[Neuromuscular scoliosis in patients with central nervous system pathologies]. / Neuromuskuläre Skoliose bei Erkrankungen des zentralen Nervensystems.

Neuromuscular scoliosis is due to pathologies within the neuromuscular pathway. These pathologies result in early deformities, usually with ongoing rapid progress. Conservative treatment has only limited value in these individuals, and posterior instrumented surgical correction to the spine is the favored treatment concept for correction and avoidance of progression. Here, we illuminate the special treatment concepts for children with NMS due to pathologies of the central nervous system also with a closer look at new treatment modalities. Moreover, we describe two typical cases in detail.

Cervical spine alignment following surgery for adolescent idiopathic scoliosis (AIS): a pre-to-post analysis of 81 patients.

BACKGROUND: Several studies have emphasized the importance of restoring thoracic kyphosis (TK) in the setting of AIS, but very few have discussed changes in cervical spine alignment following surgery. Aim of this study was to evaluate reciprocal cervical alignment change after modification of global and regional thoracolumbar alignment with surgery in the setting of adolescent idiopathic scoliosis (AIS). METHODS: Baseline and 2-yrs follow-up radiographs of AIS patients (n = 81) were analysed measuring cervical parameters (upper cervical: C2-C0, McGregor Slope; lower cervical: C2-C7, C2-C7 sagittal vertical axis (SVA), C2-T3, C2-T3SVA, C2-T1Harrison (C2-T1Ha), T1 Slope (T1S)), thoracic, lumbar, pelvic and global alignment parameters. Post-operatively, patients were grouped twice; based on changes in TK and SVA. Cervical alignment was compared between groups. Pearson correlation was conducted to examine the relationship between changes in TK, SVA, and cervical alignment. RESULTS: Stratification by change in TK, revealed significant alteration of lower cervical alignment T1S [p < 0.001]), C2-T3 [p = 0.019], C2-T1Ha [p = 0.043]), but there was no reciprocal change in the upper cervical spine. Stratification by SVA revealed a significant coexisting change in the lower cervical spine (T1S [p < 0.001], C2-C7SVA [p = 0.034], C2-T3 [p = 0.023], C2-T3SVA [p = 0.001]). SVA change was not associated to a change in the upper cervical spine. The correlation analysis showed that with a post-operative increase in TK, the cervical spine became more lordotic. Changes in TK were significantly correlated with: ΔT1S, ΔC2-C7, ΔC2-T3, and ΔC2-T3SVA. Similarly, increased cervical kyphosis was found when SVA was decreased post-operatively. Furthermore, there was a significant correlation between change of SVA and both ΔC2-T3 and ΔC2-T3SVA. CONCLUSIONS: In surgically treated AIS patients, changes in global and regional alignment of the thoracolumbar and cervical spinal segments exhibit interdependence. Thus, surgical planning with regard to sagittal deformity in AIS patients should account for the post-operative impact on cervical alignment.

[Evaluation of the sagittal profile in patients with thoracic adolescent idiopathic scoliosis Lenke type 1 following posterior correction]. / Evaluation des sagittalen Profils nach operativer Therapie der thorakalen adoleszenten idiopathischen Skoliose Lenke Typ 1.

INTRODUCTION: The principle philosophy of posterior spinal instrumentation and fusion (PSIF) for the treatment of adolescent idiopathic scoliosis (AIS) has changed during recent decades. In the past the treatment of AIS mainly focused on correction of the major curve in the frontal plane while the sagittal profile and balancing were only of inferior interest in treatment planning. Various long-term outcome studies have demonstrated that many AIS patients developed a flatback syndrome (decrease of thoracic kyphosis and lumbar lordosis) associated with pain. It was concluded that treatment of AIS should consider the sagittal profile and balance; however, there are only few studies addressing additional procedures, which include the correction of the sagittal profile. MATERIAL AND METHODS: The purpose of this study was to evaluate the effects of different posterior correction techniques on sagittal profile and balance. A total of 36 consecutive patients with thoracic AIS, who were treated with selective thoracic posterior correction were included in this retrospective study. The patients were further assigned to three different subgroups according to different surgical strategies: A: pedicle screws, B: long-head pedicle screws and C: additional Ponte osteotomy. Standardized radiographs in the standing position of the whole spine in two planes were evaluated before and at least 2 years after correction for all patients and a subgroup analysis was done to identify differences between the three groups. RESULTS: A significant correction of the major curve was achieved in all three groups (p < 0.001). There was a significant difference between the groups with groups B and C showing significantly higher levels of major curve correction in comparison to group A (p < 0.001). Concerning the sagittal profile, there was a significant difference in the development of thoracic kyphosis (TK) and lumbar lordosis (LL). While a significant reduction of TK and LL was found in groups A and B after surgery, a significant increase of TK and LL was noted in group C which was associated with a decrease of pelvic tilt and an increase of sacral slope. The 2-year follow-up showed the lowest ODI-% value only in group C which was positively correlated with reduction in pelvic tilt. CONCLUSIONS: The results of this study underline that the PSIF technique alone using pedicle screws leads to a satisfactory correction in the frontal plane but is associated with adverse effects on the sagittal profile (flat back syndrome), corroborating previous studies. It was further shown that significant improvements of sagittal parameters were achieved by adding techniques for the lengthening of the dorsal thoracic column. This approach can therefore be recommended for the treatment of AIS Lenke type 1.

