How can postoperative shoulder imbalance be prevented in adolescent idiopathic scoliosis type 2?

Postoperative shoulder imbalance (PSI) is a common complication following adolescent idiopathic scolio- sis (AIS) surgery. There is little data available in literature on prediction of PSI. Prospectively collected data of AIS with thoracic curve (Lenke 2), operated in 2014-2018 at a single scoliosis-center, were analyzed retrospectively using X-rays of whole spine and traction films (TA): age, Cobb-angle of proximal (PC), major thoracic (MC) and lumbar curve (LC), shoulder height [mm], clavicle angle [°], T1-tilt [°], plumb line [mm]. Results as mean ± standard deviation. Change over time (postOP- FU) compared using t-test (≥=0.05). Correlation of preOP parameters and curve correction with PSI (|≥|15mm) was analyzed by correlation (Pearson)- and regression-classification-analysis. 32 AIS, average age of 14±1.3 yrs. FU 16 months (84%). Curve correction was 52.5% (PC), 70.1% (MC), 69.9% (LC), significant change in FU for PC (-2.4°, p>0.05), not for MC, LC (p=0.2, p=0.6). Shoulder height was negative if right- side up: 2.9±15.1mm (preOP), 5.5±15.0 mm (TA), 17.9±14.9mm (postOP), 17.4±8.4mm (FU). 28% had preOP shoulder imbalance, 69% postOP and 44% FU had PSI. Shoulder height on TA correlated to change preOP to FU (r=0.62) and preOP shoulder height (r=-0.85), clavicle angle had strong correlation (r=- 0.81). Regression-classification-analysis: correction of MC>62.4%, 81.5% of cases had PSI; with correction of MC>64.9% and LC>93.2%, 51.9% of cases had PSI. PSI is a common in Lenke2 AIS. In preOP planning TA, shoulder position and clavicle angle should be considered to prevent PSI. Correction of MC should be moderate, overcorrection of the LC avoided.

Anterior Lumbar Interbody Fusion (ALIF) or Transforaminal Lumbar Interbody Fusion (TLIF) for Fusion Surgery in L5/S1 - What Is the Best Way to Restore a physiological Alignment?

STUDY DESIGN: A retrospective single center cohort study with prospective collected data from an institutional spine registry. OBJECTIVES: To determine whether restoration of lordosis L5/S1 is possible with both anterior lumbar interbody fusion (ALIF) and transforaminal lumbar interbody fusion (TLIF) and to find out which technique is superior to recreate lordosis in L5/S1. METHODS: Seventy-seven patients with ALIF and seventy-nine with TLIF L5/S1 were included. Operation time, estimated blood loss), and complications were evaluated. Segmental lordosis L5/S1 and L4/5, overall lordosis, and proximal lordosis (L1 to L4) were measured in X-rays before and after surgery. Oswesery disability index and EQ-5D were assessed before surgery, and 3 and 12 months after surgery. RESULTS: Mean operation time was 176.9 minutes for ALIF and 195.7 minutes for TLIF (p = 0.048). Estimated blood loss was 249.2 cc for ALIF and 362.9 cc for TLIF (p = 0.005). In terms of complications, only a difference in dural tears were found (TLIF 6, ALIF none; p = 0.014). Lordosis L5/S1 increased in the ALIF group (15.8 to 24.6°; p < 0.001), whereas no difference was noted in the TLIF group (18.4 to 19.4°; p = 0.360). Clinical results showed significant improvement in the Oswesery disability index (ALIF: 43 to 21.9, TLIF: 45.2 to 23.0) and EQ-5D (ALIF: 0.494 to 0.732, TLIF: 0.393 to 0.764) after 12 months in both groups, without differences between the groups. CONCLUSION: ALIF and TLIF are comparable methods for performing fusion at L5/S1, with good clinical outcomes and comparable rates of complications. However, there is only a limited potential for recreating lordosis at L5/S1 with a TLIF.

Recommendations for the Diagnostic Testing and Therapy of Atlas Fractures. / Empfehlungen zur Diagnostik und Therapie oberer Halswirbelsäulenverletzungen: Atlasfrakturen.

