Correlation between Adrenoceptor Expression and Clinical Parameters in Degenerated Lumbar Intervertebral Discs.

Despite advanced knowledge of the cellular and biomechanical processes of intervertebral disc degeneration (IVDD), the trigger and underlying mechanisms remain unclear. Since the sympathetic nervous system (SNS) has been shown to exhibit catabolic effects in osteoarthritis pathogenesis, it is attractive to speculate that it also influences IVDD. Therefore, we explored the adrenoceptor (AR) expression profile in human IVDs and correlated it with clinical parameters of patients. IVD samples were collected from n = 43 patients undergoing lumbar spinal fusion surgery. AR gene expression was analyzed by semi-quantitative polymerase chain reaction. Clinical parameters as well as radiological Pfirrmann and Modic classification were collected and correlated with AR expression levels. In total human IVD homogenates α1A-, α1B-, α2A-, α2B-, α2C-, ß1- and ß2-AR genes were expressed. Expression of α1A- (r = 0.439), α2A- (r = 0.346) and ß2-AR (r = 0.409) showed a positive and significant correlation with Pfirrmann grade. α1A-AR expression was significantly decreased in IVD tissue of patients with adjacent segment disease (p = 0.041). The results of this study indicate that a relationship between IVDD and AR expression exists. Thus, the SNS and its neurotransmitters might play a role in IVDD pathogenesis. The knowledge of differential AR expression in different etiologies could contribute to the development of new therapeutic approaches for IVDD.

Adrenoceptor Expression during Intervertebral Disc Degeneration.

Healthy and degenerating intervertebral discs (IVDs) are innervated by sympathetic nerves, however, adrenoceptor (AR) expression and functionality have never been investigated systematically. Therefore, AR gene expression was analyzed in both tissue and isolated cells from degenerated human IVDs. Furthermore, human IVD samples and spine sections of wildtype mice (WT) and of a mouse line that develops spontaneous IVD degeneration (IVDD, in SM/J mice) were stained for ARs and extracellular matrix (ECM) components. In IVD homogenates and cells α1a-, α1b-, α2a-, α2b-, α2c-, ß1-, and ß2-AR genes were expressed. In human sections, ß2-AR was detectable, and its localization parallels with ECM alterations. Similarly, in IVDs of WT mice, only ß2-AR was expressed, and in IVDs of SM/J mice, ß2AR expression was stronger accompanied by increased collagen II, collagen XII, decorin as well as decreased cartilage oligomeric matrix protein expression. In addition, norepinephrine stimulation of isolated human IVD cells induced intracellular signaling via ERK1/2 and PKA. For the first time, the existence and functionality of ARs were demonstrated in IVD tissue samples, suggesting that the sympathicus might play a role in IVDD. Further studies will address relevant cellular mechanisms and thereby help to develop novel therapeutic options for IVDD.

Age-related cutoffs for cervical movement behaviour to distinguish chronic idiopathic neck pain patients from unimpaired subjects.

PURPOSE: The present study aims to develop age-dependent cutoff values in a quasi-experimental, cross-sectional diagnostic test study. METHODS: One hundred and twenty (120) asymptomatic subjects (n = 100, 36♀, 18 75 years, for normative values; n = 20, 23-75 years, 15♀, for selectivity analyses) and 20 patients suffering from idiopathic neck pain (selectivity analyses, 22-71 years, 15♀) were included. Subjects performed five repetitive maximal cervical flexion/extension movements in an upright sitting position. Cervical kinematic characteristics (maximal range of motion (ROM), coefficient of variation (CV) and mean conjunct movements in rotation and flexion (CM)) were calculated from raw 3D ultrasonic data. Regression analyses were conducted to reveal associations between kinematic characteristics and age and gender and thus to determine normative values for healthy subjects. RESULTS: Age explains 53 % of the variance in ROM (decrease 10.2° per decade), 13 % in CV (increase 0.003 per decade) and 9 % in CM (increase 0.57° per decade). Receivers operating characteristic (ROC) analyses were conducted for differences between individual values of the kinematic characteristics and normative values to optimise cutoff values for distinguishing patients from unimpaired subjects (20 patients and 20 healthy). Cutoff values distinguished asymptomatic subjects' and chronic nonspecific neck patient's movement characteristics with sufficient quality (sensitivity 70-80 %, specificity 65-70 %). CONCLUSIONS: By including such classifications, the present findings expand actual research stating an age-related decrease in kinematic behaviour only using categorising span widths across decades. Future study is warranted to reveal our results' potential applicability for intervention onset decision making for idiopathic neck pain patients.

