Observations concerning different patterns of bone healing using the Point Contact Fixator (PC-Fix) as a new technique for fracture fixation.

The recent trend in all surgical disciplines has been the development of techniques in minimally invasive surgery and the optimal maintenance of the blood supply to the bone fragments during osteosynthesis. Currently, the Point Contact Fixator (PC-Fix) has been introduced as a new implant for the stabilization of forearm bones. This plate-like splint and screw fixation system, which actually acts as an internal fixator, is characterized by minimized isolated contacts to the bone and proven angular stability of the monocortically locked screws. By using the PC-Fix, a further reduction of damage to the blood supply to the bone is achieved. Since 1994, 38 patients have been treated with this new device; we have reviewed the radiographs of 52 consolidated forearm fractures/osteotomies in accordance with the patterns of bone healing associated with the different methods of implant application according to the fracture type. In the groups in which traditionally precise reduction, interfragmentary compression and stable fixation was achieved (N=31), we found in 71% an absence of periosteal callus (direct bone healing). In the groups in which compression and adaptation were combined, or even main fragments adapted without compression, with wedges remaining unreduced in soft tissue connection (N=21), we found a visible external callus in 81% (indirect healing) (P = 0.002). Indirect healing after internal fixation is no longer regarded as a disturbance to healing, but is a goal in itself. The appearance of callus is a welcome sign indicating a prompt and positive reaction in the course of bone union which will lead to progressive fracture immobilization. When using the PC-Fix in a "biological way", callus formation and solid union take place earlier than in conventional plating. The new internal fixator offers substantial technical and mechanical advantages in fracture treatment. Therefore, it is an ideal implant to satisfy the requirements of modern biological osteosynthesis without compromising the restoration of axial alignment, rotation, length and postoperative functional treatment.

Post-traumatic changes in insulin-like growth factor type 1 and growth hormone in patients with bone fractures and traumatic brain injury.

The aim of the study was to determine whether changes in serum levels of growth hormone (GH) and insulin-like growth factor type 1 (IGF-1) are related to the phenomenon of enhanced osteogenesis in patients with bone fracture combined with traumatic brain injury (TBI), which would also suggest their involvement in post-traumatic stress and their applicability in the promotion of bone fracture healing. GH values were increased during the initial post-traumatic period in all patients (those with bone fractures or TBI alone or combined injury associated with enhanced osteogenesis), declining to normal values afterwards. However, a further increase in GH was only observed in patients with combined injury overlapping with the time of clinically manifested enhanced osteogenesis. Serum levels of IGF-1 were above normal throughout the study period (14 weeks) in patients with TBI only, but not if TBI was combined with bone fractures followed by enhanced osteogenesis. In these patients IGF-1 values increased gradually during fracture healing, as was also the case in patients with bone fractures alone. Thus, different patterns of post-traumatic changes in both GH and IGF-1 were seen in patients with TBI or bone fractures in comparison to those with combined injury, indicating the involvement of these substances in the post-traumatic stress response and in the phenomenon of enhanced osteogenesis in patients with bone fractures and TBI.

Post-traumatic dynamic changes in the antibody titer against oxidized low density lipoproteins.

Oxidized low density lipoproteins (oLDL) are products of systemic oxidative stress initiated by the mechanism of free radical induced lipid peroxidation. Oxidatively modified epitopes on LDL molecules are immunogenic and antibodies against such epitopes are generated. The aim of the study was to determine whether traumatic injury and consequent oxidative stress are accompanied by changes in the titer of autoantibodies against oLDL, and to determine whether patients with different injuries can be distinguished by measuring their anti-oLDL titer. Sera of twenty-four patients divided into three groups of eight subjects each were investigated by an anti-oLDL ELISA immunoassay: 1) patients with bone fractures, 2) with traumatic brain injury (TBI) and 3) with both bone fractures and TBI. The patients were followed during four weeks after injury and anti-oLDL titers were determined on a weekly basis. The control group consisted of 22 healthy persons. The lowest antibody titer was measured in all groups during the 1st week after injury. While the serum levels of patients with combined injury did not differ from those of the other two groups, the levels of patients with TBI were significantly higher than those of patients with isolated bone fractures. During the four-week convalescence, a gradual and significant increase in the anti-oLDL titer was observed in all patients. However, this value was increased above normal values only in the sera of patients with TBI during the third and the fourth week after injury. Reactive oxygen species (ROS) play an important role in the regulation of bone synthesis and remodelling. Therefore, we assume that the combination of a fracture with TBI-mediated post-traumatic stress response might be related to the altered fracture healing (enhanced osteogenesis) frequently observed in these patients.

