[Early intraoperative and postoperative complications of C1-C2 fixation using the Goel-Harms technique : How often? Which? Why?] / Frühe intra- und postoperative Komplikationen der C1-C2-Fixation nach Goel-Harms : Wie oft? Welche? Warum?

Fractures of the axis are among the most frequent spinal injuries. Posterior C1-C2 fixation according to Goel-Harms is an accepted alternative to the more traditional procedures: initial stability has been shown and there is a wide range of indications but there is a paucity of data on possible complications. Such knowledge, however, is essential in order to improve outcomes.Thus, the aim of the study was:1. to describe the frequency, type and severity of early postoperative complications following C1-C2 fixation according to Goel-Harms,2. to investigate whether there is a correlation between frequency and severity of complications,3. to detect risk factors for complications.Patients included in this study were treated surgically using the C1-C2 fixation according to Goel-Harms between March 2011 and July 2018. Data were taken from our hospital database and checked via OPS 10 code "S12.1". We analyzed age, sex, ASA score, blood loss, operating time and complications. These data were extracted from clinical data sheets.A total of 134 patients were detected, 54% female, mean age 75 years and mean ASA score 3. There were 122 complications. All these complications were observed in 50% of the patients. These were mainly minor complications (32%), and 18% severe complications. Mortality was 2%. We found that patients with more severe complications also had significantly more complications when compared to patients with minor complications (Fisher's exact test, p = 0.001). Preoperative ASA score was the only risk factor to significantly influence the number (p = 0.001) and severity (p = 0.002) of postoperative complications. Each increase of the preoperative ASA score increased the risk to get one more complication by a factor of 2.55 (odds ratio 2.55) and increased the risk to get a severe complication by a factor of 2.43 (odds ratio 2.43). Intraoperative blood loss, patient age and duration of surgery, however, were not identified as risk factors for complications.

[Neuromuscular scoliosis in patients with central nervous system pathologies]. / Neuromuskuläre Skoliose bei Erkrankungen des zentralen Nervensystems.

Neuromuscular scoliosis is due to pathologies within the neuromuscular pathway. These pathologies result in early deformities, usually with ongoing rapid progress. Conservative treatment has only limited value in these individuals, and posterior instrumented surgical correction to the spine is the favored treatment concept for correction and avoidance of progression. Here, we illuminate the special treatment concepts for children with NMS due to pathologies of the central nervous system also with a closer look at new treatment modalities. Moreover, we describe two typical cases in detail.

[Deep lumbar back pain and neurological sensory deficits in a 56-year-old male patient]. / Tief lumbaler Rückenschmerz und sensible neurologische Ausfälle bei einem 56-jährigen Patienten.

Echinococcus infestations are rare in humans, infestation of bone occurs in less than 1% and a primary spinal infestation is extremely rare. This article reports on a clinical case of lumbar and sacral spinal infestation by Echinococcus multilocularis in a 56-year-old male Caucasian with neurological sensory deficits and deep lumbar back pain. Due to the suspicion of spondylodiscitis a computer tomography-guided biopsy was carried out without success, so that a sample was surgically obtained. The diagnosis of a spinal Echinococcus infestation could be made. A radical surgical débridement was carried out and anthelminthic treatment was started. This article describes this unusual case in detail and gives a brief summary of the current literature on this disease.

[Harlequin syndrome after scoliosis surgery]. / Harlekinsyndrom nach Skoliosechirurgie.

Harlequin syndrome is a rare combination of symptoms, characterized by unilateral facial anhidrosis and paleness on the affected side, becoming obvious by contralateral flushing mainly during sports activity. The syndrome is mostly idiopathic, however it is also described as a complication of thoracic surgery, i.e. superior lobectomy. Here, we report on two cases of Harlequin syndrome following scoliosis surgery at the cervicothoracic junction.

[Degenerative cervical spine diseases: fusion vs. total disc replacement : What can be done when?] / Degenerative Halswirbelsäulenerkrankungen: Fusion vs. bewegungserhaltende Verfahren : Wann ist was sinnvoll?

Motion preserving surgery within the cervical spine may be performed by special implants, for example, c spine disc prosthesis or total disc replacement (cTDR), or by simple decompression of the cervical nerve roots. However, also fusion surgery may be performed with good results. Here, we summarize indications as well as contraindications for motion preserving techniques and indications for fusion surgery. cTDR is indicated in special cases of soft disc herniation, especially in younger individuals without signs of myelopathy. Posterior decompression may be used as an alternative, especially if anterior surgery is not possible. If degeneration is severe, in the presence of kyphosis, severe canal encroachment, instability, and in cases of myelopathy, cervical spine fusion seems to be the better way.