[Therapy of unspecific destructive spondylodiscitis with special consideration to sagittal alignment]. / Therapie der unspezifischen destruierenden Spondylodiszitis unter besonderer Berücksichtigung des sagittalen Profils.

Nonspecific destructive spondylodiscitis is a severe illness which is accompanied by a high mortality rate. There is agreement in the literature on the indications for surgical treatment of destructive spondylodiscitis and sagittal alignment has to be considered for the operative procedure. Therefore, the operative procedure has to make considerations for the deformity, the extent of destruction, the clinical characteristics of the patient and the extent of spondylodiscitis.

[Gold standard for implant selection in operative therapy of spondylitis/spondylodiscitis]. / Goldstandard bei der Implantatwahl zur operativen Therapie der Spondylitis/Spondylodiszitis.

The operative therapy management of vertebral osteomyelitis including debridement and stabilization is well established. Autologous bone is the preferred graft material but is limited due to availability, failure of consolidation in large defects and donor morbidity. Titanium mesh cages are alternatively equally well evaluated and other materials are also mentioned. Immobilization of affected segments is the fundamental requirement for healing of osteomyelitis. The operative therapy of choice is meticulous debridement and internal stabilization of the defect. Autologous bone seems to provide the best conditions to bridge and consolidate defects. Bone marrow aspirate, reaming irrigator aspiration (RIA) and bone marrow protein (BMP) in combination with cages have the same qualities considering bone healing but they are not yet sufficiently evaluated for management of vertebral osteomyelitis. Autologous bone graft remains the gold standard, nevertheless, its disadvantages point out the need for alternative grafts. Titanium is well proven to provide stability but bone substitutes are not sufficiently evaluated but seem to be promising.

[Pyogenic spondylodiscitis: therapy algorithm and a new classification for therapeutic decision-making]. / Pyogene Spondylodiszitis : Therapiealgorithmus und neue Klassifikation zur therapeutischen Entscheidungsfindung.

The incidence of pyogenic spondylodiscitis is low but has been steadily increasing in recent years. To date there has been no consensus concerning selection of the appropriate treatment, management and strategies and the recommendations for an operative strategy are still a highly controversial issue. In the literature a few statements have been published concerning therapeutic decision-making in pyogenic spondylodiscitis. The classification given in this article is based on clinical experience and retrospective data analysis considering the degree of segmental bony destruction, grade of kyphosis and instability, epidural involvement of the disease and neurological deficits, which are pivotal for therapeutic decision-making. The therapeutic procedure can be defined based on this classification.

[Management of spinal metastases, strategies and surgical indications]. / Management der Wirbelsäulenmetastasen, Strategien und operative Indikationen.

The number of bone metastases increases with prolonged survival of primary tumors of kidney, breast, prostate and other tumors. The spine is the most frequent site of bone metastases. This leads to high number of patients where the decision has to be made what kind of treatment should be the best. Several scores have been developed to solve this problem. The decision has to include the biology of the metastatic disease according to primary tumor and dissemination of the disease, the general condition of the patient, the residual stability of the spine, the neurologic status and most important the quality of life of the patient. Treatment options range from conservative treatment up to en bloc resection of the metastatic lesion. Therefore, the strategy of treatment always has to be decided on an individual base.

[Role and limitations of vertebroplasty and kyphoplasty in the management of spinal metastases]. / Rolle und Grenzen der Vertebro-/Kyphoplastie im Metastasenmanagement der Wirbelsäule.

