Biomechanical comparison of two different compression screws for the treatment of odontoid fractures in human dens axis specimen.

BACKGROUND: Lag screw osteosynthesis for odontoid fractures has a high rate of pseudoarthrosis, especially in elderly patients. Besides biomechanical properties of the different screw types, insufficient fragment compression or unnoticed screw stripping may be the main causing factors for this adverse event. The aim of the study was to compare two screws in clinical use with different design principles in terms of compression force and stability against screw stripping. METHODS: Twelve human cadaveric C2 vertebral bodies were considered. Bone density was determined. The specimens were matched according to bone density and randomly assigned to two experimental groups. An odontoid fracture was induced, which were fixed either with a 3.5 mm standard compression screw or with a 5 mm sleeve nut screw. Both screws are certified for the treatment of odontoid fractures. The bone samples were fixed in a measuring device. The screwdriver was driven mechanically. The tests were analyzed for peak interfragmentary compression and screw-in torque with a frequency of 20 Hz. FINDINGS: The maximum fragment compression was significantly higher with screw with sleeve nut at 346.13(SD ±72.35) N compared with classic compression screw at 162.68(SD ±114.13) N (p = 0.025). Screw stripping occurred significantly earlier in classic compression screw at 255.5(SD ±192.0)° rotation after reaching maximum compression than in screw with sleeve nut at 1005.2(SD ±341.1)° (p = 0.0039). INTERPRETATION: Screw with sleeve nut achieves greater fragment compression and is more robust to screw stripping compared to classic compression screw. Whether the better biomechanical properties lead to a reduction of pseudoarthrosis has to be proven in clinical studies.

Biomechanical comparison of three different compression screws for treatment of odontoid fractures evaluation of a new screw design.

BACKGROUND: Lag screw osteosynthesis in odontoid fractures shows a high rate of pseudarthrosis. Biomechanical properties may play a role with insufficient fragment compression or unnoticed screw stripping. A biomechanical comparison of different constructed lag-screws was carried out and the biomechanical properties determined. METHODS: Two identical compression screws with different pilot holes (1.25 and 2.5 mm), a double-threaded screw and one sleeve-nut-screw were tested on artificial bone (Sawbone, densities 10-30pcf). Fragment compression and torque were continuously measured using thin-film force sensors (Flexiforce A201, Tekscan) and torque sensors (PCE-TM 80, PCE GmbH). FINDINGS: The lowest compression reached the double-threaded screw. Compression and sleeve-nut-screw achieved 214-298% and 325-546%, respectively, of the compression force of double-threaded-screw, depending on the test material. The pilot hole optimization led to a significant improvement in compression only in the densest test material. Screw stripping took place significantly later with increasing density of the test material on all screws. In compression screws this was done at a screw rotation of 180-270°, in sleeve nut screw at 270-720° and in double-threaded screws at 300-600° after reaching the maximum compression. INTERPRETATION: Double-threaded screw is robust against screw stripping, but achieves only low fragment compression. The classic compression screws achieve better compression, but are sensitive to screw stripping. Sleeve-nut screw is superior in compression and as robust as double-threaded screw against screw stripping. Whether the better biomechanical properties lead to a reduction in pseudarthrosis must be proven in clinical trials.

Microvascular Decompression for Patients With Hemifacial Spasm Associated With Common Trunk Anomaly of the Cerebellar Arteries-Case Study and Review of Literature.

BACKGROUND: Few previous studies have described the origin of both anterior and posterior inferior cerebellar arteries from one vessel as a common trunk anomaly. No previous studies have clearly described the aforementioned anomaly depending on intraoperative endoscopic visualization. OBJECTIVE: To evaluate the association of a common trunk anomaly with hemifacial spasm, which makes microvascular decompression more challenging. METHODS: All patients with common trunk anomaly associated with hemifacial spasm who received surgical treatment between 2006 and 2015 in our institution were identified in our prospectively collected database. Detection of the common trunk anomaly was performed using the intraoperative high-definition endoscopic inspection and confirmed by a retrospective review of the obtained operative videos. RESULTS: Out of 248 cases of hemifacial spasm, 21 cases with a common trunk anomaly were detected, with an incidence rate of 8.5%. In 6 cases, the spasm was caused by more than 1 offending vessel "complex compression." In 19 cases, total recovery occurred on follow-up, while in 1 case, 90% recovery occurred. One patient was spasm-free immediately after surgery, but died 3 wk after operation from herpes encephalitis. CONCLUSION: Common trunk anomaly in hemifacial spasm is rare. The surgical technique is mostly identical to decompression with normally arising vessels. However, in case of a bifurcation situated close to the compression site where the offending vessel cannot be transposed freely, an extensive cushioning along the trunk and the offending vessels with teflon pledgets should be performed. The presence of a common trunk anomaly does not affect the surgical results.