In a consensus process with four sessions in 2017, the working group on "the upper cervical spine" of the German Society for Orthopaedic and Trauma Surgery (DGOU) formulated "Therapeutic Recommendations for the Diagnosis and Treatment of Fractures to the Upper Cervical Spine", incorporating their own experience and current literature. The following article describes the recommendations for the atlas vertebra. About 10% of all cervical spine injuries include the axis vertebra. The diagnostic process primarily aims to detect the injury and to determine joint incongruency and integrity of the atlas ring. For classification purposes, the Gehweiler classification and the Dickman classification are suitable. The Canadian c-spine rule is recommended for clinical screening for c-spine injuries. CT is the preferred imaging modality; MRI is needed to determine the integrity of the Lig. transversum atlantis in complete atlas ring fractures. Conservative treatment is appropriate in very many atlas fractures. Surgical treatment is recommended in existing or potential joint incongruity or instability, which are frequently seen in Gehweiler IIIB or Gehweiler IV fractures. Posterior atlanto-axial stabilisation and fusion using transarticular screws or an internal fixator are regarded as a gold standard in the majority of surgical cases. Especially in young patients, the possibility of isolated atlas osteosynthesis should be checked. A possible option for Gehweiler IV fractures is halo-fixation with mild distraction for ligamentotaxis. Secondary dislocation should be checked for frequently. Involvement of the occipito-atlantal joint complex requires stabilisation of the occiput as well.

Recommendations for Diagnosis and Treatment of Fractures of the Ring of Axis. / Empfehlungen zur Diagnostik und Therapie oberer Halswirbelsäulenverletzungen: Axisringfrakturen.

In a consensus process with four sessions in 2017, the working group "upper cervical spine" of the German Society for Orthopaedics and Trauma Surgery (DGOU) formulated "Therapeutic Recommendations for the Diagnosis and Treatment of Upper Cervical Fractures", taking their own experience and the current literature into consideration. The following article describes the recommendations for axis ring fractures (traumatic spondylolysis C2). About 19 to 49% of all cervical spine injuries include the axis vertebra. Traumatic spondylolysis of C2 may include potential discoligamentous instability C2/3. The primary aim of the diagnostic process is to detect the injury and to determine potential disco-ligamentous instability C2/3. For classification purposes, the Josten classification or the modified Effendi classification may be used. The Canadian C-spine rule is recommended for clinical screening for C-spine injuries. CT is the preferred imaging modality and an MRI is needed to determine the integrity of the discoligamentous complex C2/3. Conservative treatment is appropriate in case of stable fractures with intact C2/3 motion segment (Josten type 2 and 2). Patients should be closely monitored, in order to detect secondary dislocation as early as possible. Surgical treatment is recommended in cases of primary severe fracture dislocation or discoligamentous instability C2/3 (Josten 3 and 4) and/or secondary fracture dislocation. Anterior cervical decompression and fusion (ACDF) C2/3 is the treatment of choice. However, in case of facet joint luxation C2/3 with looked facet (Josten 4), a primary posterior approach may be necessary.

Initial experience with the treatment of concomitant aortic pseudoaneurysm and thoracolumbar spinal fracture: Case report.

One blunt abdominal aortic disruption (BAAD) and one blunt thoracic aortic injury (BTAI) case are presented. Both aortic injuries were combined with spinal fractures. In the BAAD case the aortic pseudoaneurysm manifested just above the lumbar fracture while in the BTAI case the aortic injury appeared several vertebras below the thoracal fracture site, suggesting different mechanisms in the aortic wall damage. In both cases the aortic wall first was sealed, successfully, by endovascularly-placed stents, meaning the risks of open aortic reconstructive surgery could be avoided. The adjacent crucial vessel's preservation, despite the stent covering the left subclavian artery and the left common carotid artery in one of the cases was verified by post-operative computed tomography angiography (CTA) examination. In second stage those spinal fractures which were deemed unstable were stabilized by the fixateur interne (a transpedicular screw-rod system). With this treatment sequence we wanted to avoid the unnecessary risk of a possible rupture of the unsealed aortic wall during positioning for the spinal procedure and during the spinal surgery. Both patients recovered from their aortic and spinal injuries.