Pathoanatomic Risk Factors for Instability and Adjacent Segment Disease in Lumbar Spine: How to Use Topping Off?

PURPOSE: The goal of this review is to identify criteria indicating implantation of hybrid system into lumbar spine and to evaluate general benefits of use. METHODS: A systematic review of literature was performed using current randomized clinical trials, reviews, and meta-analyses. Data sources included relevant literature of human studies identified through searches of Medline Library until May 2015. RESULTS: Predisposing factors for Adjacent Segment Disease (ASDi) are discussed in literature: laminar horizontalization, insufficiency of fascia thoracolumbalis, facet tropism, and facet sagittalization. Currently there is no evidence for topping off. There are only 12 studies and these have no consistent statements about use of a hybrid system for avoidance of ASDi. CONCLUSION: Hybrid instrumentation of lumbar spine, either with pedicle-based technique or additional spacer, might possibly prevent ASDi from developing in previously damaged segment adjacent to a fusion. Good clinical data proving effectiveness of this new implant technique is as yet unavailable. Thus, currently one must speak of an unevaluated procedure. Various radiological classifications can assist in making a reliable decision as to whether hybrid instrumentation is an appropriate choice of therapy. Pathoanatomical conditions of facet joints and laminae as well as preservation of sagittal balance must also be considered.

Accuracy of 3D fluoro-navigated anterior transpedicular screws in the subaxial cervical spine: an experimental study on human specimens.

INTRODUCTION: Pedicle screw stabilization, the standard technique in the thoracic and lumbar spine, is increasingly used in the cervical spine. Initial studies on the use of anterior pedicle screws (ATPS) in the cervical spine have been recently published. ATPS use has theoretical advantages over posterior stabilization. We have already established a 3D-fluoroscopy navigation setup in a study of artificial bones. The aim of the current study was to evaluate the positioning quality/accuracy of ATPS introduced to human specimens. METHODS: 36 cannulated screws (3.5 mm) were implanted anteriorly into the C3-C7 segments of four spines (unfixed, frozen, cadaveric specimens) using a 3D-fluoroscopy navigation system. Placement accuracy was evaluated using a recently published classification on postoperative CT scans. Grade 1 is perfect position with pedicle wall perforation <1 mm, grade 2 is perforation <2 mm, etc., and finally grade 5 is cortical perforation of >4 mm and/or transverse foramen entry. RESULTS: 36 anterior pedicle screws were inserted into four human cervical spine specimens. Of these, seven screws were introduced to C3, five to C4 and eight each to C5, C6, and C7. Classified with the modified G&R, 21 of 36 (58.3%) were grade 1. Ten screws (27.8%) were grade 2. Grade 4 was assessed for two screws and grade 5 for three. Customary "good" positioning, combining grades 1 and 2, was thus found in 86.1%. Five screws (13.9%) did not meet this criterion (grade ≥3). CONCLUSIONS: With 86.1% of good positioning (grade 2 or better), a 3D-fluoroscopy navigation of ATPS screws into human c-spine specimens achieved a satisfying results. These are at least comparable to results presented in the literature for posteriorly introduced subaxial pedicle screws.

Predictive validity of preoperative CT scans and the risk of pedicle screw loosening in spinal surgery.

INTRODUCTION: Pedicle screw fixation is the standard technique for the stabilization of the spine, a clinically relevant complication of which is screw loosening. This retrospective study investigates whether preoperative CT scanning can offer a predictor of screw loosening. METHODS: CT-scan attenuation in 365 patients was evaluated to determine the mean bone density of each vertebral body. Screw loosening or dislocation was determined in CT scans postoperatively using the standard radiological criteria. RESULTS: Forty-five of 365 patients (12.3 %; 24 male, 21 female) suffered postoperative screw loosening (62 of 2038 screws) over a mean follow-up time of 50.8 months. Revision surgeries were necessary in 23 patients (6.3 %). The correlation between decreasing mean CT attenuation in Hounsfield Units (HU) and increasing patient age was significant (p < 0.001). Mean bone density was 116.3 (SD 53.5) HU in cases with screw loosening and 132.7 (SD 41.3) HU in cases in which screws remained fixed. The difference was statistically significant (p = 0.003). CONCLUSION: The determination of bone density with preoperative CT scanning can predict the risk of screw loosening and inform the decision to use cement augmentation to reduce the incidence of screw loosening.