Bilateral reconstructive costoplasty for razorback deformity correction in adolescent idiopathic scoliosis.

BACKGROUND: Correcting the chest wall deformity is an important goal of scoliosis surgery. A prominent rib hump deformity may not be adequately addressed by scoliosis correction alone. It has been shown that costoplasty in conjugation with scoliosis correction and instrumented spinal fusion is superior to spinal fusion alone in addressing the chest wall deformity. In cases of severe rib hump deformity unilateral convex side costoplasty alone might not adequately restore thoracic cage symmetry necessitating for additional concave side rib cage reconstruction. CASE REPORT: A 16-year-old male with adolescent idiopathic scoliosis and a sharp, cosmetically unacceptable, prominent rib hump (razorback deformity) underwent scoliosis correction with posterior spinal fusion and bilateral costoplasty. The convex-sided ribs were resected and used for concave-sided rib reconstruction. The rib hump height was reduced from 70 mm before the procedure to 10 mm after the procedure and the apical trunk rotation was reduced from 36° to 5°, respectively. Solid spinal fusion and ribs union was achieved. The patient remained very satisfied with no loss of correction at 2-year postoperative follow-up. CONCLUSION: Bilateral costoplasty in conjugation with scoliosis correction may provide a safe and effective method for the treatment of severe rib cage deformities associated with thoracic scoliosis. It should be considered in the presence of prominent rib hump deformity, where scoliosis correction alone or with unilateral costoplasty is unlikely to provide adequate correction.

[Interbody fusion procedures. Development from a historical perspective]. / Interkorporelle Fusionsverfahren an der Wirbelsäule. Die Entwicklung aus historischer Sicht.

BACKGROUND: The development of interbody fusion now stretches over many decades and is still not complete. DISCUSSION: Due to the lack of appropriate implants, the initial fusions were performed via decortication of the dorsal and lateral structures of the spine, followed by placement of an autograft. Despite acceptable fusion results, better primary stability and higher fusion rates were desired. In addition, it became known that the primary load-bearing of the spine is located ventrally in the area of the corpus of the vertebrae. These considerations led to the development of the PLIF technique that was introduced by Cloward in 1953 and gained significantly in popularity. After removal of the intervertebral disc, he positioned iliac crest bone blocks between the vertebral bodies. Based on this technique and these considerations, intervertebral implants were developed in the 1970s. The so-called Bagby Basket was the first intervertebral cage that was initially used in horses with wobbler syndrome. Other milestones in the improvement of the cage designs followed, resulting in the production of different implant shapes and materials. The elastic modulus of the interbody implants approached by modern materials became more and more similar to bone, so that subsidence of cages reduced and the fusion rate could be further increased. The primary stability could be further increased with screw-rod systems, so that dorsal instrumentation became the standard in the context of PLIF and TLIF procedures today. The TLIF procedure described by Harms was a new modification and minimized complications of lumbar fusions and reduced the invasiveness of the procedure. CONCLUSION: Nowadays a wide variety of implants and implantation techniques are available, making interbody fusions in PLIF and TLIF techniques safe and successful procedures.

Posterior-only correction of Scheuermann kyphosis using pedicle screws: economical optimization through screw density reduction.

