Pr BRONSARD Nicolas

Sacroiliac joint syndrome after lumbosacral fusion

Nicolas Bronsard, Yann Pelletier, Hugo Darmante, Olivier Andréani, Fernand de Peretti, Christophe Trojani

https://pubmed.ncbi.nlm.nih.gov/32900669/

Abstract

Introduction: One-third of low back pain cases are due to the sacroiliac (SI) joint. The incidence increases after lumbosacral fusion. A positive Fortin Finger Test points to the SI joint being the origin of the pain; however, clinical examination and imaging are not specific and minimally contributory. The gold standard is a test injection of local anesthetic. More than 70% reduction in pain after this injection confirms the SI joint is the cause of the pain. The aim of this study was to evaluate the decrease in pain on a Numerical Rating Scale (NRS) after intra-articular injection into the SI joint. We hypothesised that intra-articular SI injection will significantly reduce SI pain after lumbosacral fusion.

Methods: All patients with pain (NRS>7/10) suspected of being caused by SI joint syndrome 1 year after lumbosacral fusion with positive Fortin test were included. Patients with lumbar or hip pathologies or inflammatory disease of the SI joint were excluded. Each patient underwent a 2D-guided injection of local anesthetic into the SI joint. If this failed, a second 2D-guided injection was done; if this also failed, a third 3D-guided injection was done. Reduction of pain on the NRS by>70% in the first 2 days after the injection confirmed the diagnosis. Whether the injection was intra-articular or not, it was recorded. Ninety-four patients with a mean age of 57 years were included, of which 70% were women.

Results: Of the 94 patients, 85 had less pain (90%) after one of the three injections. The mean NRS was 8.6/10 (7-10) before the injection and 1.7/10 after the injection (0-3) (p=0.0001). Of the 146 2D-guided injections, 41% were effective and 61% were intra-articular. Of the 34 3D-guided injections, 73% were effective and 100% were intra-articular.

Discussion: This study found a significant decrease in SI joint-related pain after intra-articular injection into the SI joint in patients who still had pain after lumbosacral fusion. If this injection is non-contributive when CT-guided under local anesthesia, it can be repeated under general anesthesia with 3D O-arm guidance. This diagnostic strategy allowed us to confirm that pain originates in the SI joint after lumbosacral fusion in 9 of 10 patients.

Conclusion: If the first two CT-guided SI joint injections fail, 3D surgical navigation is an alternative means of doing the injection that helps to significantly reduce SI joint-related pain after lumbosacral fusion.

Level of evidence: IV, retrospective study.

Keywords: Diagnosis; Lumbosacral fusion; Sacroiliac joint pain; Test injection.

Copyright © 2020 Elsevier Masson SAS. All rights reserved.

Spino-femoral muscles affect sagittal alignment and compensatory recruitment: a new look into soft tissues in adult spinal deformity

Hongda Bao, Bertrand Moal, Shaleen Vira, Nicolas Bronsard, Celia Amabile, Thomas Errico, Frank Schwab, Wafa Skalli, Jean Dubousset, Virginie Lafage

https://pubmed.ncbi.nlm.nih.gov/32529524/

Abstract

Objective: To quantify muscle characteristics (volumes and fat infiltration) and identify their relationship to sagittal malalignment and compensatory mechanism recruitment.

Methods: Female adult spinal deformity patients underwent T1-weighted MRI with a 2-point Dixon protocol from the proximal tibia up to the T12 vertebra. 3D reconstructions of 17 muscles, including extensors and flexors of spine, hip and knee, were obtained. Muscle volume standardized by bone volume and percentage of fat infiltration (Pfat) were calculated. Correlations and regressions were performed.

Results: A total of 22 patients were included. Significant correlations were observed between sagittal alignment and muscle parameters. Fat infiltration of the hip and knee flexors and extensors correlated with larger C7-S1 SVA. Smaller spinal flexor/extensor volumes correlated with greater PI-LL mismatch (r = – 0.45 and – 0.51). Linear regression identified volume of biceps femoris as only predictor for PT (R2 = 0.34, p = 0.005) and Pfat of gluteus minimus as only predictor for SVA (R2 = 0.45, p = 0.001). Sagittally malaligned patients with larger PT (26.8° vs. 17.2°) had significantly smaller volume and larger Pfat of gluteus medius, gluteus minimus and biceps femoris, but similar values for gluteus maximus, the hip extensor.