The spine is the most common site for skeletal metastases. Tumor-induced osteolysis may lead to pain, dysfunction and ultimately vertebral fracture. In some patients conventional surgery is not suitable because of the palliative therapy approach. Just for this patient population it was shown that cement augmentation of the vertebra is an effective therapy option and plays an important role. Nevertheless, cement augmentation of the vertebra has its limitations and should only be applied by appropriate indications.

[Radiological diagnostics of spinal tumors. Part 2: special diagnostics of intradural tumors and tumor-like lesions]. / Radiologische Diagnostik spinaler Tumoren. Teil 2: Spezielle Diagnostik intraduraler Tumoren und tumorähnlicher Läsionen.

Intradural tumors are classified into extramedullary and intramedullary localization. A distinct attribution to one of these compartments is essential for finding the appropriate diagnosis. In the radiological evaluation of intradural tumors magnetic resonance imaging (MRI) is the most important method and in contrast to osseous spinal tumors, radiography and computed tomography are of minor importance. According to the globally established WHO grading system, tumors of the central nervous system are histopathologically classified into four grades. Through grades I to IV malignancy and proliferative activity increase. Prognosis is inversely correlated to the WHO grade. Intradural tumors are generally treated by neurosurgeons. Besides neurological symptoms intradural tumors often cause spinal malpositioning. Thus knowledge of the most frequent intradural tumors and their characteristic magnetic resonance findings are important in the orthopedic practice.

[Radiological diagnostics of spinal tumors. Part 1: general tumor diagnostics and special diagnostics of extradural tumors]. / Radiologische Diagnostik spinaler Tumoren. Teil 1: Allgemeine Tumordiagnostik und spezielle Diagnostik extraduraler Tumoren.

Radiological investigation of spinal tumors includes identification of the suspect lesions as well as their relation to surrounding critical structures, such as nerve roots and the myelon. With the use of computed tomography (CT) the delineation of bone and with magnetic resonance tomography the assessment of bone marrow and soft tissue are possible with high-spatial resolution and multi-planar reconstructions. The consolidation of clinical information, distribution pattern and morphology of the lesion itself results in the final radiological evaluation. Because of low invasiveness and complications, CT-guided biopsy is a common tool in cases of suspected lesions. With the help of multi-planar reconstructions even difficult approaches are possible without impairment of critical structures. This review article discusses typical imaging characteristics of common tumors originating from the vertebral column after a section on basic and general aspects of tumor diagnostics.

[Vertebral stability in management of spinal metastases. Criteria and strategies for operative interventions]. / "Wirbelkörperstabilität" im spinalen Metastasenmanagement. Kriterien und Strategien zur operativen Intervention.

BACKGROUND: Metastases are responsible for most tumor manifestations of the spine. About 25% are symptomatic; however, due to interdisciplinary management the tumor-associated mortality is regressing. Associated acute spinal cord injury (SCI) syndromes raise patient morbidity with a loss of independence and quality of life associated with a fair potential for recovery. Therefore, the management is focused on the avoidance of SCI. The assessment of mechanical stability of vertebral bodies is a central part of decision-making when considering operative therapy. This review gives an update on the current evidence-based data for metastasis management. DECISION MAKING: The NOMS concept is well established. Especially the parameters origin, neurologic symptoms, stability and vascularization are described and illustrated by clinical cases. OPERATIVE THERAPY CONCEPTS: Evidence-based operative therapy concepts are shown reflecting palliative and curative approaches. ASSESSMENT OF PARAMETERS FOR THERAPY ALGORITHM: Clinical and radiological parameters help to find the individual therapy. Generally a number of scores with significant time expenditure are needed. The spine instability neoplastic score (SINS) simplifies the management. Operative therapy shows the best results for the parameters pain and quality of life. However, potential perioperative and postoperative complications have to be estimated and should be avoided. Using these facts our therapy algorithm is helpful for therapy management. CONCLUSIONS: With rising life expectancy operative therapy is of increasing relevance. Decision-making uses information about tumor origin, neurologic symptoms, stability, prognostic factors and vascularisation to determine the individual therapy.

[Radiofrequency ablation in spinal osteoid osteoma. Options and limits]. / Radiofrequenzablation bei Osteoidosteomen der Wirbelsäule. Möglichkeiten und Grenzen.