INTRODUCTION: Posterior-only approach using pedicle screws' fixation has emerged as the preferred surgical technique for Scheuermann kyphosis (SK) correction. Insertion of multiple pedicle screws while increasing stability increases also the risk of complications related to screw malpositioning and surgical cost. The optimal screw density required in surgical correction of SK remains unclear. This study compares the safety and efficacy of low screw density (LSD) versus high screw density (HSD) technique used in posterior-only correction of SK. METHODS: Twenty-one patients underwent surgical correction of SK between 2007 and 2011 and were reviewed after a mean of 29 months. HSD technique (i.e., 100 % of available pedicles, averaged 25.2 ± 4 screws) was used in 10 cases and LSD technique (i.e., 54-69 % of available pedicles in a pre-determined pattern, averaged 16.8 ± 1.3 screws; p < 0.001) was used in 11 cases. Kyphosis correction was assessed by comparing thoracic kyphosis, lumbar lordosis and sagittal balance on preoperative and postoperative radiographs. Cost saving analysis was performed for each group. RESULTS: Preoperative thoracic kyphosis, lumbar lordosis and sagittal balance were similar for both groups. The average postoperative kyphosis correction was similar in both HSD and LSD groups (29° ± 9° vs. 34° ± 6°, respectively; p = 0.14). Complication occurred in four patients (19 %) in the HSD group and in two patients (9 %) in the LSD group (p = 0.56). Three patients required re-operation. Compared to HSD using LSD saves 4,200 pounds sterling per patient in hardware and 88,200 pounds sterling for the entire cohort. CONCLUSION: LSD technique is as safe and effective as HSD technique in posterior-only correction of SK. Implant-related cost could be reduced by 32 %.

Management of Deep Spinal Wound Infections Following Instrumentation Surgery with Subfascial Negative Pressure Wound Therapy.

BACKGROUND AND STUDY AIMS: The treatment of infections following a spine surgery continues to be a challenge. Negative pressure wound therapy (NPWT) has been an effective method in the context of infection therapy, and its use has gained popularity in recent decades. This study aims to analyze the impact of known risk factors for postoperative wound infection on the efficiency and length of NPWT therapy until healing. PATIENTS AND METHODS: We analyzed 50 cases of NPWT treatment for deep wound infection after posterior and posteroanterior spinal fusion from March 2010 to July 2014 retrospectively. We included 32 women and 18 men with a mean age of 69 years (range, 36-87 years). Individual risk factors for postoperative infection, such as age, gender, obesity, diabetes, immunosuppression, duration of surgery, intraoperative blood loss, and previous surgeries, as well as type and onset (early vs. late) of the infection were analyzed. We assessed the associations between these risk factors and the number of revisions until wound healing. RESULTS: In 42 patients (84%), bacterial pathogens were successfully detected by means of intraoperative swabs and tissue samples during first revision. A total of 19 different pathogens could be identified with a preponderance of Staphylococcus epidermidis (21.4%) and S. aureus (19.0%). Methicillin-resistant S. aureus (MRSA) was recorded in two patients (2.6%). An average of four NPWT revisions was required until the infection was cured. Patients with infections caused by mixed pathogens required a significantly higher number of revisions (5.3 vs. 3.3; p < 0.01) until definitive wound healing. For the risk factors, no significant differences in the number of revisions could be demonstrated when compared with the patients without the respective risk factor. CONCLUSION: NPWT was an effective therapy for the treatment of wound infections after spinal fusion. All patients in the study had their infections successfully cured, and all spinal implants could be retained. The number of revisions was similar to those reported in the published literature. The present study provides insights regarding the effectiveness of NPWT for the treatment of deep wound infection after spinal fusion. Further investigations on the impact of potential risk factors for postoperative wound healing disorders are required. Better knowledge on the impact of specific risk factors will contribute to a higher effectiveness of prophylaxis for postoperative wound infections considering the patient-specific situation.

Postoperative cage migration and subsidence following TLIF surgery is not associated with bony fusion.

Pseudarthrosis following transforaminal interbody fusion (TLIF) is not infrequent. Although cage migration and subsidence are commonly regarded as evidence of the absence of solid fusion, there is still no evidence of the influence of cage migration and subsidence on fusion. This study aimed to evaluate cage migration and subsidence using computed tomography (CT) DICOM data following lumbar interbody fusion. The effects of cage migration and subsidence on fusion and clinical outcomes were also assessed. A postoperative CT data set of 67 patients treated with monosegmental TLIF was analyzed in terms of cage position. To assess the effects of cage migration and subsidence on fusion, 12-month postoperative CT scans were used to assess fusion status. Clinical evaluation included the visual analog scale for pain and the Oswestry Disability Index. Postoperative cage migration occurred in 85.1% of all patients, and cage subsidence was observed in 58.2%. Radiological signs of pseudarthrosis was observed in 7.5% of the patients Neither cage migration nor subsidence affected the clinical or radiographic outcomes. No correlation was found between clinical and radiographic outcomes. The incidence of cage migration was considerable. However, as cage migration and subsidence were not associated with bony fusion, their clinical significance was considered limited.

