopy under physiological conditions. The non-injured joint is not large enough for introduction of even the smallest arthroscope into the joint space. After traumatic injury however, or in the event of an inflammatory condition or tumour formation, it is theoretically possible to position an endoscope in the joint space. Study of the anatomy of the sacroiliac joint and knowledge of the anatomic relations, particularly the vascular and nervous relations, is a prerequisite for arthroscopic exploration of the sacroiliac joint space. The posterior approach must account for the bone configuration of the iliac wing and the orientation of the sacroiliac joint line. A cadaver study confirmed the feasibility of endoscopic exploration of the sacroiliac joint via a posterior percutaneous access. Based on this anatomic experience, we positioned an arthroscope in an injured sacroiliac joint and report the different phases. A technique for obtaining a biopsy of the anterior aspect under endoscopic control has already been described, but to our knowledge, there is no arthroscopic description of the sacroiliac joint via a posterior access. Indications for arthroscopy of the sacroiliac joint remain very limited. This technique can be used to remove osteocartilaginous fragments or foreign bodies incarcerated in the joint and to obtain biopsy material, drain collections and, in the near future, should allow avivement of the cartilage surfaces with the objective of a percutaneous arthrodesis.

Purpose of the study: We present a review of the two-year outcome of a new clinical sacroiliac fixation technique used in our first seven patients.

Material and methods: Between May 2002 and March 2003, seven patients with a Tile C fracture of the pelvic girdle were stabilized with a new operative technique. This technique used two sacral screws linked to two iliac expansive screws via a 5.5 mm rod. Three of the patients presented preoperative neurological injuries attributed to the trauma (L5 or S1 paralysis). All presented associated lesions: lower limb (n=3 patients), spine (n=2), acetabulum (n=2). Mean patient age was 36.3 years. We present a retrospective clinical and radiological review of these seven cases. The Majeed score, the radiological index of lower limb length, and the combined index of vertical displacement and sacroiliac CT results were noted.

Results: The mean Majeed score was 93. Reduction of the combined vertical displacement was considered excellent or good (< 10 mm) in all patients; The reduction in the leg length discrepancy was considered good for all patients. There was no loss of reduction at last follow-up. There were no septic or skin complications and no complications related to implanted material. The implants were removed in one patient. The sacroiliac CT revealed formation of ossification bridges in all patients.

Discussion: The results of our small series are encouraging, particularly for vertical stability over time. There was no case of lysis around the screws and the clinical results were satisfactory.

Conclusion: For us, this technique is the optimal method for the treatment of Tile C injury to the pelvic girdle. This technique enables vertical stabilization while maintaining a certain degree of horizontal mobility facilitating reduction and fixation of the associated anterior injuries. This technique has its limitations since it is not particularly adapted for posterior lesions with fracture of the sacrum in Denis zone 2. These early encouraging results will require further long-term assessment in a larger group of patients.