Post-traumatic hormonal disturbances: prolactin as a link between head injury and enhanced osteogenesis.

Traumatic brain injury (TBI) combined with fractures of long bones or large joints is often associated with enhanced osteogenesis (early fracture healing accompanied by hypertrophic callus formation and/or heterotopic ossifications). Humoral factors that cause enhanced osteogenesis in patients with TBI are not yet identified. The aim of this study was to reveal if post-traumatic change(s) of hormone levels in patients with TBI and bone fractures could be associated with the phenomenon of enhanced osteogenesis. The blood values of adrenocorticotropic hormone (ACTH), cortisol, growth hormone (GH), parathyroid hormone (PTH) and prolactin (PRL) were studied weekly over a period of three months after injury in patients with bone fractures only, those with TBI only or combined bone fractures and TBI (patients exerting enhanced osteogenesis). Stress-hormones, ACTH and cortisol, or the hormones related to the bone growth (GH and PTH) did not show any particular post-traumatic changes in the blood of patients with combined injury that could be associated with the enhanced osteogenesis. On the other hand, patients with combined bone fractures and TBI accompanied by enhanced osteogenesis had significantly elevated PRL levels in blood during the 5th week of the post-traumatic period. Thus, the maximal PRL values were measured at the time when in this group of patients fractures were in consolidation and hypertrophic callus or heterotopic ossifications were developing (as verified by x-ray imaging). Hence, PRL does not only influence physiology of the bone metabolism but also seems to be one of the humoral factors involved in the phenomenon of enhanced osteogenesis in patients with TBI.

Unstable fractures of the upper thoracic spine.

Unstable fractures of the upper thoracic spine are a therapeutic challenge because of the high rate of associated injuries and frequent occurrence of spinal cord lesions. This study focuses on the operative treatment of these injuries. We present nine patients with unstable injuries of the upper thoracic spine. According to the classification of Magerl et al., there are seven type C and two type B fractures. Eight patients had complete transverse lesions of the cord and one had no evidence of spinal cord injury. All patients presented associated injuries: nine patients had fractured ribs, three a fractured sternum and three a severe haemothorax. All underwent operative treatment: six posterior fusions only, two anterior interbody fusions only after thoractotomy owing to severe bleeding from ruptured intercostal arteries, and one a combined fusion after failure of posterior fusion. The treatment of these patients should be individualized, depending on the associated injuries, loss of blood owing to fractured spine and ruptured vessels and depending on the back pain resulting from an unstable thorax. In general, we prefer the posterior approach to unstable fractures of the upper thoracic spine.

[Hypertrophic callus formation and craniocerebral trauma: early diagnosis and behavior of basic fibroblast growth factor]. / Hyperthrophe Kallusformation und Schädel-Hirn-Trauma: Frühdiagnostik und das Verhalten des basischen Fibroblastenwachstumsfaktors.

Hypertrophic callus formation in patients with severe head injury leads to an early fracture consolidation, whereas in joint fractures the enhanced ossification can even end in ankylosis of the injured joint. It is already known that these ossifications can be at least partly prevented by non-steroid anti-inflammatory drugs. Therefore, serum parameters have been determined that could predict this phenomenon. The mean values for alkaline phosphatase (ALP) and its bone isoenzyme were significantly increased in patients with severe head injury and bone fractures as soon as the 2nd week (reaching peak values in the 3rd week after injury) compared with patients with isolated fractures or head injury only and with normal healthy subjects. Procollagen I (PICP) was significantly increased even in the 1st week, reaching its peak during the 2nd week after injury. Compared with the callus volume at the time of fracture consolidation the size was determined from the X-rays--it was even possible to predict the volume of callus with the aid of these serum parameters as early as in the first few weeks after injury. A possible link between head injury and the increased bone formation could be the basic fibroblast growth factor (bFGF). In our study, bFGF was determined in serum by an immunoassay (ELISA), and an unusual pattern of dynamic change was observed in the patients with head injury and bone fractures. Compared with patients with isolated bone fractures bFGF immunoreactivity was significantly increased in patients with brain and bone lesions even in the 1st week after injury, with further peaks in the 2nd, 4th and 7th-8th weeks, with sudden decreases in between. In patients with isolated bone fractures a transient increase of bFGF was observed only during the 2nd week after injury. A similar increase was also determined in the sera of patients with head injury only, but it lasted longer. Thus, a posttraumatic increase of the serum bFGF was induced by bone as well as by brain injury, but was not causally related with the growth-promoting effects of the sera, as was proven by an in vitro analysis of the effects of the patients sera on L929 fibroblast growth.