Sensitivity and specificity of ultrasound in spinal trauma in 29 consecutive patients.

PURPOSE: Indication for surgery in spine trauma patients depends on the extent of destruction of the spine. Computer-assisted tomography scan (CAT scan) is not suitable to diagnose type B-injuries. Aim of the study was to investigate whether ultrasound is able to detect destruction of the posterior ligament complex (PLC). METHODS: Twenty-nine patients were included. The results of ultrasound were compared with magnetic resonance imaging (MRI), CAT scan, X-ray, intraoperative findings. Statistical analysis was carried out by an independent observer. RESULTS: In 27 cases both ultrasound and MRI had the same result. In two cases, ultrasound failed to detect ligamentous injury. The sensitivity of ultrasound was 0.82 (CI 0.48-0.98), its specificity: 1. MRI and Ultrasound findings had a strong positive correlation (phi = 0.85, Cohen's kappa: 0.85, with 95 % confidence interval 0.65-1) and a high significance (Fischer's exact test: p < 0.0001). CONCLUSION: Ultrasound may indicate rupture or integrity of PLC in cases where MRI is missing.

[Challenges and characteristics of spondylodiscitis of the cervical spine]. / Herausforderungen und Besonderheiten der Spondylodiszitiden der Halswirbelsäule.

The human cervical spine is a unique structure that differs dramatically from the thoracic and lumbar spine. The main differences concern the topographic anatomy of the spinal cord, anatomy and physiology of the occipito-atlanto-axial joint complex, the close course of the vertebral artery to the cervical spine and the very close relationship of the esophagus, vessels, peripheral and cranial nerves to the spine. To avoid serious complications during surgical treatment of spondylodiscitis within the cervical spine, these aspects must be kept in mind. They will be explained in detail in this article.

Balloon kyphoplasty improves back pain but does not result in a permanent realignment of the thoracolumbar spine.

INTRODUCTION: Balloon kyphoplasty (BKP) has been established as a standard procedure for treatment of osteoporotic compression fractures of the spine in elderly patients, as it results in pain relief for most of the patients. Moreover, BKP may result in a partial realignment of the sagittal shape of the vertebra and the spine. However, it is unclear whether BKP may result in long-term improvement of the sagittal alignment of the spine. The aim of the current study was to investigate if there is a significant loss of correction of the sagittal alignment of the thoracolumbar spine following BKP. METHODS: A prospective, noncontrolled, nonrandomized study, consisting of 71 patients treated for single level osteoporotic compression fracture by BKP at 1 institution and by 1 surgeon, was done. We checked the following radiographic outcome parameters: Beck's ratio, the kyphosis angle of the treated vertebra, the angle of kyphosis including the treated vertebra and the adjacent disc (monosegmental angle), the angle of kyphosis, including the treated segment, the adjacent disc as well as the adjacent vertebra (bisegmental angle). RESULTS: BKP resulted in significant pain relief with a score decreasing from 7.11 to 1.73 on a visual analogue scale immediately after the procedure. The effekt persisted after 1 year with a score of 1.58 VAS points. BKP also led to an improvement of each radiographic outcome parameter immediately after surgery. Beck's ratio was improved from 0.71 to 0.83. The Cobb's angle of the relevant vertebral bodies decreased from 11.4° to 6.8°. Monosegmental and bisegmental kyphosis angles decreased from 8.12° to 4.9° and from 6.9° to 4.5° respectively. Within 1 year, however, there was a significant loss of correction in each radiographic parameter analyzed. Beck's ratio decreased to 0.72, Cobb's angle increased to 10.8°, and the mono- and bisegmental kyphosis angles to 8.8° and 8.3°, respectively.BKP does not result in a permanent realignment of the thoracolumbar spine following treatment of single level osteoporotic compression fractures.

[Microsurgical decompression of lumbar spinal stenosis]. / Mikrochirurgische Dekompression der lumbalen Spinalkanalstenose.

Lumbar spinal stenosis in most cases is due to progressive degeneration of the spine, resulting in thickening of facet joints and flaval ligament. Thus the diameter of the lumbar spinal canal is reduced to less than 12 mm in the AP direction. Typically complaints consist in neurogenic claudication. Patients usually experience improvement of pain when bending their back or walking up a hill. Diagnosis of lumbar spinal stenosis is confirmed by MRI. CT myelography may help detect where compression is most pronounced. Surgical treatment should be based on the clinical symptoms of the mostly elderly people and should be performed as microsurgical decompression or in cases of clinical instability as TLIF.