A Prospective, Randomized Study Evaluating Clinical and Radiographic Efficacy of Lumbar Interbody Fusion Performed Using a Truss Technology-Based Interbody Fusion Device With Homologous Bone or Bone Marrow Aspirate.

BACKGROUND: Our group used vertebral bone marrow aspirate (BMA) with an anterior truss-based interbody implant to promote fusion. This implant has biomechanical characteristics that may enhance bone on-growth and through-growth and allow for the use of BMA clot alone. The primary end point was comparison of the proportion of patients who achieved fusion with the implant packed with either crushed cancellous homologous bone chips (CCB) alone or with BMA clot alone. METHODS: Patients were randomized to receive either BMA clot or CCB in the implant. Both groups also had supplemental fixation. Clinical assessments were performed preoperatively and postoperatively at 3, 6, and 12 months, including for the Oswestry Disability Index, leg and back visual analog scale, EQ5-D, reoperations, complications, and adverse events. Radiographs were obtained prior to discharge and at 3, 6, and 12 months postoperatively. A computed tomography scan was performed 3 months postoperatively. Radiographs were assessed by an independent radiologist to determine fusion status and evidence of subsidence. RESULTS: Between January 2015 and February 2016, 42 consecutive patients were randomized into 1 of the 2 study groups. There were significant postoperative changes within both groups in pain improvement across all outcome scales. There were no significant differences between groups in change scores from preoperative to assessments at any follow-up time point, with the exception of the change in EQ-5D and visual analog scale at 6 months; however, there was no difference at 3 or 12 months. There were no device-related adverse events in either group. All patients achieved grade II fusion at 3 months postoperatively. There was no significant difference in implant subsidence between groups or smokers versus nonsmokers. CONCLUSIONS: The clinical outcomes of this study suggest that reliable fusion can be obtained using an anterior truss-based implant with either CCB or BMA alone. LEVEL OF EVIDENCE: 2.

Carbon fiber-reinforced pedicle screws reduce artifacts in magnetic resonance imaging of patients with lumbar spondylodesis.

The study investigated whether the use of carbon fiber-reinforced PEEK screw material (CF-PEEK) can reduce magnetic resonance imaging (MRI) artifact formation. Two consecutive groups of patients were treated for degenerative spinal disorders of the lumbar spine with dorsal transpedicular spinal fusion. The first group (n = 27) received titanium pedicle screws. The second group (n = 20) received CF-PEEK screws. All patients underwent an MRI assessment within the first four postoperative weeks. For each operated segment, the surface of the artifact-free vertebral body area was calculated as percentage of the total vertebral body. For each implanted segment, the assessability of the spinal canal, the neuroforamina, and the pedicle screws, as well as the surrounding bony and soft-tissue structures was graded from 1 to 5. A mean artifact-free vertebral body area of 48.3 ± 5.0% was found in the in the titanium group and of 67.1 ± 5.6% in the CF-PEEK group (p ≤ 0.01). Assessability of the lumbar spine was significantly improved for CF-PEEK screws (p ≤ 0.01) for all measurements. CF-PEEK pedicle screws exhibit smaller artifact areas on vertebral body surfaces and their surrounding tissues, which improves the radiographic assessability. Hence, CF-PEEK may provide a diagnostic benefit.

Clinical Outcome After Anterior Lumbar Interbody Fusion With a New Osteoinductive Bone Substitute Material: A Randomized Clinical Pilot Study.

