[Odontoid fracture after high impact trauma : Assess instability correctly]. / Densfraktur nach Hochrasanztrauma : Instabilität richtig einschätzen.

Odontoid process fractures are frequent injuries of the cervical spine and usually occur at an advanced age and often due to minor trauma. In younger patients they are mainly observed in the context of high impact trauma. Odontoid fractures are classified according to Anderson and D'Alonzo. In rare cases the fracture results in cervical myelopathy, which can be life-threatening.In this article, two cases of patients with odontoid fractures and traumatic myelopathy are presented. The first case concerns a type III fracture, the second a type II fracture. In both cases the instability present was incorrectly assessed on the basis of the anatomical position in the initial computed tomography (CT). In the further course both cases showed considerable instability, which led to fatal spinal cord injuries.The purpose of this case report is to draw attention to the possible presence of spinal cord injuries in supposedly trivial odontoid fractures when high speed trauma has occurred. In particular, spinal cord compression should be considered in patients requiring resuscitation without having an internal medical cause. If the patient with a bone injury on CT, e.g. cannot be adequately assessed clinically by intubation, the indications for magnetic resonance imaging must be generously considered. This is the only way to ensure early detection of a myelopathy and timely treatment.

Implementation of a multidisciplinary infections conference improves the treatment of spondylodiscitis.

Establishing a multidisciplinary approach regarding the treatment of spondylodiscitis and analyzing its effect compared to a single discipline approach. 361 patients diagnosed with spondylodiscitis were included in this retrospective pre-post intervention study. The treatment strategy was either established by a single discipline approach (n = 149, year 2003-2011) or by a weekly multidisciplinary infections conference (n = 212, year 2013-2018) consisting of at least an orthopedic surgeon, medical microbiologist, infectious disease specialist and pathologist. Recorded data included the surgical and antibiotic strategy, complications leading to operative revision, recovered microorganisms, as well as the total length of hospital and intensive care unit stay. Compared to a single discipline approach, performing the multidisciplinary infections conference led to significant changes in anti-infective and surgical treatment strategies. Patients discussed in the conference showed significantly reduced days of total antibiotic treatment (66 ± 31 vs 104 ± 31, p < 0.001). Moreover, one stage procedures and open transpedicular screw placement were more frequently performed following multidisciplinary discussions, while there were less involved spinal segments in terms of internal fixation as well as an increased use of intervertebral cages instead of autologous bone graft (p < 0.001). Staphylococcus aureus and Staphylococcus epidermidis were the most frequently recovered organisms in both patient groups. No significant difference was found comparing inpatient complications between the two groups or the total in-hospital stay. Implementation of a weekly infections conference is an effective approach to introduce multidisciplinarity into spondylodiscitis management. These conferences significantly altered the treatment plan compared to a single discipline approach. Therefore, we highly recommend the implementation to optimize treatment modalities for patients.

[Minimally invasive posterior and anterior stabilization of the thoracolumbar spine after traumatic injuries]. / Minimal-invasive dorsale und ventrale Stabilisierung der thorakolumbalen Wirbelsäule bei traumatischen Verletzungen.

Injuries of the thoracolumbar junction are the most common fractures of the spine due to their anatomical position and load. Common classification systems differentiate between stable and unstable injuries and thus also between operative and conservative therapy. The majority of injuries can be treated conservatively; however, unstable injuries require surgical treatment for a variety of reasons. In the grey area between stable and unstable injuries, a clinical decision based on clinical experience is necessary in order to select the best treatment. A wide variety of parameters must be included and a change in strategy from conservative to operative may also be necessary. Posterior instrumentation is the most common procedure; purely anterior stabilization is rarely used. The length of the instrumentation/spondylodesis depends on bone quality, age of the patient, and fracture. The decision as to whether anterior operative treatment should be performed depends on fracture morphology, success of reduction, and the resulting stability. The open surgical procedure is increasingly being replaced by minimally invasive procedures in posterior and anterior techniques but can be an advantage in complex injuries (B and C injuries according to AO). Hybrid procedures are also possible. This also applies to the treatment of osteoporotic fractures, since a clear assignment between traumatic and osteoporotic cause is not always easy and possible. This article describes the principles, the possible indications, and limitations of minimally invasive posterior and anterior stabilization.

[Posterior vertebral column resection for correction of kyphotic deformity due to osteoporotic fractures of the thoracic spine]. / Posterior vertebral column resection (PVCR) zur Korrektur von Hyperkyphosen bei osteoporotischen Frakturen der Brustwirbelsäule.

OBJECTIVE: The posterior vertebral column resection (PVCR) comprises a one-step resection of the vertebral body by a costotransversectomy together with a 360° spondylodesis. After removing the vertebral body, straightening of the existing kyphotic malposition is possible. INDICATIONS: Pronounced thoracic kyphosis after osteoporotic sintering fractures in one or more vertebral bodies. CONTRAINDICATIONS: General contraindications for surgical procedures, ASA >3 (American Society of Anesthesiologists). SURGICAL TECHNIQUE: First, dorsal stabilization of the vertebral column on at least two levels cranial and caudal of the VCR. Next, in a one-step procedure the laminectomy with costotransversectomy and the resection of the vertebral body is done. The ventral defect gap is filled by a mesh cage to provide ventral support. By compression the malposition is reduced and the mesh cage is fixed into position. Finally the vertebrae joints are opened up using a chisel and bone or bone substitute is placed to complete the 360° spondylodesis. POSTOPERATIVE MANAGEMENT: Functional treatment without peak load exercises as well as appropriate osteoporosis treatment. RESULTS: In a retrospective study 10 patients treated with this surgical technique were investigated. The results show a very good correction of the kyphotic maldeformity while the complications remain moderate.

[Pedicle subtraction osteotomy to correct rigid deformities]. / Pedikelsubtraktionsosteotomie zur Korrektur rigider Deformitäten.

OBJECTIVE: The aim of the surgery is to restore the sagittal profile in the event of a mismatch of the patient's spinopelvic parameters and high patient suffering. INDICATIONS: Clinically symptomatic sagittal imbalance due to degeneration, trauma or after spinal surgery which can not be adequately treated by conservative therapy. CONTRAINDICATIONS: Severe general disease of the patient; local or systemic inflammation. SURGICAL TECHNIQUE: A dorsal approach is used to resect the dorsal vertebral structures and to perform an osteotomy to the anterior edge of the spine. POSTOPERATIVE MANAGEMENT: Rest with a load limit of 5 kg for 3 months. Prohibition of deep sitting for this time. RESULTS: The pedicle subtraction osteotomy is described in the literature as a reliable method for the treatment of sagittal imbalance. The high rate of described complications should be discussed preoperatively with the patient.