Cervical spondylolisthesis C6-C7 in a young wrestler: case report.

We present both the clinical and radiographic data of a 15-year-old boy, suffering from a lytic spondylolisthesis C6-C7 and treated by circumferential fusion.

Radiographic analysis of fusion progression following one-level cervical fusion with or without plate fixation.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) using bone graft or a cage with plate fixation is an accepted technique for the treatment of symptomatic degenerative disc disease. It is, however, debatable whether a plate is really necessary to increase the progress of fusion. Thus, the aim of this randomized and controlled prospective study was to evaluate whether ACDF with a cage and anterior plate fixation results in a greater progress of fusion compared with ACDF using a stand-alone cage. METHODS: 37 candidates for ACDF were treated either with a stand-alone cage (study group) or with a cage+plate fixation (control group). 19 patients were randomized to be stabilized with a stand-alone cage and 18 patients were treated with a cage and additional anterior plate fixation. The progress of cervical fusion over time was compared by radiostereometric analysis (RSA). Follow-up examinations pre- and postoperatively were done using the Visual Analogue Scale (VAS) for neck and arm pain. Radiographic assessment of fusion using an RSA-control was done after one, six and twelve weeks, as well as after six months, and one and two years postoperatively. Mann-Whitney test for unpaired values was used to determine the statistical differences in residual intervertebral motion. RESULTS: Three-dimensional analysis of segmental motion (left-right, cranio-caudal, and posterior-anterior) did not reveal any statistical differences between both groups at any examination time postoperatively ( P>0.05). The VAS score did not differ between the groups ( P>0.05). CONCLUSION: Anterior plate fixation did not demonstrate an improvement in the progress of fusion in one-level ACDF.

Disc replacement using Pro-Disc C versus fusion: a prospective randomised and controlled radiographic and clinical study.

Anterior cervical discectomy and fusion (ACDF) may be considered to be the gold standard for treatment of symptomatic degenerative disc disease within the cervical spine. However, fusion of the segment may result in progressive degeneration of the adjacent segments. Therefore, dynamic stabilization procedures have been introduced. Among these, artificial disc replacement by disc prosthesis seems to be promising. However, to be so, segmental motion must be preserved. This, again, is very difficult to judge and has not yet been proven. The aim of the current study was to first analyse the segmental motion following artificial disc replacement using a disc prosthesis. A second aim was to compare both segmental motion as well as clinical result to the current gold standard (ACDF). This is a prospective controlled study. Twenty-five patients with cervical disc herniation were enrolled and assigned to either study group (receiving a disc prosthesis) or control group (receiving ACDF, using a cage with bone graft and an anterior plate.) Radiostereometric analysis was used to quantify intervertebral motion immediately as well as 3, 6, 12 and 24 weeks postoperatively. Further, clinical results were judged using visual analogue scale and neuro-examination. Cervical spine segmental motion decreased over time in the presence of disc prosthesis or ACDF. However, the loss of segmental motion is significantly higher in the ACDF group, when looked at 3, 6, 12 and 24 weeks after surgery. We observed significant pain reduction in neck and arm postoperatively, without significant difference between both groups (P > 0.05). Cervical spine disc prosthesis preserves cervical spine segmental motion within the first 6 months after surgery. The clinical results are the same when compared to the early results following ACDF.

Filling a cervical spine cage with local autograft: change of bone density and assessment of bony fusion.

To date, it remains debatable whether cervical spine fusion cages should be filled with any kind of bone or bone substitute. Using a bone substitute would produce additional costs, using an autologous bone graft from the iliac crest would make the use of the cage at least questionable. As an alternative, cortical and subcortical bone from the anterior osteophytes of the segment in which the disc has been removed could be used to fill the cage: higher costs and complications at the iliac crest could both be avoided and the cage could be filled. However, the fate of these bone chips made from the anterior osteophytes is unclear as well as whether fusion will occur using this technique. The objective of the current study was to investigate possible changes in the bone density of this local autograft in the cage within the first 12 months after surgery by means of computed tomography. A second objective was to assess segmental bony fusion using this technique. 21 patients, suffering from degenerative disc disease of the cervical spine, were included into this prospective study. They all underwent anterior decompression, cage insertion and plate stabilisation. The cage (Rabea, Signus Medizintechnik, Alzenau, Germany), was filled with bone chips made from the anterior osteophytes of the segment that underwent discectomy. On the third day after surgery as well as three, six and 12 months after surgery, an axial computed tomography scan through the cage was taken and density within the apertures of the cage was measured in a standardised manner. Flexion-extension lateral radiographs were taken to investigate segmental fusion. Statistical significance was assumed to be at a 95 % level of significance. 23 cages were implanted. The mean value of the bone density obtained by computed tomography was 505 (+/- 119) HU on day three, 635 (+/- 156) HU after three months, 769 (+/- 162) HU after six months, and 814 (+/- 198) after 12 months. There was a significant difference when the values after 12 months were compared to those obtained after three days (p < 0.001) and after three months (p = 0.004). Bony fusion was seen in 21 out of 23 segments (91.3 %) after 12 months. It may be concluded that this technique could be an alternative to the current treatment options.

