Impact of Anxiety During Hospitalization on the Clinical Outcome of Patients With Osteoporotic Thoracolumbar Vertebral Fracture.

STUDY DESIGN: Multicenter prospective cohort study. OBJECTIVES: Anxiety in combination with osteoporotic vertebral compression fractures (OVCFs) of the spine remains understudied. The purpose of this study was to analyze whether anxiety has an impact on the short-term functional outcome of patients with an OVCF. Furthermore, a direct impact of the fracture on the patient's anxiety during hospitalization should be recognized. METHODS: All inpatients with an OVCF of the thoracolumbar spine from 2017 to 2020 were included. Trauma mechanism, analgetic medication, anti-osteoporotic therapy, timed-up-and-go test (TuG), mobility, Barthel index, Oswestry-Disability Index (ODI) and EQ5D-5L were documented.For statistical analysis, the U test, chi-square independence test, Spearman correlation, General Linear Model for repeated measures, Bonferroni analysis and Wilcoxon test were used. The item anxiety/depression of the EQ5D-5L was analyzed to describe the patients' anxiousness. RESULTS: Data from 518 patients from 17 different hospitals were evaluated. Fracture severity showed a significant correlation (r = .087, P = .0496) with anxiety. During the hospital stay, pain medication (P < .001), anti-osteoporotic medication (P < .001), and initiation of surgical therapy (P < .001) were associated with less anxiety. The anxiety of a patient at discharge was negatively related to the functional outcomes at the individual follow-up: TuG (P < .001), Barthel index (P < .001), ODI (P < .001) and EQ5D-5L (P < .001). CONCLUSIONS: Higher anxiety is associated with lower functional outcome after OVCF. The item anxiety/depression of the EQ5D-5L provides an easily accessible, quick and simple tool that can be used to screen for poor outcomes and may also offer the opportunity for a specific anxiety intervention.

Effect of subsequent vertebral body fractures on the outcome after posterior stabilization of unstable geriatric fractures of the thoracolumbar spine.

PURPOSE: The purpose of this study was analyzing the effect of subsequent vertebral body fractures on the clinical outcome in geriatric patients with thoracolumbar fractures treated operatively. METHODS: Retrospectively, all patients aged ≥ 60 with a fracture of the thoracolumbar spine included. Further inclusion parameters were acute and unstable fractures that were treated by posterior stabilization with a low to moderate loss of reduction of less than 10°. The minimal follow-up period was 18 months. Demographic data including the trauma mechanism, ASA score, and the treatment strategy were recorded. The following outcome parameters were analyzed: the ODI score, pain level, satisfaction level, SF 36 score as well as the radiologic outcome parameters. RESULTS: Altogether, 73 patients were included (mean age: 72 years; 45 women). The majority of fractures consisted of incomplete or complete burst fractures (OF 3 + 4). The mean follow-up period was 46.6 months. Fourteen patients suffered from subsequent vertebral body fractures (19.2%). No trauma was recordable in 5 out of 6 patients; 42.8% of patients experienced a low-energy trauma (significant association: p < 0.01). There was a significant correlation between subsequent vertebral body fracture and female gender (p = 0.01) as well as the amount of loss of reduction (p = 0.02). Thereby, patients with subsequent vertebral fractures had significant worse clinical outcomes (ODI: 49.8 vs 16.6, p < 0.01; VAS pain: 5.0 vs 2.6, p < 0.01). CONCLUSION: Patient with subsequent vertebral body fractures had significantly inferior clinical midterm outcome. The trauma mechanism correlated significantly with both the rate of subsequent vertebral body fractures and the outcome. Another risk factor is female gender.

[Lumbar fusion-Indications and techniques]. / Lumbale Spondylodese ­ Indikationen und Techniken.

BACKGROUND: Lumbar spinal fusion is an established surgical technique in spine surgery. The goal of spinal fusion is a biomechanically lasting interbody union, which can be accomplished through different surgical approaches, implants and grafts. TECHNIQUES: The mainly surgical techniques used are: posterior lumbar fusion (PLF), posterior interbody lumbar fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), oblique lumbar interbody fusion (OLIF) and extreme lateral interbody fusion (XLIF). These procedures, their indications, complications and results are described in this narrative review.