Conclusion: This study is the first to quantify the relationship between degeneration of spino-femoral muscles and sagittal malalignment. This pathoanatomical study identifies the close relationship between gluteal, hamstring muscles and PT, SVA, which deepens our understanding of the underlying etiology that contributes to adult spinal deformity.

Keywords: Adult spinal deformity; Compensatory recruitment; Sagittal malalignment; Spino-femoral muscles.

Imaging of intervertebral disc prostheses

N Amoretti, A Iannessi, V Lesbats, P-Y Marcy, E Hovorka, N Bronsard, M-E Fonquerne, O Hauger

https://pubmed.ncbi.nlm.nih.gov/22277706/

Abstract

Disc arthroplasty is the replacement of a painful pathological intervertebral disc by a prosthesis, which, unlike spinal fixation, has the advantage of retaining vertebral mobility in the segment concerned. The success of the procedure is dictated by the indication. The radiologist must look for radiographic arguments indicating or contraindicating fitting an implant, and particularly for the presence of facet arthritis which will prompt the surgeon to choose an arthrodesis. Moreover, radiological information plays a major part in preparing for a surgical procedure, as far as access to the disc via the anterior approach is concerned and assessment by CT angiography of the risk of vascular complications. After insertion, radiological monitoring using dynamic X-ray images checks that the implant is correctly positioned and that mobility is restored. In the long term, it can detect complications related to the prosthesis and premature wear to other points of support such as adjacent discs and the facet joints.

Copyright © 2011 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

One-stage percutaneous treatment in a patient with pelvic and vertebral compression fractures

Jacques Sedat, Yves Chau, Cesar Razafidratsiva, Nicolas Bronsard, Fernand de Peretti

https://pubmed.ncbi.nlm.nih.gov/19774411/

Abstract

An active 38-year-old patient presenting a vertebral compression fracture associated with a pelvic fracture was treated in one stage with CT-guided fixation of the sacrum and kyphoplasty. This treatment decreased the pain, restored the vertebral height, and enabled the patient to be ambulatory. The main advantage of this double approach was to shorten the hospital stay and the nonworking period.

Centering of cervical disc replacements: usefulness of intraoperative anteroposterior fluoroscopic guidance to center cervical disc replacements: study on 20 discocerv (scient’x prosthesis)

Pascal Kouyoumdjian, Nicolas Bronsard, Jean Marc Vital, Olivier Gille

https://pubmed.ncbi.nlm.nih.gov/19564767/

Abstract

Study design: This is a prospective randomized computed tomographic scan study on the centering of cervical disc prosthesis (Discocerv; Scient’X) with and without anteroposterior (AP) fluoroscopic guidance.

Objective: Analyze interest of AP fluoroscopic guidance for coronal positioning in cervical disc replacements.

Summary of background data: This series consisted of 20 patients. One group of 10 patients was operated using only lateral fluoroscopic guidance (L guidance) and the other group of 10 patients was operated using both lateral and AP fluoroscopic guidance (AP + L guidance). Total disc replacements positioning is analyzed in the 2 groups.

Methods: All patients had a computed tomographic scan 24 hours after surgery. Specific reconstructions were obtained from the native slices. Three planes P1, P2, and P3 are defined to quantify centering of the prosthesis in axial sagittal and coronal planes. RESULTS.: In the coronal plane P1, there is no difference in lateralization between the L guidance (absolute value of average M = 0.93 mm; SD = 0.59 mm) and AP + L guidance groups (M = 1.28 mm; SD = 0.75 mm). In the axial plane, there is no difference in lateralization between the L guidance and AP + L guidance groups. In the L guidance group, average was 1.96 degrees (SD = 1.43 degrees ) and 3.18 degrees (SD = 2.94 degrees ) in AP + L guidance. There is no significative difference between 2 groups in coronal (P = 0.26) and axial plane (P = 0.19).

Conclusion: Unci are reliable landmarks for coronal centering of total disc replacements. AP fluoroscopic guidance does not improve this positioning.