[Conservative treatment of nonspecific, chronic low back pain : Evidence of the efficacy - a systematic literature review]. / Konservative Therapie beim unspezifischen, chronischen Kreuzschmerz : Evidenz der Wirksamkeit - eine systematische Literaturanalyse.

OBJECTIVES: Non-specific chronic low back pain (NSCLBP): Which conservative therapy shows an evident effectiveness - A review of the current literature. MATERIALS AND METHODS: Our results are based on literature reviews of current randomised control studies, reviews and meta-analysis drawn from the Cochrane Library and Medline-Database between the years 2004 until 2015. German and English Studies were included. We focused on different conservative Treatments of NSCLBP, which are listed at, the NVL-Guidelines. Based on the given evidence we evaluated their effectiveness. RESULTS: As part of the review we identified 4657 Publications, 85 were included in this study. Therapeutic options such as bed rest, TENS, Massage, Spine Supports, Back Schools and Antidepressants showed no evident effectiveness. Injections, NSAR analgesic therapy, Thermotherapy and Opioid analgesic therapy indicated a short-time effectiveness. A long term success (> 6 weeks) however, can not be shown. Only the Movement therapy can, in the summation of the included studies, postulate an evident (Evidence Level I) long-term effect treating NSCLBP. Only a few therapy options indicate a significant evident effectiveness for treating NSCLBP conservatively. At short notice methods such as injection therapy, thermo-therapy and analgesic therapies with NSAR and/or opioids help coping the acute phase. In the long term only movement therapy seems to provide an evident effectiveness. In the case of therapy-refractory NSCLBP a multimodal therapy should be considered.

[Nonunion of the femoral neck and artificial heart. How far may we go?]. / Duokopfprothesenimplantation bei Schenkelhalspseudarthrose und liegendem Kunstherz. Wie weit darf man gehen?

Due to medical improvements surgeons are increasingly confronted with conditions associated with severe medical comorbidities. Fracture or nonunion of the femoral neck would have been classified as "inoperable" in the past. We report the successful operative treatment of a patient with femoral neck nonunion after screw osteosynthesis and associated existence of a left ventricular assist device for dilated cardiomyopathy.

Current concepts in the treatment of Anderson Type II odontoid fractures in the elderly in Germany, Austria and Switzerland.

Although currently there are many different recommendations and strategies in the therapy of odontoid fractures in the elderly, there are still no generally accepted guidelines for a structured and standardised treatment. Moreover, the current opinion of spine surgeons regarding the optimal treatment of odontoid fractures Type II of the elderly is unknown. In order to have an objective insight into the diverging strategies for the management of Anderson Type II odontoid fractures and form a basis for future comparisons, this study investigated the current concepts and preferences of orthopaedic, neuro- and trauma surgeons. Spine surgeons from 34 medical schools and 8 hospitals in Germany, 4 university hospitals in Austria and 5 in Switzerland were invited to participate in an online survey using a 12-item 1-sided questionnaire. A total of 44 interviewees from 34 medical institutions participated in the survey, consisting of trauma (50%), orthopaedic (20.5%) and neurosurgeons (27.3%). Out of these, 70.5% treated 1-20 fractures per year; 63.6% favoured the anterior screw fixation as therapy for Type II odontoid fractures, the open posterior Magerl transarticular C1/C2 fusion, the posterior Harms C1/C2 fusion, and conservative immobilisation by cervical orthosis was preferred by 9.1% in each case. 59.1% preferred the anterior odontoid screw fixation as an appropriate treatment of Anderson Type II odontoid fractures in the elderly. 79.5% chose cervical orthosis for postsurgical treatment. Following operative treatment, nonunion rates were reported to be <10% and <20% by 40.9% and 70% of the surgeons, respectively. 56.8% reported changing from primary conservative to secondary operative treatment in <10% of cases. The most favoured technique in revision surgery of nonunions was the open posterior Magerl transarticular fusion technique, chosen by 38.6% of respondents. 18.2% preferred the posterior Harms C1/C2 fusion technique, 11.4% the percutaneous posterior Magerl technique and the anterior odontoid screw fixation in each case. This study discovered major variations in the treatment of Anderson Type II odontoid fractures in the elderly in terms of indication for conservative and operative treatment between several treatment centres in 3 European countries. Difficulty and complexity in formulating general guidelines based on multicenter studies is conceivable.