[Nonsurgical and surgical management of osteoporotic vertebral body fractures : Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)]. / Nichtoperative und operative Behandlung der osteoporotischen Wirbelkörperfraktur : Empfehlungen der Sektion Wirbelsäule der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU).

STUDY DESIGN: Prospective clinical cohort study (data collection); expert opinion (recommendation development). OBJECTIVES: Treatment options for nonsurgical and surgical management of osteoporotic vertebral body fractures differ widely. Based on the current literature, the knowledge of the experts, and their classification for osteoporotic fractures (OF classification), the Spine Section of the German Society for Orthopaedics and Trauma has now introduced general treatment recommendations. METHODS: A total of 707 clinical cases from 16 hospitals were evaluated. An OF classification-based score was developed for guidance in the option of nonsurgical versus surgical management. For every classification type, differentiated treatment recommendations were deduced. Diagnostic prerequisites for reproducible treatment recommendations were defined: conventional X­rays with consecutive follow-up images (standing position whenever possible), magnetic resonance imaging, and computed tomography scans. OF classification allows for upgrading of fracture severity during the course of radiographic follow-up. The actual classification type is decisive for the score. RESULTS: A score of less than 6 points advocates nonsurgical management; in cases with more than 6 points, surgical management is recommended. The primary goal of treatment is fast and painless mobilization. Because of the expected comorbidities in this age group, minimally invasive procedures are preferred. As a general rule, stability is more important than motion preservation. It is mandatory to restore the physiological loading capacity of the spine. If the patient was in a compensated unbalanced state at the time of fracture, reconstruction of the individual prefracture sagittal profile is sufficient. The instrumentation technique has to account for compromised bone quality. We recommend the use of cement augmentation or high purchase screws. The particular situations of injuries with neurological impairment, the necessity to fuse, multiple level fractures, consecutive and adjacent fractures and fractures in ankylosing spondylitis are addressed separately. CONCLUSIONS: The therapeutic recommendations presented here provide a reliable and reproducible basis to decide for the treatment choices available. However, intermediate clinical situations with a score of 6 points remain, allowing for both nonsurgical and surgical options. As a result, individualized treatment decisions may still be necessary. In the subsequent step, the recommendations presented will be further evaluated in a multicentre controlled clinical trial.

[Thoracolumbar spinal fractures in the elderly : Classification and treatment]. / Thorakolumbale Wirbelsäulenfrakturen beim alten Menschen : Klassifikation und Therapie.

Thoracolumbar fractures in the elderly are frequently associated with osteoporosis. Osteoporosis can cause fractures or be a significant comorbidity in traumatic fractures. The OF classification is based on conventional X­ray, computed tomography (CT) scan and magnetic resonance imaging (MRI). It is easy to use and provides a clinically relevant classification of the fractures. Therapeutic decisions are made based on the clinical and radiological situation by using the OF score. The score takes the current clinical situation including patient-specific comorbidities into consideration. The treatment recommendations are based on an expert consensus opinion and include conservative and operative options. If surgery is indicated, vertebral body augmentation, percutaneous stabilization and even open surgery can be used.

[Management of postoperative wound infections following spine surgery : First results of a multicenter study]. / Management postoperativer Wundinfektionen nach Wirbelsäuleneingriffen : Erste Ergebnisse einer multizentrischen Studie.