Osteoid osteoma was first described by Jaffe in 1935 as a benign bone neoplasm mainly located in the diaphyseal areas of long bones: 10% are located in the spine, mainly in the lumbar and thoracic posterior elements. Therapy is required due to nocturnal pain independent of the physical load and responds especially well to anti-inflammatory drugs due to the excessive production of prostaglandins in the nidus. Diagnosis is confirmed by multi-slice computed tomography (CT), magnetic resonance imaging (MRI) and skeletal scintigraphy scans. In cases with typical symptoms and imaging, open biopsies are rarely needed. Although CT-guided radiofrequency ablation is accepted as the gold standard treatment option for osteoid osteoma in the extremities, this technique is limited in spinal applications due to the risk of thermal damage to adjacent neurovascular structures. Technical advances in the administration of radiofrequency ablation have, however, resulted in new and expanded indications in the spine so that the necessity for open surgical excision of spinal osteoid osteoma is becoming less.

The effect of polytrauma as a possible confounder in the outcome of monotraumatic vs polytraumatic paraplegic patients: a clinical cohort study.

STUDY DESIGN: Clinical cohort study. OBJECTIVE: To evaluate if the impact of the severity of the trauma as a possible confounding factor influences the neurological and functional recovery in paraplegia during the course of a 6-month follow-up period after injury. SETTING: Spinal Cord Injury Center, Heidelberg University Hospital, Germany. METHODS: A retrospective monocentric analysis, from 2002 to 2008, of the Heidelberg European Multicenter Study about spinal cord injury database was performed. We included 31 paraplegic patients (neurological level T1-T12) who were assigned either to a monotrauma (polytraumaschluessel (PTS) 1) or to a polytrauma (PTS≥2) group. The American Spinal Injury Association Impairment Scale, lower extremity motor score, pin prick, light touch and the spinal cord independence measure (SCIM) were obtained at five distinct time points after trauma. Data were analyzed using Mann-Whitney U-test (α<0.05). RESULTS: The changes in lower extremity motor score, pin prick and light touch showed no significant differences in both groups over the whole evaluation period. Polytraumatic paraplegics showed a significantly delayed increase of SCIM between 2 and 6 weeks compared with monotraumatic patients, followed by a quantitative increase in the subitems bladder management, bowel management, use of toilet and prevention of pressure sores between 3 and 6 months (P=0.031). The mean length of primary rehabilitation in the polytrauma group was 5.5 vs 3.6 months in monotrauma. CONCLUSIONS: The prognosis of polytraumatic paraplegics in terms of neurological recovery is not inferior to those with monotrauma. Multiple-injured patients need a prolonged hospital stay to reach the functional outcome of monotraumatic patients.

[Correction of adolescent kyphosis. What is the state of the art?]. / Korrektur der Adoleszentenkyphose : Was ist State of the Art?

Thoracic and thoracolumbar kyphosis is a common deformity in pediatric and adolescent populations. Kyphotic deformation of the spine is defined as a curve which shows an increase in the dorsal convex angulation. The most common causes of kyphosis in pediatric and adolescent populations are Scheuermann's disease, postural and congenital kyphosis. The fundamental principles of treatment are analysis of the kyphotic deformity and restoration or maintenance of sagittal balance. Clinically significant sagittal deformities can lead to severe pain, substantial cosmetic alterations, spinal cord dysfunction, problems with swallowing, gastrointestinal and cardiopulmonary complications. When the kyphotic deformity exceeds a certain point and conservative therapy options are no longer sufficient surgical intervention is indicated. The available operative options for treatment of the various types of pediatric and adolescent thoracolumbar kyphosis include dorsal instrumentation and fusion combined with ventral fusion and purely ventral instrumentation and fusion.

[Sagittal deformity. Basic principles of surgical strategies]. / Sagittale Deformität : Grundlagen der operativen Strategien.

There is a large body of literature supporting the importance of restoring sagittal balance to the spine. The main message is this: regardless of the specific surgical strategy and treatment or pathology, rebalancing results in a positive patient outcome. Complex deformity patients need to be evaluated with attention to the global balance and the operative planning and strategy must be adapted accordingly. Spinal fusions are not always considered within the framework of sagittal balance. Unsuccessful outcome including continued pain, adjacent level disease, accelerated degenerative changes of the spine, pseudarthrosis and hip and knee changes, may then ensue. Certainly, those patients need to be re-evaluated with attention to the global balance of the spine. The reason for the outcome may be sagittal imbalance and osteotomy techniques as well as fusion extension may be needed. The postoperative outcome can only be improved when the sagittal balance is already considered in the planning and treatment strategy during initial correction surgery. Concerning sagittal balance a paradigm shift seems to occur.

[Importance of sagittal alignment in spinal revision surgery]. / Bedeutung des sagittalen Profils bei Revisionseingriffen an der Wirbelsäule.