STUDY DESIGN: Pilot, single-center, single-blinded, parallel-group, randomized clinical study. OBJECTIVE: The aim of this study was to pilot a randomized clinical study to evaluate whether instrumented anterior lumbar interbody fusion (ALIF) with a new nanocrystalline hydroxyapatite embedded in a silica gel matrix (NH-SiO2) leads to superior radiologic and clinical outcomes at 12-month follow-up compared with instrumented ALIF with homologous bone. SUMMARY OF BACKGROUND DATA: ALIF completed with interbody cages is an established technique for performing arthrodesis of the lumbar spine. There is ongoing discussion about which cage-filling material is most appropriate. This is the first study to assess the efficacy of NH-SiO2 in ALIF surgery. MATERIALS AND METHODS: This randomized, clinical, pilot trial included 2 groups of 20 patients with monosegmental or multisegmental degenerative disease of the lumbar spine who were suitable to undergo monosegmental or bisegmental ALIF fusion at the level L4/L5 and L5/S1 with a carbon fiber reinforced polymer ALIF cage filled with either NH-SiO2 or homogenous bone. Primary outcome was postoperative disability as measured by the Oswestry Disability Index (ODI). Secondary outcomes were postoperative radiographic outcomes, pain, and quality of life. Patients were followed 12 months postoperatively. RESULTS: Mean (±SD) 12-month ODI was 24±17 in the NH-SiO2 group and 27±19 in the homologous bone group (P=0.582). Postoperative radiography, functional outcomes, and quality-of-life indices did not differ significantly between groups at any of the regularly scheduled follow-up visits. CONCLUSIONS: This clinical study showed similar functional, radiologic, and clinical outcomes 12 months postoperatively for instrumented ALIF procedures with the use of NH-SiO2 or homologous bone as cage filling. In the absence of any relevant differences in outcome, we postulate that the pivotal clinical study should be designed as an equivalence trial.

Radiological evaluation of kyphoplasty with an intravertebral expander after osteoporotic vertebral fracture.

Spinal deformities due to osteoporotic vertebral compression fractures can be reduced by balloon kyphoplasty, but the correction may be partly lost when the balloon is deflated. The present study aimed to evaluate an intravertebral expander developed to reduce and maintain vertebral body height while cement is injected to correct spinal deformities due to osteoporotic vertebral fractures. The study included 31 osteoporotic vertebral body fractures in 31 patients, classified as A1 according to the AO classification, who underwent kyphoplasty using an intravertebral expander. The kyphosis angle was significantly corrected from 13.4 degrees prior to kyphoplasty to 10.8 degrees (p < 0.01) after surgery, but this correction was lost at 12 months (13.3 degrees). The correction of the kyphosis angle best correlated with the pre-operative mobility of the fracture (r = 0.59, p < 0.01), and the loss of the kyphosis improvement correlated with the amount of correction (r = 0.49, p = 0.01). All patients, except for six with adjacent vertebral fractures, experienced significant pain reduction (VAS 8.7 pre-operatively and 2.0 at 12 months; p < 0.01), and the pain was not affected by the correction of the spinal deformity or the loss of correction in the follow-up period. These results suggest that the mobility of the fracture mainly determines the extent of deformity correction rather the device used for reduction, and greater corrections are at increased risk for losing the improvement. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:457-465, 2019.

Forearm rotation in healthy adults of all ages and both sexes.

Factors such as sex, age, or hand dominance are supposed to influence forearm rotation; however, available data are scarce. This study therefore analyzed range of active supination and pronation bilaterally in 752 healthy white adults (age range, 20-95 years) of both sexes. Range of supination was higher than pronation. Range of forearm rotation was comparable between both sides, but it was higher in women than in men and inversely correlated with age. In contrast with women, where range started to decrease during the fifth decade of life, onset was later in men (seventh decade). No influence was observed with respect to hand dominance or constitutional variations. Thus, the contralateral side serves for clinical comparison independent from age, sex, hand dominance, or constitutional variances. The fact that several patients with a major limitation of pronation considered themselves healthy, but only 1 patient with limited supination did so, indirectly underlines the importance of restoring deficits of supination rather than pronation.

Effect of lumbar spinal fusion surgery on the association of self-report measures with objective measures of physical function.