INTRODUCTION: The number of spinal surgeries has increased significantly in the last decade, which has led to a correlating increase in the number of problems related to wound healing infection. Current literature has reported a spinal wound infection rate of 0.4 to 20 %. The gold standard for surgical restoration of the infection is to use supportive antibiotics, but this concept of wound management in infections is often not sufficiently standardized and shows a large variance between individual clinics. The present study is to first collect data on the number of wound infections, the clinic's internal standards, the use of methods and tools and the management of revisions in Germany. MATERIAL AND METHODS: A questionnaire has been designed for detecting the number of postoperative wound infections, which need to be treated surgically, and the various treatment regimens used. The questionnaire was sent to all members of the DWG (n = 1275). An example of the questionnaire was to determine clinical internal standards and the procedure for the initial treatment of wound infection, the procedure for second look surgery and the number of revisions requested to infection healing. RESULTS: The study has accepted 67 answer sheets covering a period from June 2013-November 2013. On average, the participating hospitals perform 582 spinal operations and an average of 8 revision surgeries due to infection annually. The average rate of infection was 1.7 %. 55 % reported having no fixed standard of care. 97 % reported wound irrigation and debridement during the first revision. Indication for second look revisions was based on the local examination of the wound conditions. On average 2.2 revisions had been performed to reach effective wound healing. 81 % of the colleagues showed readiness to participate in a multicenter trial. CONCLUSION: The results show that there is a need for uniform standards in the treatment of postoperative infections. Surgical debridement and lavage have a major role in the treatment of infection. The overall rate of postoperative infections, of the clinics surveyed, was approximately 1.7 % per year. The infections were healed with approximately 2 revisions utilizing variety of different treatment strategies.

[Cement augmentation of pedicle screws : Pros and cons]. / Zementaugmentation von Pedikelschrauben : Vorteile und Nachteile.

Cement augmentation of pedicle screws biomechanically increases screw purchase in the bone. However, clinical complications may occur. The pros and cons of the technique are discussed from different clinical perspectives.

[The AOSpine Classification of Thoraco-Lumbar Spine Injuries]. / Die AOSpine-Klassifikation thorakolumbaler Wirbelsäulenverletzungen.

Optimal treatment of injuries to the thoracolumbar spine is based on a detailed analysis of instability, as indicated by injury morphology and neurological status, together with significant modifying factors. A classification system helps to structure this analysis and should also provide guidance for treatment. Existing classification systems, such as the Magerl classification, are complex and do not include the neurological status, while the TLICS system has been accused of over-simplifying the influence of fracture morphology and instability. The AOSpine classification group has developed a new classification system, based mainly upon the Magerl and TLICS classifications, and with the aim of overcoming these drawbacks. This differentiates three main types of injury: Type A lesions are compression lesions to the anterior column; Type B lesions are distraction lesions of either the anterior or the posterior column; Type C lesions are translationally unstable lesions. Type A and B lesions are split into subgroups. The neurological damage is graded in 5 steps, ranging from a transient neurological deficit to complete spinal cord injury. Additional modifiers describe disorders which affect treatment strategy, such as osteoporosis or ankylosing diseases. Evaluations of intra- and inter-observer reliability have been very promising and encourage the introduction of this AOSpine classification of thoracolumbar injuries to the German speaking community.

[Fusion criteria for cages as vertebral body replacement in thoracolumbar fractures]. / Fusionskriterien für Cages als Wirbelkörperersatz bei thorakolumbalen Frakturen.

BACKGROUND: No commonly accepted criteria to evaluate bony incorporation of cages as vertebral body replacement in thoracolumbar fractures exist. The goal of this study was a thorough radiological evaluation of the fusion process in posterior-anterior stabilized fractures. PATIENTS AND METHODS: In this study 35 patients were evaluated radiologically including computed tomography (CT) scanning and bone mineral density measurement inside the cages. Correction loss, cage subsidence and tilting, bone growth in and around the cages as well as bone mineral density were assessed. Fusion grading was assessed with defined criteria (i.e. bridging bone, bone growth through the cage, stability in functional X-rays and no radiolucent lines). RESULTS: After 12 months minor subsidence and tilting of the cages had caused significant correction loss of the basal plate angle of 2.4° on average. Of the patients 20 (57%) fulfilled the criteria for complete or incomplete fusion and 5 (14%) showed no signs of bony fusion. Bone mineral density measurements were unreliable due to metallic artefacts. CONCLUSIONS: The advocated criteria allow accurate assessment of bony incorporation of cages. Bony incorporation can be detected in and around the cages over time; however, only 57% of patients showed signs of bony fusion after 1 year.