[Cervical disc prostheses]. / Zervikale Bandscheibenprothesen.

Endoprosthetic replacement for spinal cord disorders represents an attractive alternative to fusion in those cases where surgery appears necessary for degenerative disc disease. At least in theory it has been proven that placement of an endoprosthesis minimizes undue stress on the adjoining segments and its possible negative consequences. Furthermore, cervical endoprostheses facilitate speedier rehabilitation and the problems involved in removal of the bone chip become irrelevant. Clinical results reported to date for the cervical spine are very encouraging and indicate that endoprosthetic replacement has been quite successful particularly for difficulties in multilevel approaches. However, long-term results for cervical endoprostheses have not yet been published and therefore at present there are no reference values for the viability of the prosthesis with regard to the aseptic loosening rate. There are also no findings available on how the implanted cervical prosthesis will behave when bone quality diminishes at an advanced age.

Regional variations in the thickness of cervical spine endplates as measured by computed tomography.

PURPOSE: To determine regional variations in the thickness of human cervical spine endplates with high spatial resolution. MATERIAL AND METHODS: Six explanted human cadaveric spine specimens underwent computed tomography (CT) scanning. Measurement of endplate thickness was done fully automatically at every point of the endplate using a computer program written specifically for this purpose. Variations in thickness along sagittal and coronal lines were determined and statistical parametric mapping was used to test for significant regional variations at every point. RESULTS: Anterior and medial aspects of superior endplates were shown to be significantly thinner than lateral and dorsal parts. Superior endplates were found to be thicker than inferior endplates. CONCLUSION: Fully automatic assessment of endplate thickness from CT data is feasible. Central regions of the cervical spine endplates are thinner than peripheral parts of the endplates. This distribution is more pronounced in superior than in inferior endplates.

Factors affecting the interface of cervical spine facet screws placed in the technique by Roy-Camille et al.

The objective of the study was to investigate the influence of bone cement, length of burr hole and bone density on pullout force and insertional screw torque of cervical spine facet screws. Both facets of 24 human cervical vertebrae were scanned for bone mineral density (BMD) and assigned to two groups for measuring of insertional screw torque and pullout strength. Maximal insertional screw torque was measured and removal of the screws was performed in displacement control (0.25 mm/s) without bone cement (PMMA), with 0.1 ml of PMMA and with the burr hole completely filled with PMMA. Screw torque was 59.1 N cm (+/-25.7 N cm), pullout force was 382.8 N (+/-140.5 N) without PMMA. Injection of 0.1 ml PMMA did not change significantly both screw torque (p=0.73) and pullout (p=0.129). Filling of the burr holes with PMMA increased significantly both screw torque (p<0.0001) and pullout force (p=0.028) when compared with injection of 0.1 ml of PMMA. A positive, moderate correlation was seen between BMD and screw torque before (r=0.501; p=0.097) and after filling with PMMA (r=0.514; p=0.088), BMD and pullout force before (r=0.441; p=0.152) and after complete filling with PMMA (r=0.673; p=0.047). The PMMA does increase both screw torque (p<0.0001) and pullout force (p=0.028) of facet screws significantly if the burr hole is filled with PMMA completely when compared with injection of 0.1 ml PMMA. Bone mineral density of the cervical facets moderately correlates with peak insertional torque and pullout force. This is true for a facet without PMMA and for a facet filled with PMMA. The length of the burr hole seems to be less important.

[Complaints and findings at the iliac crest donor site following anterior cervical fusion]. / Postoperative Beschwerden und Befunde im Bereich der Spanentnahmestelle am Becken bei ventraler zervikaler Fusion.