BACKGROUND: Self-report measures are used to evaluate surgery outcome but are not necessarily indicative of actual disabilities. RESEARCH QUESTION: The aim of the present study was to determine the association between self-report assessments of quality of life and objective measures of function in patients with symptomatic lumbar degenerative disease. Additionally, we evaluated the effect of lumbar spinal fusion surgery on this relationship. METHODS: Before and 6 month after surgery 26 patients completed self-report questionnaires and assessments of 3D gait analysis and trunk range of motion (ROM) during standing. RESULTS: Before surgery, questionnaires were not correlated with any of the gait parameters and with only 2 trunk ROM parameters. Six month after surgery, the questionnaires showed 12 significant correlations with gait parameters and 19 with trunk ROM parameters. A better Oswestry Disability Index (ODI) (r = 0.464, p = .026), EQ-5D (r = -0.440, p = .036), and EQ VAS (r = -0.472, p = .023) score were correlated with a reduced anterior thorax tilt during walking. Maximum forward flexion of the trunk during standing was correlated with a better EQ-5D (r = 0.684, p = .001) and ODI (r = -0.560, p = .008) score as well as with reduced pain scores. SIGNIFICANCE: The lack of association between self-reported questionnaires and objective measures of function before surgery was likely due to psychological distress, correlating with emotional and cognitive function rather than true functional capacities. The influence of these psychological factors might be reduced after surgery due to a reduction of low back pain. To obtain an accurate assessment of impairment, there is a need to evaluate function by measuring objective physiologic parameters that are unsusceptible to voluntary or affective influences.

Small cavity creation in the vertebral body reduces the rate of cement leakage during vertebroplasty.

Cement leakage is the most common complication during vertebroplasty and may result in serious morbidity. Measures to reduce the rate of cement leakage are valuable ways to improve vertebroplasty safety. The present study aimed to evaluate whether creating a small cavity in the vertebral body prior to cement injection would reduce the rate of cement leakage during vertebroplasty. The study included 36 consecutive patients with 42 painful osteoporotic vertebral body compression fractures that were classified as A1 fractures according to AO classification. Patients were randomly assigned to receive either treatment with vertebroplasty (control) or with a procedure termed cavuplasty, in which a small cavity was created in the vertebral body prior to cement injection. CT scanning was performed to detect cement leakage. Cement leakage was observed in 14 (66.6%) of the 21 vertebral bodies treated with vertebroplasty and 5 (23.8%) of the 21 vertebral bodies treated with cavuplasty (p = 0.012). These results suggest that the creation of a small cavity in the vertebral body prior to cement injection is an effective way to reduce cement leakage during vertebroplasty. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:154-159, 2017.

Differentiation of Osteophytes and Disc Herniations in Spinal Radiculopathy Using Susceptibility-Weighted Magnetic Resonance Imaging.

OBJECTIVE: The aim of this study was to evaluate the diagnostic performance of susceptibility-weighted magnetic resonance imaging (SW-MRI) for the differentiation of osteophytes and disc herniations of the spine compared with that of conventional spine MR sequences and radiography. MATERIALS AND METHODS: This study was approved by the local ethics review board; written consent was obtained from all subjects. Eighty-one patients with suspected radiculopathy of the spine were included prospectively. Radiography, T1/T2, and SW-MRI of the cervical/lumbar spine were performed. As reference standard, 93 osteophytes (n = 48 patients) were identified on radiographs in combination with conventional T1/T2 images. One hundred fourteen posterior disc herniations (n = 60 patients) were identified on T1/T2 in combination with radiography excluding osteophytes. For this study, 2 observers independently assessed the presence of osteophytes and disc herniations on T1/T2 and SW-MRI, with radiographs excluded from the analysis. In a subgroup of patients (n = 19), additional computed tomography images were evaluated. Sensitivity, specificity, and interobserver agreement were calculated. RESULTS: Most osteophytes (n = 92 of 93) and disc herniations (n = 113 of 114) could be identified and differentiated on SW-MRI magnitude/phase images, if radiographs were excluded from analysis. Susceptibility-weighted magnetic resonance imaging achieved a sensitivity of 98.9% and specificity of 99.1% for the identification of osteophytes. Conventional T1/T2 spine MR sequences achieved a sensitivity and specificity of 68.6% and 86.5%, respectively, if radiographs were excluded from analysis. Regarding the size of osteophytes, SW-MRI showed a strong correlation with computed tomography (R = 0.96) and radiography (R = 0.95). In addition, SW-MRI achieved a higher interobserver agreement compared with conventional MR. CONCLUSIONS: Susceptibility-weighted magnetic resonance imaging enables the reliable differentiation of osteophytes and disc herniations in patients with spinal radiculopathy with a higher sensitivity and specificity compared with conventional T1/T2 MR sequences.

Staged Correction of Severe Thoracic Kyphosis in Patients with Multilevel Osteoporotic Vertebral Compression Fractures.