[Dislocation of double-threaded screws after stabilization of the odontoid process with the Knöringer technique]. / Dislozierte Doppelgewindeschrauben nach Densosteosynthese in Knöringer-Technik.

A type III fracture of the odontoid process according to Anderson-D'Alonzo in a 92-year-old patient was stabilized anteriorly with two double-threaded screws using the technique of Knöringer. Postoperatively, cranial dislocation of the screws was evident and attempts to correct the screw position failed resulting in screw proximity to the brain stem. In a second revision the screws could be removed by an anterior approach and fusion was achieved by a posterior approach. Type III fractures of the odontoid process are usually stable and should be treated conservatively. In case of instability posterior stabilization techniques should be selected. Anterior osteosynthesis of the odontoid process with double-threaded screws in osteoporotic bone carries the risk of screw dislocation.

[Cervical disc herniation]. / Der zervikale Bandscheibenvorfall.

The cervical disc herniation is characterized by prolapsed nucleus pulposus material through the annulus into the spinal canal. The local mechanical or chemical irritation of neural structures typically leads to symptoms of radiculopathy, cervicocephalgia or myelopathy. Pronounced sensorimotor deficits or intractable pain constitute surgical treatment. In all other cases conservative treatment is indicated, including pain medication, active and passive physiotherapy, and local injections, respectively. Anterior cervical discectomy and interbody fusion (ACDF) is still the surgical treatment of choice. Predominantly, cages with or without plates are in use to obtain solid fusion. The implantation of a total disc replacement is a viable alternative, if no contraindications exist. Other surgical techniques may be performed in proper selected cases. The overall clinical and radiological results of both surgical and conservative treatment are good.

[Cement-augmented anterior odontoid screw fixation of a Anderson-D'Alonzo type II fracture with massive osteoporosis. Case report]. / Zementaugmentierte anteriore Densverschraubung bei Densfraktur Typ Anderson II und massiver Osteoporose. Fallbeschreibung.

Anterior screw fixation is a standard treatment procedure in the case of an uncomplicated Anderson-D'Alonzo type II odontoid fracture in younger patients. Insufficient bony screw hold can cause severe procedure-related complications and result in screw breakouts with secondary fracture dislocation. Hence, the procedure is limited to patients with an adequate bone mineral density. This case report summarises a technical modification of anterior screw fixation in elderly patients suffering from severe osteoporosis to avoid a posterior spondylodesis of C1/2. Two patients with odontoid fractures of Anderson-D'Alonzo type II were operated using anterior screw fixation and additional vertebroplasty of C2 to increase the screw hold. During follow-up a regular bony healing without screw complication was observed. In conclusion, cement-augmented anterior screw fixation of odontoid fractures type II according to Anderson-D'Alonzo and persistent severe osteoporosis can be an alternative to posterior C1/2 spondylodesis in individual cases.

[Recommendations for the treatment of thoracolumbar and lumbar spine injuries]. / Therapieempfehlungen zur Versorgung von Verletzungen der Brust- und Lendenwirbelsäule.

This paper gives recommendations for treatment of thoracolumbar and lumbar spine injuries. The recommendations are based on the experience of the involved spine surgeons, who are part of a study group of the "Deutsche Gesellschaft für Unfallchirurgie" and a review of the current literature. Basics of diagnostic, conservative, and operative therapy are demonstrated. Fractures are evaluated by using morphologic criteria like destruction of the vertebral body, fragment dislocation, narrowing of the spinal canal, and deviation from the individual physiologic profile. Deviations from the individual sagittal profile are described by using the monosegmental or bisegmental end plate angle. The recommendations are developed for acute traumatic fractures in patients without severe osteoporotic disease.

A new zero-profile implant for stand-alone anterior cervical interbody fusion.