Heat Generation During Bony Decompression of Lumbar Spinal Stenosis Using a High-Speed Diamond Drill with or without Automated Irrigation and an Ultrasonic Bone-Cutting Knife: A Single-Blinded Prospective Randomized Controlled Study.

OBJECTIVE: The main objective of the present prospective, randomized, single-blinded controlled study was to measure heat during bony decompression of lumbar spinal stenosis with high-speed drills and an ultrasonic bone-cutting knife. METHODS: Ninety patients diagnosed with lumbar spinal stenosis were included in this study and randomized for lumbar spinal canal decompression using either a high-speed drill with automatic irrigation, high-speed drill with manual irrigation, or an ultrasonic bone-cutting knife with automatic irrigation (USBCD). For evaluation of group homogeneity, a visual analog scale pain score and neurologic findings were measured preoperatively and postoperatively. Temperatures during bony decompression were measured using a forward-looking infrared camera system. RESULTS: Clinical results among the 3 groups did not differ in pain reduction, improvement of neurologic findings, or the rate of complications. However, significantly lower values were found for absolute and mean maximal temperatures during bony decompression in the USBCD group compared with the groups of patients who received the high-speed drill with automatic irrigation and the high-speed drill with manual irrigation, indicating this technique to be less aggressive in terms of thermal induction of bone necrosis. USBCD allows more precise bone removal compared with high-speed drills, and despite increased device time, no significant difference in the overall decompression time was observed. CONCLUSIONS: All methods examined produced short temperature peaks with possible, at least temporary, damage to bone and neural tissue. Automatic irrigation was associated with lower heat development compared with manual irrigation. Despite evidence of critical temperatures, no clinical correlation (e.g., neurologic deficits) was encountered in this study. Clinically, all 3 methods presented equally good results.

Syringomyelia associated with cervical spondylotic myelopathy causing canal stenosis. A rare association.

BACKGROUND: Although cervical spondylosis is extremely common, only few cases with associated syrinx have been reported. Depending on review of two large data bases, we report this case series. In addition, we evaluated the posterior decompression as the management option in treatment of this rare condition. MATERIALS AND METHODS: Data of all cases with cervical spondylosis and canal stenosis that sought medical advice or needed decompressive laminectomy/laminoplasty between the years 2006 and 2015 were checked in manually. Perioperative data, together with follow up were reviewed. RESULTS: Out of five cases found in the reviewed data; four cases undergone posterior decompression (laminectomy in two cases and laminoplasty in the other). One case refused surgery. Along mean follow up period of 6.25 months; three cases improved markedly, while in one case no improvement occurred. CONCLUSION: Cervical spondylotic myelopathy can rarely cause syringomyelia. Posterior decompression would be the preferable management option with clinical improvement of most of the cases.

Neuronavigation and 3D fluoroscopy-guided lag screw reduction and osteosynthesis for traumatic spondylolistheses of the axis: a path worth exploring?

OBJECTIVE In traumatic spondylolistheses of the axis, there is a marked heterogeneity of the observed injury patterns, with a wide range of the severity-from stable fractures, which can be treated conservatively with very good success, to highly unstable fractures, which should be treated surgically. A number of classification systems have been devised to assess the instability of the injuries and to derive a corresponding therapy recommendation. In particular, the results and recommendations regarding medium-severity cases are still inconclusive. Minimally invasive percutaneous procedures performed using modern techniques such as 3D fluoroscopy and neuronavigation have the potential for improvements in the therapeutic outcome and procedural morbidity against open surgical procedures and conservative therapy. METHODS A minimally invasive method using 3D fluoroscopy and neuronavigation for percutaneous lag screw osteosynthesis of the pars interarticularis was performed in 12 patients with a Levine-Edwards Type II fracture. Ten patients had an isolated hangman's fracture and 2 patients had an additional odontoid fracture of the axis (Type II according to the Anderson and D'Alonzo classification system). Complications, operating parameters, screw positions, and bony fusion were evaluated for the description and evaluation of the technique. RESULTS In 6 men and 6 women, percutaneous lag screw osteosynthesis was performed successfully. Correct placement could be verified postoperatively for all inserted screws. In the case series, nonunion was not observed. In all patients with a complete follow-up, a bony fusion, an intact vertebral alignment, and no deformity could be detected on CT scans obtained after 3 months. CONCLUSIONS The percutaneous pars interarticularis lag screw osteosynthesis is a minimally invasive and mobility-preserving surgical technique. Its advantages over alternative methods are its minimal invasiveness, a shortened treatment time, and high fusion rates. The benefits are offset by the risk of injury to the vertebral arteries. The lag screw osteosynthesis is only possible with Levine-Edwards Type II fractures, because the intervertebral joints to C-3 are functionally preserved. A further development and evaluation of the operative technique as well as comparison with conservative and alternative surgical treatment options are deemed necessary.

