[Collected data on freehand technique instrumentation and literature comparison on fluoroscopic and CT-assisted navigation]. / Erhobene Daten zur Instrumentierung in Freihandtechnik und Literaturvergleich zu fluoroskopisch- und CT-gestützter Navigation.

BACKGROUND: A proven and frequently used surgical procedure in patients with idiopathic scoliosis (IS) is posterior transpedicular corrective spondylodesis using the freehand technique. Novel procedures with fluoroscopically and computed tomography (CT)-assisted navigation are presumed to be less risky and more accurate. OBJECTIVE: Is the freehand technique for IS safe with respect to screw-associated complications and intraoperative radiation exposure? MATERIAL AND METHODS: Prospectively collected data (2017-2018) from 39 consecutive patients (average age 18.7 years) with thoracic single curvature IS (61.7°â€¯± 13.9°) from a specialized scoliosis center were evaluated for the following parameters (mean ± standard deviation): total radiation product, fluoroscopy time, fused segments, operative time, blood loss and screw-associated complications. A comparison with data from the literature on intraoperative radiation exposure using navigation procedures was carried out. RESULTS: The total radiation product per patient was 71.7 ± 44.0 cGy*cm2, fluoroscopy time 17.4 ± 8.6 s. (7.8 segments), operative time 183.5 ± 54.2 min and blood loss 379.5 ± 183 ml. There were no screw-associated complications in the entire collective. Correction of the main curvature was 75.7%. Comparison of the data with index data from the literature showed a 1.25-12.5-fold higher radiation exposure for patients with fluoroscopically assisted navigation and 9.25-12.3-fold higher radiation exposure with CT-assisted procedures compared to the present results. CONCLUSION: The results of this study showed that with appropriate experience freehand positioning of pedicle screws is associated with comparable accuracy and less radiation exposure for patients than navigation procedures. With respect to the young age of patients, a radiation-induced long-term risk for malignant diseases should be taken into consideration.

[Anterior scoliosis surgery. State of the art and a comparison with posterior techniques]. / Ventrale Skolioseoperationen. Stand der Technik und Vergleich mit dorsalen Verfahren.

For more than 2 decades ventral derotation spondylodesis (Zielke VDS) as a major improvement over Dwyer instrumentation (DI) was the gold standard of instrumented curve correction and stabilization from the anterior approach. As the first available system it enables a true three-dimensional curve correction. A disadvantage is the low internal stabilization capability with a need for long-term external stabilization by means of cast and brace treatment postoperatively. Meanwhile with the development of modern single and dual solid rod systems these disadvantages can be avoided completely. Video-assisted (thoracoscopic) anterior scoliosis surgery accounts for less than 2% of anteriorly treated scoliosis cases, mainly due to a long operating time and significant learning curve.From the posterior approach the Cotrel-Dubousset instrumentation (CDI) as a polysegmentally attached posterior hook threaded dual rod system used to be state of the art for a long time, since it eliminated the disadvantages of Harrington instrumentation (HI) in terms of only one-dimensional correction and low stabilization capabilities. However even with CDI effective derotation was impossible. In posterior scoliosis surgery there is a strong trend away from hook systems towards transpedicular segmentally fixed dual rod systems not only in the lumbar spine but also in the thoracic area. Advantages of these newer techniques are shorter fusion, improved correction, and less loss of correction over time.Advantages of modern anterior instrumentation systems in comparison to posterior transpedicular instrumented dual rod systems are less blood loss, better derotation, slightly shorter fusion levels, and a better influence on sagittal plane control or improvement especially for hypokyphotic thoracic scoliosis cases. Our data also document a superior spontaneous correction of the lumbar curve after selective anterior instrumented correction (Lenke 1B+C), although other studies could not find significant differences. In our experience the neurological risk of anterior instrumented correction is also lower than that of posterior scoliosis surgery, although the morbidity and mortality data of the Scoliosis Research Society could not prove that anymore in recent years. A negative effect of anterior transthoracic scoliosis surgery in comparison to posterior surgery is a more negative effect on lung function, which improves slower after surgery and does not quite reach the levels of posterior surgery at follow-up. But new data on posterior segmental transpedicular correction and fusion also prove a lordosating effect with negative effect on lung function.

[Surgical management of adult scoliosis. The challenge of osteoporosis and adjacent level degeneration]. / Die operative Behandlung der adulten Skoliose. Osteoporose und Versagen des Anschlusssegments als besondere Herausforderung bei der operativen Versorgung.

Adult scoliosis is defined as a spinal deformity with a Cobb angle of more than 10 degrees in the coronal plain in a skeletally mature patient. Patients predominantly suffer from back pain symptoms, often accompanied by signs of spinal stenosis (central as well as lateral). Asymmetric degeneration leads to asymmetric load and therefore to a progression of the degeneration and deformity as either scoliosis (0.5-1 degree per year), kyphosis, or both. The diagnostic evaluation includes static and dynamic imaging, magnetic resonance imaging, and myelo-computed tomography, as well as invasive diagnostic procedures such as discograms, facet blocks, and epidural and root blocks. The treatment, either conservative or surgical, is then tailored to the patient's specific symptomatology. Surgical management is usually complex and must take into account an array of specific problems, including the patient's age and general medical condition, the length of the fusion, the condition of the adjacent segments, the condition of the lumbosacral junction, osteoporosis, and any previous scoliosis surgery. The main goal of corrective surgery is a balancing of the coronal and sagittal planes.This review focuses on the special indications for vertebral body cement augmentation in patients with osteoporosis and the problem of adjacent level degeneration and its surgical management.

[Modern scoliosis surgery under the conditions of the German DRG-system]. / Finanzierbarkeit der modernen Skoliosechirurgie unter den Bedingungen des DRG-Systems.

In the German health system the payment of a hospital stay is standardised. The common basis is the G-DRG System (German diagnosis-related groups) in which every stay is paid by a lump sum. Scoliosis correction in our times means pedicle screw-based multilevel double rod instrumentation or anterior plate-rod instrumentation with primary stability. The outcome of those methods has improved the results of correction and decreased the complication rate but also means high costs due to the implants. Scoliosis correction is covered by DRG I06. Due to constant efforts a general improvement took place in the assessment of DRG I06. That is the reason why the losses incurred in DRG I06C could be lowered to 38% and in I06D to 22% in 2008. For an appropriate assessment further improvements are required.