Comparison of the values of basic fibroblast growth factor determined by an immunoassay in the sera of patients with traumatic brain injury and enhanced osteogenesis and the effects of the same sera on the fibroblast growth in vitro.

In patients with severe traumatic brain injury, the early healing of fractures is accompanied by hypertrophic callus formation or heterotopic ossifications, which might even result in ankylosis of the affected joints. Analysis of the sera of patients with traumatic brain injury revealed post-traumatic dynamic changes of basic fibroblast growth factor immunoreactivity, similar to those observed during fracture healing associated with enhanced osteogenesis. The aim of this study was to determine whether such changes in basic fibroblast growth factor concentrations could be related to the phenomenon of enhanced osteogenesis. Basic fibroblast growth factor immunoreactivity was determined (using an IEMA kit) in the sera of patients with traumatic brain injury and bone fractures (n = 8) and in the sera of patients with either traumatic brain injury alone (n = 10) or bone fractures alone (n = 7), and the effects of these sera on L929 fibroblast growth were analysed in vitro. The results did not prove a causative relationship between the changes of basic fibroblast growth factor immunoreactivity and in vitro growth promoting effects of the sera. However, it is apparent that, in addition to changes in the growth-promoting activity and basic fibroblast growth factor concentration of serum, other as yet unknown post-traumatic changes can cause enhanced osteogenesis.

Released PMN elastase: an indicator of postsurgical uneventful wound healing and early inflammatory complications. A contribution to the search for objective criteria in wound healing monitoring.

Monitoring of postoperative wound healing is important for the early diagnosis of postoperative infective complications in order to decrease morbidity. The purpose of this study was to search for a discriminatory time point between uneventful wound healing and early wound infections after operations for orthopaedic trauma using PMN elastase. This proteolytic enzyme is a biochemical marker for pathological granulocyte stimulation. The two groups of injured patients comprised persons with 'per priman' (pp) wound healing without complications--group 1 (N = 31)--and the early manifestation of a bacterial wound infection 'per secundam' (ps) during the healing phase--group 2 (N = 4). In group 1, surgical trauma was accompanied by an increase in PMN elastase levels reaching the maximum within the first 3 postoperative days; values returned to normal on day 10. In group 2 PMN elastase median levels showed recurring increases throughout. No normal values were observed. There was a highly significant difference (P < 0.01) on days 4 and 5 in group 2 compared with the control group 1. Since PMN elastase can be determined on an autoanalyser, and the enzyme is of proven discriminatory value, it is suggested that this marker should become part of the daily diagnostic routine in the care of the injured.

[The postoperative cervical spine and evaluation of the spinal cord with magnetic resonance tomography]. / Postoperative Halswirbelsäule und Beurteilung des Rückenmarks mittels Magnestresonanztomographie.

We present the cases of ten patients who underwent postoperative magnetic resonance assessment after dislocation injuries of the cervical spine and treatment with anterior interbody fusion and titanium implants. Eight patients had spinal cord injuries and two had nerve root disorders. In two patients who had intracranial haematomas and dislocation fractures of the cervical spine, MRI proved useful for identification of parenchymal spinal cord injuries as the reason for transverse lesions. Severe MR findings of the parenchymal spinal cord injuries (haematoma or transection) correlated with complete transverse lesions (4 patients) and oedema of the spinal cord, with incomplete transverse lesions (3 patients). MR enables us to examine the spinal cord after operations to ensure that correct spinal cord decompression has been achieved (3 patients). MRI is useful for detecting disc protrusion or chronic spinal stenosis in patients with titanium implants. All in all, MRI is an important modality in the evaluation of the posttraumatic cervical spine.

[Hyperextension injury of the lower cervical spine and diagnosis of dorsal unstable motion segments]. / Hyperextensionsverletzung der unteren Halswirbelsäule und die Diagnostik von dorsal instabilen Bewegungssegmenten.