Blunt cerebrovascular injuries in acute trauma care: a screening protocol.

INTRODUCTION: Blunt cerebrovascular injuries (BCVI) of the extra- or intracerebral vessels are frequently observed lesions which may lead to thrombembolic events with focal neurological deficits, stroke or death particularly in patients <60 years. However, a comprehensive standardised clinical algorithm for screening and management of these secondary injuries is still lacking. MATERIALS AND METHODS: We developed a standardised screening protocol applicable for mild as well as severely injured patients. In this prospective cohort study, we evaluated the feasibility of this diagnostic algorithm in a level 1 trauma centre setting. Trauma patients who met the inclusion criteria underwent a computed tomographic angiography (CTA) as part of standard diagnostic procedure at admission. All suspicions or positive findings were reevaluated by a conventional four-vessel catheter angiography within the first 72 h after trauma. Within this period, anticoagulation with low-dose heparin was started. BCVI confirmation indicated a shift to systemic heparinisation with overlapping phenprocoumon therapy for at least 6 months. All patients were reevaluated after 6 months by another four-vessel angiography. Depending on the diagnostic findings, oral anticoagulation may be discontinued or continued for another 6 months. RESULTS: A total of 44 patients (8 male, 6 female, age range 19-95 years) were included in the study. 20 BCVIs were detected in 16 patients (36.3%). The most common injuries identified were Biffl Type II (40%) and Type IV lesions (30%). 86.4% of the patients received a CTA upon admission, 93.2% of which were conducted within 12 h posttrauma. None of the patients had a secondary thrombembolic neurological event during the hospital stay or within 3 months postdischarge. CONCLUSION: Our results indicate that implementation of the screening protocol can prevent strokes in patients without primary thrombembolic neurological deficits.

[Enchondroma of the hand - treatment and long-term outcome]. / Enchondrome des Handskeletts - Therapeutisches Vorgehen und funktionelle Langzeitergebnisse.

BACKGROUND: An enchondroma is with up to 90% the most common benign tumour of the hand. Functional long-term outcome studies of the several treatments do not exist. The aim of this study is thus to evaluate the information from our 147 patients about diagnostics, operative treatment and follow-up treatment. METHODS: 147 patients with 183 histologically secured enchondromas of the hand, who had been treated between 1973 and 2004, were analysed by follow-up examination and radiological findings retrospectively. RESULTS: We found 136 mono- and 11 polyostotic lesions. The proximal phalanx was afflicted most commonly (44.8%). There was no preference for one special finger, only the thumb was afflicted below average (9.8%). The most common symptoms were pain and swelling (51.7%) or pathological fracture (25%). We found 11 relapses (7.5%) after an average of 4.4 years. In two cases we found a grade 1 chondrosarcoma. 84.2% of the patients achieved a "very good" or a "good" functional long-term outcome, 11.7% a "fair" and 4.2% a "poor" outcome. CONCLUSION: Standard treatment should be the accurate extirpation of the tumour and subsequent filling of the defect with cancellous bone. Only very small, asymptomatic lesions can be treated conservatively with six-month check-up examinations.

Is there a way to diagnose spinal instability in acute burst fractures by performing ultrasound?