Extension reserve of the hip in relation to the spine: Comparative study of two radiographic methods

I Hovorka, P Rousseau, N Bronsard, M Chalali, M Julia, M Carles, N Amoretti, P Boileau

https://pubmed.ncbi.nlm.nih.gov/19070721/

Abstract

Free-hip movement is necessary for good spinal function. Limitation generally affects extension. The range of hip extension from the standing position can be considered as the hip’s « extension reserve ». The amplitude of this reserve must be known because any deficit requires a pathological solicitation of the vertebral column. Measurement of the extension reserve of the hip is useful for analyzing spinal disease and for preoperative planning. Physical examination can measure extension, but cannot differentiate movement produced by the hip from that originating in the spine. We have been unable to locate any radiographic method in the literature. The purpose of this study was to evaluate radiographic measurements and to propose a novel method. The study was conducted with 37 patients with spinal disease. Two radiographic methods were compared. Four lateral views, including the lumbar spine, the pelvis and the femur were obtained in each patient: neutral position, retroversion of the pelvis and extension of each hip in lunge position. The X-rays were digitalized for computer processing. The extension reserve of the hip was calculated for each radiographic method. Extension reserve was defined as the difference in the pelvis-femoral angle between the neutral position and extension. There was a positive correlation between the two methods (p<0.0006; p<0.0009). Mean extension using the pelvis retroversion method was 1.8 degrees +/-6.77; with the hip-extension method, it was hip I (side with the superior value): 15.9 degrees +/-6.57; hip II 10.0 degrees +/-7.89. The pelvis-retroversion method gave a lower measurement compared with the lunge position method (p<0.0001). For 13 of 37 subjects (35%), this method gave negative values, that is, failure of the measurement method. The method of hip extension in lunge position was superior to the pelvis-retroversion method, which gave lower measurements that were often incoherent and unable to provide specific information for each hip. The method using the lunge position for hip extension appears to be preferable. We are currently conducting a clinical trial to include extension reserve in the analysis of sagittal balance and for determining curvature corrections. We propose a mathematical formula using extension reserve for determining sagittal correction. Radiographic determination of extension reserve of the hip joint is of major importance for assessing spinal disease in addition to its contribution to the analysis of hip and pelvic disease. The methods presented here enable radiographic measurement of the extension reserve of the hip.

Percutaneous osteosynthesis of lumbar and thoracolumbar spine fractures without neurological deficit: surgical technique and preliminary results

C Pelegri, A Benchikh El Fegoun, M Winter, N Brassart, N Bronsard, I Hovorka, F de Peretti

https://pubmed.ncbi.nlm.nih.gov/18774020/

Abstract

Purpose of the study: The aim of this work was to study the technique of percutaneous osteosynthesis of lumbar and thoracolumbar spine fractures without neurological deficit and to report preliminary results.

Material and methods: This retrospective study included 15 patients with lumbar or thoracolumbar spine fractures who were treated between January 2004 and January 2006 by percutaneous osteosynthesis. There were seven men and eight women, mean age 36 years (range 16-58 years). The Magerl classification (AO) was A1 (n=4), A2 (n=1), A3 (n=9), B2 (n=1). Levels were T12 (n=1), L1 (n=10), L2 (n=2), L3 (n=1), L4 (n=1). A specific instrument set was used to insert a short fixation using two pedicular screws on either side of the fractured vertebra and two prebent 5.5mm rods introduced with an aiming device. The operation was performed under fluoroscopy. Ten patients wore a removable corset. The upright position was allowed if there were no other injuries. Computed-tomography scans were obtained preoperatively, postoperatively and at two years follow-up. Function was assessed with the Oswestry score.

Results: Mean operative time was 108 minutes (range 40-180 minutes). None of the patients with an isolated spinal injury required blood transfusion. Mean hospital stay was 12 days (range 4-28). Results were expressed for 13 patients whose operations were exclusively percutaneous. Mean follow-up was 17 months (range 6-30). The visual analog scale (VAS) was 1.6/10. The mean Oswestry score was 16. Three quarters of the patients resumed their occupational activities. None of the patients was dissatisfied. Mean vertebral kyphosis (VK) improved from 16 to 8.1 degrees , corrected regional angle (CRA) from 12 to 2.5 degrees at last follow-up. Loss of correction at last follow-up was 1.1 degrees for VK and 2.5 degrees for CRA. The rate of pedicle screw malposition was 3.8%. There were no cases of disassembly nor material failure. There were no infections. None of the implants had to be removed.

Discussion: Percutaneous osteosynthesis of the spine is technically feasible, but requires considerable experience. Functional and subjective results have been good. The loss of correction at last follow-up has been comparable to that observed with conventional open surgery. This technique is an intermediary method between orthopaedic treatment and conventional surgery. Exact indications must be established.

Conclusion: Percutaneous osteosynthesis of lumbar and thoracolumbar spine fractures is an attractive therapeutic option. Our results are encouraging. Indications and limitations of this technique must be carefully identified.