Five patients with hyperextension injuries and dorsally instable motion segments are presented. In the diagnosis of posterior instabilities plain roentgenograms demonstrated no characteristic signs of an injured cervical spine. Flexion and extension views detected a mild degree (2 mm) of retrospondylolisthesis in four cases and a widened disc space in one case. In all five patients the MR findings that made use suspect a posterior unstable motion segment were disc protrusions; in addition, in two patients these was hemorrhage in the spinal cord and in one patient cord edema.

PMN-related parameters for the monitoring of wound healing in traumatology.

In the search for objective methods to monitor the course of wound healing, the proteinase PMN elastase (n=56 pat.), the lipid peroxidation product malondialdehyde (MDA) (n=18 pat.), and polymorphonuclear neutrophil granulocytes (PMN) migratory behaviour were measured [1, 6, 7, 11]. This "stimulated PMN-locomotion" was quantified by a new PMN migration filter assay (n=10 pat.) [2]. We determined the clinical course during "per primam (pp)" wound healing (group 1), "pp" wound healing with secondary inflammatory disease (group 2), manifestation of a bacterial wound infection during healing-"per secundam (ps)" (group 3) and manifest wound infection ("ps") at the time of admission (group 4).In group 1 PMN elastase returned to normal values on the 10th postsurgical day. Median values in group 3 reflected a highly significant difference (p<0,01) on day 4 and 5 compared with group 1. In group 2 and 4 medians reflected consistent high values without reaching normal ranges throughout. MDA did not exceed the normal range in group 1, in group 3 low levels persisted, and in group 4 a recurring increase was noticed.The total migration index median (TMI) in Group I, which quantifies the percentage of stimulated PMN, reflected its highest value immediately post-surgically and dropped to the lowest on the 13th postsurgical day (decrease by 54%). The mean invasion depth (T/2), a parameter of PMN distribution, showed only slight variation with time. In a group 3-patient, T/2 reflected a maximal migratory stimulation on day 6, 4 days before clinical infection signs could be noticed; then it dropped to the lowest on day 10. This decrease probably reflects a PMN behavioural change from migration to phagocytosis [9].

Basic fibroblast growth factor (BFGF) immunoreactivity as a possible link between head injury and impaired bone fracture healing.

Healing of fractures of long bones or large joints is often accelerated in patients with severe traumatic brain injury (TBI). However, in these patients an early fracture healing is accompanied by hypertrophic callus formation or heterotopic ossifications which might even result in an ankylosis of the affected joints. It seems that enhanced osteogenesis in patients suffering from TBI could be caused by some humoral factors, since the sera of these patients strongly promote the growth of osteoblast cells in vitro. However, humoral growth promoting factors which could perhaps induce enhanced osteogenesis are not yet identified. Hence, the aim of this study was to analyse if basic fibroblast growth factor (bFGF) could be related to the phenomenon of enhanced osteogenesis, since bFGF stimulates the growth of osteoblasts in vitro and could be found both in the brain and the bone tissue. For that purpose the values of bFGF immunoreactivity were determined in the sera of patients with TBI and bone fractures (n = 8) as well as in the sera of patients with either TBI alone (n = 10) or bone fractures alone (n = 7), during a period of three months after injury. Quantification of the bFGF immunoreactivity was done using the ELISA based on monoclonal antibodies raised against the recombinant human bFGF. The bFGF immunoreactivity values obtained were also compared with the values determined in the sera of normal, healthy persons (n = 9). In the group of patients with bone fractures alone only a transient increase of bFGF immunoreactivity (threefold above the normal values) was observed in the second week after injury. A similar increase of the values of bFGF immunoreactivity was also determined in the sera of patients with TBI only, but it lasted longer (from the 1st until the 7th to 8th week after injury). In the case of patients with TBI and bone fractures a specific pattern of post-traumatic dynamic change of the values of serum bFGF immunoreactivity was observed. Namely, the increase of bFGF immunoreactivity (up to seven-fold above the normal values) was determined even during the first week after injury. Afterwards, periods of high values of bFGF immunoreactivity observed during the 2nd, 4th and the 7-10th weeks after injury were interrupted by sudden decreases even to the normal values (during the 3rd and the 5-6th week after injury).(ABSTRACT TRUNCATED AT 400 WORDS)

Polymorphonuclear leucocyte migration response in uneventful wound healing following trauma surgery. A contribution to the search for objectifiable criteria in wound healing monitoring.