Cement leakage in pedicle screw augmentation: a prospective analysis of 98 patients and 474 augmented pedicle screws.

OBJECTIVE Loosening and pullout of pedicle screws are well-known problems in pedicle screw fixation surgery. Augmentation of pedicle screws with bone cement, first described as early as 1975, increases the pedicle-screw interface and pullout force in osteoporotic vertebrae. The aim of the present study was to identify cement leakage and pulmonary embolism rates in a large prospective single-center series of pedicle screw augmentations. METHODS All patients who underwent cement-augmented pedicle screw placement between May 2006 and October 2010 at the authors' institution were included in this prospective cohort study. Perivertebral cement leakage and pulmonary cement embolism were evaluated with a CT scan of the area of operation and with a radiograph of the chest, respectively. RESULTS A total of 98 patients underwent placement of cement-augmented pedicle screws; 474 augmented screws were inserted in 237 vertebrae. No symptomatic perivertebral cement leakage or symptomatic pulmonary cement embolism was observed, but asymptomatic perivertebral cement leakage was seen in 88 patients (93.6%) and in 165 augmented vertebrae (73.3%). Cement leakage most often occurred in the perivertebral venous system. Clinically asymptomatic pulmonary cement embolism was found in 4 patients (4.1%). CONCLUSIONS Perivertebral cement leakage often occurs in pedicle screw augmentation, but in most cases, it is clinically asymptomatic. Cement augmentation should be performed under continuous fluoroscopy to avoid high-volume leakage. Alternative strategies, such as use of expandable screws, should be examined in more detail for patients at high risk of screw loosening.

Proton-density fat fraction and simultaneous R2* estimation as an MRI tool for assessment of osteoporosis.

OBJECTIVE: To investigate multi-echo chemical shift-encoded MRI-based mapping of proton density fat fraction (PDFF) and fat-corrected R2* in bone marrow as biomarkers for osteoporosis assessment. METHODS: Fifty-one patients (28 female; mean age 69.7 ± 9.0 years) underwent dual energy X-ray absorptiometry (DXA). On the basis of the t score, 173 valid vertebrae bodies were divided into three groups (healthy, osteopenic and osteoporotic). Three echo chemical shift-encoded MRI sequences were acquired at 3 T. PDFF and R2* with correction for multiple-peak fat (R2*MP) were measured for each vertebral body. Kruskal-Wallis test and post hoc analysis were performed to evaluate differences between groups. Further, the area under the curve (AUC) for each technique was calculated using logistic regression analysis. RESULTS: On the basis of DXA, 92 samples were normal (53 %), 47 osteopenic (27 %) and 34 osteoporotic (20 %). PDFF was increased in osteoporosis compared with healthy (P = 0.007). R2*MP showed significant differences between normal and osteopenia (P = 0.004), and between normal and osteoporosis (P < 0.001). AUC to differentiate between normal and osteoporosis was 0.698 for R2*MP, 0.656 for PDFF and 0.74 for both combined. CONCLUSION: PDFF and R2*MP are moderate biomarkers for osteoporosis. PDFF and R2*MP combination might improve the prediction in differentiating healthy subjects from those with osteoporosis.

Comparison of waterjet dissection and ultrasonic aspiration: an in vivo study in the rabbit brain.

OBJECT: The waterjet method of dissection has been shown to enable the precise dissection of the parenchyma vessels while preserving blood in cadaveric pig brains. The waterjet device has also been applied clinically to treat various diseases and disorders without complications. Evidence still remains to be gathered as to how the instrument performs in reducing surgical trauma, intraoperative blood loss, and postsurgical brain edema. In the present study the authors investigate these parameters in a comparison between waterjet dissection and ultrasonic aspiration in the rabbit brain in vivo. METHODS: Thirty-one rabbits received identical bilateral frontal corticotomies, which were created using the waterjet device or an ultrasonic aspirator. The animals were killed 1, 3, or 7 days, or 6 weeks after surgery and their brains were processed for immunohistological analysis. Blood vessel preservation, intraoperative hemorrhage, postsurgical brain edema, and posttraumatic microglial and astoglial reactions were evaluated. Only in animals subjected to waterjet dissection were preserved vessels observed within the corticotomies. In addition, less intraoperative bleeding occurred in animals in which the waterjet was used. The microglial reaction was significantly reduced by waterjet dissection compared with ultrasonic aspiration; however, no difference in edema formation or astrocytic reactivity was observed. CONCLUSIONS: These results demonstrate that waterjet dissection appears to be less traumatic than ultrasonic aspiration with respect to intraoperative hemorrhage and postoperative microglial reactivity in the rabbit model. Nevertheless, no difference in edema formation could be demonstrated. It remains to be proven that the observed differences are of clinical relevance.