A high rate of donor site complications has been described following bone graft harvesting at the anterior iliac crest for anterior cervical fusion. However, no prospective study exists dealing with this topic. The objectives of the study presented were to evaluate minor and major donor site complications following graft harvesting at the anterior iliac crest, to investigate postoperative changes at the donor site using computed tomography and ultrasound imaging and to judge the patients satisfaction. 67 patients were included in a clinical prospective study. All patients underwent anterior cervical discectomy and fusion using an autologous iliac crest graft. Clinical examination was performed three and ten days and two and three months after the operation. Computed tomography and ultrasound imaging of the donor site were performed 10 days after surgery. Complications were classified as "minor" and "major" complications. Minor complications were found in 62.7%. A significant decrease of minor complication rate was seen between the first and second examination after surgery. At the last follow-up, 80.5% of all patients were free from pain concerning the donor site. Haematomas and seromas were detected by ultrasound in 67.2% and donor site fractures in 6% using computed tomography. Major complications were seen in 11.9% of all patients. The current study revealed a high rate of minor complications and haematomas at the graft donor site. However, the majority of all patients is free of pain at the donor site three months after surgery and satisfied with the surgical result. Techniques without the need of bone grafting may help to avoid these complications and to ameliorate the initial postoperative status.

Variation of endplate thickness in the cervical spine.

The purpose of the study was to investigate possible variation of thickness of the cervical spine endplate with respect to endplate orientation (superior or inferior endplate) and level distribution (C4-C7). Six human cervical spine segments C4-C7 were used to create six specimen of C4, C5, C6, and C7, respectively. The bony endplates of each vertebra were cleaned carefully from disc tissue without damaging the endplates. Six endplates with severe degenerative changes were excluded from the study. The posterior elements were removed, and a midaxial cut using a bone saw was performed through each vertebral body, thus producing a superior and inferior half. Each half-vertebra was then glued onto a piece of wood with the endplate oriented upwards and horizontally. For each specimen, four computed tomography scans were taken and thickness of the endplate was measured at five points on each scan perpendicular to the midaxial cut. Factorial analysis of variance (ANOVA) and Scheffe-test were used to detect significant differences. All peripheral regions were significantly thicker than the central point of the endplate if all measuring points were considered for statistical analysis, regardless of scan, endplate orientation or level (Scheffe-test, P<0.001). In both superior and inferior endplates, peripheral areas were thicker than the central region (Scheffe-test, P<0.001). For all levels, the endplate within the peripheral regions was thicker than within the central region and the difference reached significance for the superior and inferior endplate of C4, C5, and C6 and the inferior endplate of C7 (Scheffe-test, P<0.05). The peripheral regions of the cervical spine endplate are usually thicker than its central region, regardless of endplate orientation and level (C4, C5, C6, C7) distribution.

Screw fixation to the posterior cortical shell does not influence peak torque and pullout in anterior cervical plating.

There is no consensus over whether screw fixation for anterior cervical plating should include the posterior cortical shell of the vertebral bodies or not. Thus, the purpose of this study was to investigate the function of the posterior cortical shell with respect to maximal screw torque and pullout force. Twenty-four fresh frozen human cervical vertebrae coming from six spinal segments C4-C7 were used. They were scanned for bone mineral density (BMD) and then assigned to two groups with comparable bone density and segmental distribution. The posterior longitudinal ligament was resected carefully and two parallel burr holes were drilled into each vertebral body. The posterior cortical shell was removed in one burr hole, using a 6-mm steel burr, producing a shallow excavation with a depth of approximately 2 mm. An ABC screw was inserted into each burr hole. The screw to be inserted into the hole with the posterior excavation was called "monocortical". In contrast, the contralateral screw was called "bicortical". Peak torque was measured in one group, while pullout force was analyzed using the specimens of the second group. Mean value and standard deviation were calculated for peak torque and pullout force with respect to the type of fixation. A paired t-test was used to determine the effect of fixation type on peak torque and pullout force. Pearson moment correlation coefficients were calculated to determine the effect of BMD on peak torque and pullout force with respect to whether the screw was "mono- or bicortical". A 95% level of significance was used for all tests. No significant differences for peak torque and pullout force could be found comparing monocortical and bicortical screw fixation. However, for both monocortical and bicortical screw fixation, a positive correlation was seen for peak torque versus BMD and for pullout force versus bone mineral density, respectively. The importance of the posterior cortical shell for screw pullout force and screw peak torque seems to be negligible. In constrast, BMD greatly influences both peak torque and pullout force for both types of fixation.