In a study of the clinical importance of polymorphonuclear granulocytes (PMN) for the monitoring of wound healing we investigated the postsurgical course of nine patients all of whom had undergone trauma surgery and had no wound complications. The "stimulated random PMN locomotion" was evaluated by a new migration filter device which preserves the cells in their genuine priming state, simulating in vivo conditions. The percentage of all activated PMN, expressed by the total migration index (TMI) reflected the highest median immediately after surgery (Zmax = 30.1%) and dropped to the lowest value on day 13 (Zmin = 13.9%). The mean invasion depth (T/2) of the cells along the migration distance into the filter showed only slight variations over time. The neutrophil migration activity (NMA), described by T/2 and TMI, behaved in a similar way to TMI. In studying physiological healing, preliminary results indicate that TMI, which expresses PMN activation, is an efficient tool in the postoperative monitoring of patients, and might in the future serve as a basis for an early warning system for wound healing complications.

Post-traumatic dynamic change of carboxyterminal propeptide of type I procollagen, alkaline phosphatase and its isoenzymes as predictors for enhanced osteogenesis in patients with severe head injury.

Patients suffering from severe head injury and fractures of long bones or large joints often show enhanced osteogenesis, with hypertrophic callus formation and/or heterotopic ossifications. The advantage of this phenomenon is early consolidation of the fractures. An extreme disadvantage is extensive periarticular calcification, resulting in complete ankylosis of the affected joint. In spite of numerous efforts aimed at clarifying the way in which severe head injury can influence osteogenesis at a distant site, this phenomenon is still not understood. The process, once started, seems irreversible, but if diagnosed in time, could be prevented with non-steroid anti-inflammatory drugs that inhibit development of heterotopic ossifications. The major prerequisite for testing this possibility is to define parameters of an early diagnosis of enhanced osteogenesis. Thus, the aim of this study was to test whether serum values of some parameters related to bone regeneration could allow an early prediction of enhanced ossification following bone fracture in patients with severe head injury. Samples of sera were obtained from three groups of injured patients: fractures of long bones or large joints only (n = 6), severe head injury only (n = 8), severe head injury and fractures of long bones and large joints (n = 7) and from a group of apparently healthy volunteers (n = 10). The values for alkaline phosphatase (ALP), the bone isoenzyme, and the carboxy terminal propeptide of type I procollagen (PICP) were significantly higher (5-20 times as high) in patients with severe head injury and bone or joint fractures than in any other group. Significantly increased concentrations of PICP were already found in the 1st week after injury, and those of ALP and of the bone isoenzyme increased during the 2nd week after injury. Results show that these parameters are helpful for an early diagnosis of enhanced osteogenesis and heterotopic ossifications in patients with severe head injury and bone fractures. Further studies are necessary to verify these findings, while analysis of reasons for the specific patterns of dynamic change of these parameters could lead to better understanding of the mechanisms underlying the uncontrolled bone formation.

Dorsal stabilization of thoracolumbar spinal instability. Comparison of three different implantation systems.

Many unstable fractures and fracture dislocations of the lower thoracic and the lumbar spine are treated operatively. Internal fixation is mostly done via a posterior approach, anchoring the screws in the pedicles of the vertebrae. In the Traumatology Section of the Department of Surgery, Graz University, three different implantation systems have been employed in recent years. Sixty of all the patients operated on were available for follow-up an average of 36 months after operation. We compared them with respect to type of implant, paying special attention to any loss of reduction.

[Biochemical wound monitoring. PMN elastase in different healing stages after trauma surgery-orthopedic interventions]. / Biochemisches Wundmonitoring. Die PMN-Elastase bei unterschiedlichen Heilungsverläufen nach unfallchirurgisch-orthopädischen Eingriffen.

