Purpose of the study: Management of the spinal neuroarthropathy of Charcot’s disease is recommended. Vertebral fusion should be extensive and often circumferential. The natural history of this disease, often diagnosed late, is poorly understood and the results of functional treatments not well studied. The purpose of this study was to describe the elements motivating surgical abstention and to analyse the natural course of the vertebral lesions.

Material and methods: The diagnosis of spinal neuroarthropathy was established in seven patients from 1997 to 2007. Six has paraplegia and one female patient Friedrich ataxia. The initial neurological disease was known for 18 years on average before diagnosis of the spinal neuroarthropathy. The management decision was based on patient motivation, comorbid conditions, and successive functional, clinical and imaging assessments. The patients were classed by the progression of vertebral destruction. Four patients had a non-evolving destruction, two with a stable spine and two with spinal hypermobility.

Results: The spinal stability, the absence of progression of the spinal neuroarthropathy, and in certain cases the presence of an ossification process were determining in deciding to abstain from surgery. Despite the collapse of the trunk, surgical abstention was decided for two patients basically because of the loss of spinal mobility resulting from the arthrodesis. For three other patients with progressing spinal lesions, the presence of comorbid factors (major risk of infection), patient refusal of the risk of temporary or definitive loss of function were the reasons surgery was decided against.

Discussion: According to the literature, it is assumed that abstention from surgery will invariably lead to neurological or infectious complications and even patient death. We did not observe these events in our series. The major surgery exposes to a risk of failure; certain authors have reported a complication rate of 60% and others have had 40% repeat operations. The instability induced by the spinal neuroarthropathy can be considered providential by the patient. The fact that several patients declined surgery because of the fear of worsening their handicap after arthrodesis is noteworthy. Simulation with a rigid corset was determining. The spinal neuroarthropathy does not appear to be a continuous destructive process but its natural history is not well known. Predictive elements were not identified in this study.

Conclusion: Charcot’s spinal neuroarthropathy is a challenging condition in frail patients. Disease progression, comorbid conditions, and multidisciplinary functional assessments are needed for adequate management and decision making.

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.