The aim of this study is to examine the predictive value of ultrasound diagnostics for the assessment of traumatic lesions of the posterior ligament complex (PLC) in burst fractures of the thoracolumbar spine. This was a prospective validating cohort study. Judgment about instability and treatment of burst fractures depends on the condition of the PLC. There have been some studies describing underdiagnosis of PLC injuries due to classification problems in ligamentary distraction type fractures. The gold standard for assessing these lesions is magnetic resonance imaging (MRI). Even then, there are often limits in contemporary operational availability and technical limitations of MRI. Ultrasound was described being an alternative. In a prospective study, 54 levels of 18 patients with acute burst fractures of the thoracic and lumbar spine have been examined by ultrasound and additional MRI scans preoperatively. The condition (intact vs. ruptured) of supraspinous ligament (SSL) and the interspinous ligament has been assessed for the ligaments separately. Hematoma below the SSL has also been evaluated as an indirect sign of an injured PLC. In all the patients the primary performed operative treatment was a posterior spinal instrumentation. Postoperatively the blinded results of the ultrasound procedures have been matched against intraoperative and MRI findings. Assessments of all target structures have been contributed to the calculation of the sensitivity and specificity of ultrasound. A total of 18 patients, 14 males and 4 females, with acute burst fractures have been qualified for inclusion in the study. The patients' mean age was 43.4 years. Comparing intraoperative findings with preoperatively performed investigations, ultrasound archived a sensitivity of 0.99 and a specificity of 0.75 (P < 0.05) to detect traumatic lesions to the PLC. As hypothesized the obtained predictive value using ultrasound correlates closely with intraoperative findings. Anyway MRI still seems to be the superior diagnostic method for examining the PLC. However, ultrasound can be considered to be an adequate alternative method in cases with contraindications for MRI such as ferromagnetic side effects, claustrophobia, availability or emergency diagnostics in multiple injuries.

Self-inflicted gunshot injury simulating a criminal offence.

An extraordinary case of a young woman with a gunshot wound to her left hand is presented. A typical near-contact entrance wound at the palm of the hand, extensive soft tissue destruction including nerve and vessel injury and a large stellate exit wound at the back of the hand were diagnosed and surgically treated. The woman initially stated that she had tried to repulse the pistol when a man shot her from close-range, which is consistent with the injury findings. After questioned thoroughly, however, she confessed self-infliction using a 8 mm blank pistol. This case demonstrates that a self-inflicted injury simulating a criminal offence can be present even if very atypical features such as the use of a firearm and mutilating or defence-like injuries clearly speak against it.

[3D navigated osteosynthesis of calcaneal fractures. Open and minimally invasive techniques]. / 3D-navigierte Fersenbeinosteosynthese: Offene und minimal-invasive Technik.

BACKGROUND: It is hypothesized that misplacement of sustentacular screws during osteosynthesis of intraarticular calcaneal fractures can be reduced with the help of navigation. A method for three-dimensional (3D) navigated placement of sustentacular screws for treating intraarticular calcaneal fractures is presented and evaluated. MATERIAL AND METHODS: 11 consecutive patients with 15 intraarticular calcaneal fractures were treated using 3D navigation. In 12 cases osteosynthesis was done through an extended lateral approach; in three cases, it was achieved through a minimally invasive percutaneous approach. For verification and documentation of the placed screws, a second 3D scan was performed. RESULTS: A total of 20 screws were placed using 3D navigation. None of the navigated screws was misplaced. Extra operating time due to navigation averaged 11.9 minutes (+/-2.2 min). CONCLUSION: Through a combination of intraoperative 3D imaging and navigation, placement of sustentacular screws is possible and can yield precise and reliable results. Especially in minimally invasive treatment, a high quality of osteosynthesis can be achieved.

[Persistent dysphagia and mechanical glottic paralysis. Complications of a ventral fracture spondylodesis with Forestier's disease]. / Persistierende Dysphagie und mechanische Glottisparese: Komplikation einer ventralen Frakturspondylodese bei Morbus Forestier.

Persistent dysphagia after ventral instrumentation of a patient with a cervical spine fracture and diffuse idiopathic skeletal hyperostosis (DISH, or Forestier's disease) is a rare but dramatic complication. In this case report some pathogenetic factors are discussed. Accurate resection of the spondylophytes should be considered to avoid a ventral protrusion of the plate.