Laboratory parameters are of proven value in the diagnosis of early postsurgical infections, since clinical aspects cannot always be clearly defined. Neutrophil granulocytes (PMN) are major inflammatory cells taking effect following ingestion and degradation of foreign material, such as bacteria and cell debris, for example after mechanical trauma. In patients who had undergone surgery we monitored the course of plasma PMN elastase in uncomplicated wound healing (n = 22), in uncomplicated wound healing associated with secondary infections (n = 6), and in defective wound healing (manifestation of a bacterial wound infection: n = 3; wound infection already manifest at the time of entry on study: n = 11). Surgical trauma was accompanied by an increase in PMN elastase and C-reactive protein (CRP) in all patients studied, reaching a maximum within the first 3 postsurgical days. When a bacterial wound infection became manifest during the course of healing there was a highly significant difference on the 4th postsurgical day (p < 0.01) compared with the group with uncomplicated healing. Since PMN elastase can now be determined automatically with an autoanalyser and a commercial kit and its discriminatory time point is as soon as 4-5 days after surgery, it is suggested that this marker should be determined routinely together with CRP in traumatology.

Arthroscopic treatment of meniscal cysts.

In a series of 1160 arthroscopies we found 16 meniscal cysts; 12 involved the lateral joint line and two the medial, and two were intra-articular. In all but two cases, arthroscopy showed meniscal tears. We recommend arthroscopy of all cases to correct the meniscal lesion, and to evacuate the cyst into the joint by opening the joint capsule. This was successful in 12 cases, with no recurrence after an average follow-up of 18 months. Only two patients with no meniscal lesion on arthroscopy required an additional external incision for cyst removal.

[Blood supply to the cervical spinal cord and possible therapeutic consequences in cervical spinal cord injuries]. / Die Blutversorgung des zervikalen Rückenmarks und mögliche therapeutische Konsequenzen bei zervikalen Rückenmarkverletzungen.

The study was designed to demonstrate the blood supply to the cervical cord through radicular branches and was carried out in 23 human cadavers into which preparations were injected by the intra-articular route. One corrosion cast of the head and neck showed extravertebral anastomotic pathways. After removal of the vertebral bodies and discs from C1 to D3, the anterior spinal artery and radicular branches were identified and dissected back to their origins from the vertebral, deep or ascending cervical arteries. Twelve preparations had only one or two radicular branches reaching the cervical spinal cord. If there is traumatic compression of an ascending branch a high risk of ischaemic damage to cranial areas of the spinal cord arises. The blood supply to the cervical enlargement of the spinal cord was provided by branches of the deep cervical artery in eight preparations, but only in one by branches of the vertebral artery. We therefore plead for decompression of the anterior spinal artery and the spinal cord and for sufficient arterial blood pressure, and give our reason for these demands.

In vivo monitoring of circulation in the intact anterior cruciate ligament using the laser Doppler flowmeter.

Laser Doppler flowmetry permits observation of circulation in the microcapillary regions of structures under in vivo conditions. We used a laser device manufactured by the Swedish company Perimed and a special probe to observe the capillary circulation in the anterior cruciate ligament during arthroscopic surgery. This produces measured values in millivolts; these values are relative in nature and cannot be used to determine an absolute value for capillary circulation by volume per unit time. Under standardized conditions, circulation measurements and simultaneous recordings with a two-channel recorder were made from 11 patients. In all cases, pulsations of the capillary circulation synchronous with the heart beat could be seen on three measuring points on the anterior cruciate ligament; these disappeared upon complete deprivation of blood supply. We found a large individual range of variation in the so-called blood cell flux values from 30 to 620 mV. The magnitude of the heart-synchronous pulsations ranged between 20 and 240 mV. Only vague linear relationships were found (a) between the individual measuring points and (b) between the flux values and the magnitude of pulsation; there was no relationship between the flux values and blood pressure and/or red blood count (erythrocyte count, hemoglobin, hematocrit).

MR findings and treatment of four patients with cervical spinal cord injuries.

We report the value of magnetic resonance imaging (MRI) in the assessment of cervical spine injuries with neurological deficit and the implications such information might have in the management of acute spinal cord injuries. Four cases are presented that were neurologically classified according to the 5-step Frankel scale. Three patients presented with an intramedullary hemorrhage. One of these patients showed additional mild compression of the spinal cord due to a retropulsed bony fragment, and one an epidural hematoma without any evidence of spinal cord compression. The fourth patient had compression of the spinal cord secondary to bony fragments from a burst fracture. We carried out two decompressions of the spinal cord by removing the disc and bony fragments. In addition, we performed two interbody fusions. In one patient we applied a halo vest, and in one case surgical intervention was not necessary after MRI assessment.