[Surgical management of ankylosing spondylitis (Bechterew's disease)]. / Operationen bei ankylosierender Spondylitis (Morbus Bechterew).

Ankylosing spondylitis is an inflammatory rheumatic disease that is often associated with back pain and restricted spinal movement. In the later stages of the disease, complete ossification of the entire spine and severe deformity can occur, often resulting in a marked reduction in quality of life and an increased risk of loss of independence due to diminished visual field. Patients with ankylosing spondylitis are at greater risk of spinal fractures. These are generally complex fractures associated with high morbidity and mortality; in addition, neurological deficits are not unusual. Conventional radiological diagnosis is often insufficient to establish a diagnosis. Conservative treatment of fractures of the spine in this patient group is unsatisfactory. Surgical procedures, if necessary combined with decompression, are often the preferred treatment of choice in the fractured or malaligned ankylosed spine. Rebalancing of the sagittal profile with normalization of the visual axis and an improvement of quality of life is achieved through corrective osteotomies. Despite the high rate of complications, long-term results following spinal surgery in patients with ankylosing spondylitis are good. Minimally invasive surgery is appropriate for a further reduction in the complication rate. Meticulous preoperative planning is essential in the treatment of patients with ankylosing spondylitis.

[Simultaneous thoracoscopically assisted anterior release in prone position and posterior scoliosis correction : What are the limits?]. / Thorakoskopisches ventrales Release in Bauchlage simultan zur dorsalen Korrekturspondylodese : Wo sind die Grenzen?

BACKGROUND: In spite of modern pedicle-based systems, the correction of a rigid rib hump or hypokyphosis remains a problem in posterior-only scoliosis surgery. As there has so far been no reliable method of predicting the intraoperative extent of kyphosis restoration or rib hump correction by posterior-only surgery, it has been difficult to determine the indication for an additional anterior release. METHODS: The method described here circumvents this dilemma. Like an optional module, horacoscopically assisted release in prone position (TARP) can be added when it is obvious during posterior surgery that the correction is insufficient. RESULTS: Between 1996 and 2005, a total of 161 patients (115 male, 46 female) under the age of 30, including 113 cases of idiopathic scoliosis, were released by simultaneous TARP and posterior surgery. Using the two-portal technique, 131 were mobilized from the right and 30 from the left hand side. Average surgical time spanned 69 min, in which on average 3.2 apical segments were addressed. In 3 individuals, an additional retroperitoneoscopic release was used to liberate a rigid lumbar curve. After 10 years, in a prospectively evaluated subgroup of 32 patients with adolescent idiopathic scoliosis, the index curve had maintained a coronal correction of 70 % (immediately post-surgery 75 %), kyphosis was permanently normalized at 30° (Th5-Th12), and indirect rib hump was reduced to 2.2 cm. In 23 out of 32 patients the lumbar curve corrected spontaneously, obviating the need for fusion. In 13 patients, the lower instrumented vertebra lay at Th12 or higher, thus leaving the thoraco-lumbar junction fairly free. Minor complications (Huang 1or 2) occurred in 4 patients; 1 patient with hematothorax required revision. A distance <25 mm from the spine to the chest wall precludes TARP. Other limitations (e.g., pleural adhesions) were not encountered. CONCLUSION: Long-term evaluation after 10-18 years shows that an additional thoracoscopically assisted anterior release at the same time as a posterior standard scoliosis procedure is a justified and effective tool, yielding better results and maintaining them.

Cervical spondylodiscitis: change in clinical picture and operative management during the last two decades. A series of 50 patients and review of literature.

PURPOSE: The incidence of spondylodiscitis is increasing. This study evaluates the behavior of cervical spondylodiscitis over a period of two decades in a single institution and compares the findings with the literature. METHODS: Between 1994 and 1999, 20 consecutive patients (group A) suffering from cervical spondylodiscitis underwent surgical treatment in our institution. These were compared to another group consisting of 30 patients (group B) undergoing surgery for the same disease between 2004 and 2009 again in our institution. All patients in both series underwent surgical debridement and reconstruction followed by antibiotic therapy for 8-12 weeks. RESULTS: The mean age at presentation increased significantly from 59.7 to 64.5 years. Male predominance was noticed in both groups. Accompanying neurological deficit was almost the same (40-45 %), while septicaemia increased from 15 to 40 %. Radiologically, epidural abscess formation increased from 60 to 80 %. The disease was mostly monosegmental in group A (85 %); while in group B, the disease became significantly more aggressive affecting two and three segments in 43.3 % of the cases. There was an increased tendency toward anterior alone surgery in group B (56.7 %) in comparison to group A (35 %). Mean period of follow-up was 2.8 years. Healing of the inflammation was the rule. Mortality rate increased from 5 to 10 %. CONCLUSIONS: Cervical spondylodiscitis has increased and became more aggressive. While radical surgical debridement, stable reconstruction together with antibiotic therapy remained a reliable approach to achieve complete healing of the inflammation, anterior alone surgery became more applicable.

[Current treatment strategies for spondylodiscitis in surgical clinics in Germany]. / Aktuelle Behandlungsstrategien der Spondylodiszitis in deutschen Akutkliniken.

BACKGROUND: Spondylodiscitis is a rare disease which is associated with high mortality. No guidelines for treatment exist and the available studies are not homogeneous. Attempts have been made in recent years to structure therapy using algorithms. Early recognition of the disease is above all important for its later outcome. Therapy takes place in not only orthopaedic/trauma surgery clinics but also in neurosurgical clinics. MATERIAL AND METHOD: We sent an online survey on this subject to orthopaedic clinics, trauma surgery and neurosurgery clinics in Germany. The aim was to ascertain current care strategies in Germany. A further objective was to elicit differences between the specialist fields. RESULTS: A total of 164 clinics responded to the survey. The response rate was 16% of the orthopaedic/trauma surgery clinics and 32% of the neurosurgical clinics. Differences between the two specialist fields can be found particularly in the use of systemic and local antibiotics, in the choice of surgical access to the thoracic spine and the lumbar spine and in post-operative imaging. In both specialist fields, patients with neurological dysfunctions are treated primarily in clinics with high case numbers. In terms of surgery, 2/3 of the responding clinics choose a one-stage operative treatment. Minimally invasive procedures and the use of cages are widespread. The participants estimate that, on the whole, a better outcome and higher patient satisfaction tend to exist after operative treatment. CONCLUSIONS: The lack of homogeneity regarding treatment strategies which is indicated here clearly shows the need for therapy guidelines as an aid to orientation. This will be a challenge for the future due to the low incidence and the situation regarding currently available studies.