Study Design Technical report. Objective Multilevel osteoporotic vertebral compression fractures may lead to considerable thoracic deformity and sagittal imbalance, which may necessitate surgical intervention. Correction of advanced thoracic kyphosis in patients with severe osteoporosis remains challenging, with a high rate of failure. This study describes a surgical technique of staged vertebral augmentation with osteotomies for the treatment of advanced thoracic kyphosis in patients with osteoporotic multilevel vertebral compression fractures. Methods Five patients (average age 62 ± 6 years) with multilevel osteoporotic vertebral compression fractures and severe symptomatic thoracic kyphosis underwent staged vertebral augmentation and surgical correction of their sagittal deformity. Clinical and radiographic outcomes were assessed retrospectively at a mean postoperative follow-up of 34 months. Results Patients' self-reported back pain decreased from 7.2 ± 0.8 to 3.0 ± 0.7 (0 to 10 numerical scale; p < 0.001). Patients' back-related disability decreased from 60 ± 10% to 29 ± 10% (0 to 100% Oswestry Disability Index; p < 0.001). Thoracic kyphosis was corrected from 89 ± 5 degrees to 40 ± 4 degrees (p < 0.001), and the sagittal vertical axis was corrected from 112 ± 83 mm to 38 ± 23 mm (p = 0.058). One patient had cement leakage without subsequent neurologic deficit. Decreased blood pressure was observed in another patient during the cement injection. No correction loss, hardware failure, or neurologic deficiency was seen in the other patients. Conclusion The surgical technique described here, despite its complexity, may offer a safe and effective method for the treatment of advanced thoracic kyphosis in patients with osteoporotic multilevel vertebral compression fractures.

Has a Mono- or Bisegmental Lumbar Spinal Fusion Surgery an Influence on Self-Assessed Quality of Life, Trunk Range of Motion, and Gait Performance?

STUDY DESIGN: This investigation prospectively compared self-assessed quality of life and biomechanical measures of physical function before and after spinal fusion surgery in 26 adult patients with symptomatic lumbar degenerative disease. OBJECTIVE: The objective was to demonstrate that (1) due to a reduction of low back pain, quality of life as well as gait parameters would improve after a spinal fusion surgery and (2) gait performance is more similar to that observed in healthy controls at the same age, whereas trunk range of motion remains unchanged after surgery. SUMMARY OF BACKGROUND DATA: Current outcome evaluations of spinal fusion surgery are based on radiological changes and self-report questionnaires. However, these traditional measures do not sufficiently assess the functionality. METHODS: Twenty-six patients with a mean age of 59.3 (SD: 10.1) years and 20 healthy subjects at the same age were evaluated. Before and approximately 6 months after a mono- or bisegmental spinal fusion surgery, patients completed self-report questionnaires and biomechanical assessments of gait analysis and trunk range of motion in the 3 principal planes of the body. RESULTS: Results indicated an improvement in quality of life as well as an increased pain-free walking distance, walking speed, step length, and maximum hip extension during the stance phase of gait. Anterior pelvis and thorax tilt were significantly reduced after the surgery without significant differences compared with the control group. Regarding the trunk range of motion, we observed a decrease in maximum forward flexion and an increase in the fingertip-floor distance after surgery. CONCLUSION: The study results show that lumbar spinal fusion is a useful procedure to improve patient's quality of life and gait performance. Although we performed only mono- and 2-level fusions, the sagittal alignment of the pelvis and thorax during walking was normalized. Clinical gait analysis contributes to the advancement of our knowledge regarding the functional changes after a spinal fusion surgery. LEVEL OF EVIDENCE: 2.

Outcome in Pelvic Ring Fractures.

Pelvic ring fractures represent a negative prognostic factor for what concerns morbidity and mortality of a polytraumatized patient. The subjective and functional prognosis of a pelvic ring fracture is dependent upon its degree of instability. Associated severe peripelvic soft tissue injuries and neurovascular lesions (complex pelvic trauma) affect outcome negatively. Although high rates of anatomic reduction and stable fixation have been achieved in recent years, only 60% of patients have an excellent or good clinical result. Sequelae of neurologic lesions and genitorurinary injuries are typically associated with considerable rates of persistent functional impairment. Chronic pain and disability are often very difficult to treat. Health-related quality of life and life satisfaction after pelvic ring fractures caused by high-energy trauma is substantially lower when compared to a reference population.