BACKGROUND: Several studies suggest fusion rates are higher with anterior cervical discectomy and fusion procedures if supplemented with a plate. However, plates may be associated with higher postoperative morbidity and higher rates of dysphagia. This led to the development of a cervical stand-alone cage with integrated fixation for zero-profile segmental stabilization. QUESTIONS/PURPOSES: We asked whether this new implant would be associated with a low rate of dysphagia and other short-term complications in patients having anterior cervical discectomy and fusion and would be able to achieve solid fusion and maintain postoperative reduction in pain. METHODS: We prospectively followed 38 patients with radiculopathy/myelopathy undergoing anterior cervical discectomy and fusion using the new implant. Intraoperative parameters, clinical features (Neck Pain Disability Index, visual analog scale score for neck/arm pain, Odom's criteria), and dysphagia scores were recorded. Radiographs were taken to assess implant failure. Thirty-four patients had a minimum 6 months' followup (mean, 8 months; range, 6-11 months). RESULTS: Three patients at 6 weeks and one patient at 6 months complained about minor dysphagia-related symptoms. There was no hardware failure recordable and all patients had evidence of fusion. Compared to preoperatively, visual analog scale pain score and Neck Pain Disability Index were reduced at 6 weeks' followup without change during further followup. CONCLUSIONS: The new cervical stand-alone anterior fusion device allows decompression and fusion with low complication rates. The incidence of chronic postoperative dysphagia was infrequent in comparison to published data. Prospective randomized trials with more patients and longer followup are necessary to confirm these observations. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

[Ultrasound examination of the posterior ligament complex in thoracolumbar spinal fractures]. / Ultraschall zur beurteilung des posterioren ligamentkomplexes bei thorakolumbalen wirbelsäulenfrakturen.

BACKGROUND: thoracolumbar distraction injuries (AO classification type B) with damage to the posterior ligament complex (PLC) represent an indication for surgery but the use of X-ray and CT imaging often does not identify injuries of the PLC. The aim of this study was to evaluate the accuracy of ultrasound imaging in the assessment of the PLC status in thoracolumbar fractures of the spine. MATERIAL AND METHODS: in a prospective study the findings of the preoperative ultrasound examination were compared to the intraoperative findings. RESULTS: over a period of 2 years a total of 24 patients with 27 thoracolumbar fractures (18 type A, 9 type B) were examined. In 22 cases ultrasound examination was possible and correct ultrasound findings were made in 20 cases (91%). The sensitivity was 83.3%, specificity 93.8%, positive predictive value 83.3% and negative predictive value 93.8%. CONCLUSION: the use of ultrasound examination in thoracolumbar fractures is a suitable diagnostic tool for injuries of the posterior ligament complex in addition to radiological imaging.

[Partial nucleotomy of the ovine disc as an in vivo model for disc degeneration]. / Die partielle Nukleotomie der ovinen Bandscheibe als In-vivo-Modell für die Bandscheibendegeneration.

AIM: The aim of this study was to develop a suitable animal model for the clinical situation of progressive disc degeneration after microsurgical nucleotomy. METHODS: Twenty sheep underwent standardised partial anterolateral nucleotomy at lumbar segment 3/4. After randomisation, 10 animals were sacrificed after 12 weeks (group 1). The remainder was sacrificed after 48 weeks (group 2). For radiological examination X-rays, MRI and post-mortem CT scans were performed. Lumbar discs L 3/4 with adjacent subchondral trabecular bone were harvested and analysed macroscopically and histologically. An image-analysing computer program was used to measure histomorphometric indices of bone structure. RESULTS: 17 segments could be evaluated. After 12 weeks (group 1) histological and radiological degenerative disc changes were noted. After 48 weeks (group 2), radiological signs in MRI reached statistical significance. Furthermore, group 2 showed significantly more osteophyte formations in CT scans. Histomorphometric changes of the disc and the adjacent vertebral bone structure suggest a significant progressive degenerative remodelling. The facet joints did not show any osteoarthrosis after 48 weeks. CONCLUSIONS: Partial nucleotomy of the ovine lumbar disc leads to radiological and histological signs of disc degeneration similar to those seen in humans after microsurgical nucleotomy. The presented in vivo model may be useful to evaluate new orthopaedic treatment strategies.