Ignoring the sagittal profile in primary spinal fusion surgery is a common reason for revision surgery. Therefore, it is important that in cases of spinal revision surgery the sagittal alignment is realized. The physiological alignment of the instrumented spine should also indirectly influence the profile of the non-stabilized spine cranial and caudal to the fusion. Patients with normal C7 plumb-line and a physiological sacral inclination have a lower incidence of adjacent segment degeneration. Sagittal imbalance after revision surgery is a risk factor for recurrent pseudarthrosis. In cases of pseudarthrosis a combined approach may be more effective in realizing sagittal balance und enhancing rates of fusion.

[Multiplan correction of a 3D deformity. Options and relevance of optimizing the thoracic kyphosis in reconstructive scoliosis surgery]. / Dreidimensionale Korrekturprinzipien einer dreidimensionalen Deformität : Möglichkeiten und Relevanz der operativen Optimierung der Thorakalkyphose in der Skoliosechirurgie.

BACKGROUND: There is presently still no consensus on how to operatively treat adolescent idiopathic scoliosis (AIS), i.e. a clearly reduced thoracic kyphosis. For a long time the primary focus was mostly on correcting the coronal plane while neglecting the sagittal profile. Based on the current literature and own retrospective data a comprehensive review will be given on the optimal correction of the spine and how to avoid secondary complications. Different operative standard procedures are demonstrated with special attention to the sagittal balance and the special parameters sagittal vertical axis (SVA), lumbar lordosis (LL), thoracic kyphosis (TK), pelvic tilt (PT), sagittal slope (SSL) and pelvic incidence (PI). RESULTS: A total of 24 patients (2 groups of 12 patients) with AIS and posterior fusion with (group A) and without (group B) additional osteotomy were analyzed with respect to the impact on spinopelvic balance and health-related quality of life (HRQoL) parameters. Patients in group A had a significant reduction of TK, LL and SSL and an increase in PT whereas patients in group B showed the opposite. Correlation analysis revealed a significant dependence of HRQoL on PT. DISCUSSION: Both the results from the literature and own data confirm that operative correction of AIS needs a careful planning including sagittal spinopelvic parameters. Rigid thoracic hypokyphosis require additional osteotomy.

[Effect of lumbar hybrid instrumentation and rigid fusion on the treated and the adjacent segments. A biomechanical study]. / Auswirkung der lumbalen Hybridinstrumentierung und der rigiden Fusion auf das versorgte und anschließende Segment. Eine biomechanische Untersuchung.

BACKGROUND: Degeneration of the upper adjacent segment after operative treatment of degenerative spinal diseases of the lumbar spine (degenerative disc disease DDD) is an unsolved problem. There is also no consensus on whether a rigid or dynamic treatment of DDD should be carried out to protect the segments. This study was carried out to evaluate the effect of bisegmental rigid 360° fusion and bisegmental hybrid fusion on the treated segment as well as on the upper adjacent segment under the aspect of segment protection. MATERIAL AND METHODS: A total of six human spinal column preparations (L2-5) were tested under native conditions (NAT), with bisegmental rigid fusion (RIG 360°) and with hybrid fusion (Hybrid) in all three movement directions under physical load and with an preload. The range of motion (ROM) and neutral zone (NZ) were evaluated. The intradiscal pressure (IDP) was measured in the upper adjacent segment (OAS). RESULTS: The RIG 360° led to a significant reduction in movement in all directions compared to NAT but Hybrid only in lateral bending (LB). In the OAS the NZ was showed a much greater increase than the ROM. The RIG 360° showed an increase of the NZ in flexion-extension of 86.8% and in LB of 49.6% as well as a significant increase in axial rotation of 52.5%. The increase in the Hybrid was not significant compared to NAT in all directions. Pressure measurements in OAS showed no significant differences for RIG 360° and for Hybrid compared to NAT for both load scenarios. DISCUSSION: The range of motion of the treated segments for Hybrid were close to NAT in comparison to RIG 360° indicating a segment-protective effect. The hypothesis that rigid fusion has a significant effect on intersegmental mobility and the increase in intradiscal pressure in the upper adjacent segment could not be confirmed. The data indicate that the primary effect of fusion on the adjacent segment is very low but the fusion-linked increased frequency of extreme loads of the OAS falling within the significance level leads to degeneration. Even if the NZ values for Hybrid and RIG 360° do not significantly differ from NAT, the NZ alterations between the instrumentations tend to be strongly shifted in favor of Hybrid. CONCLUSIONS: The data confirm that the clear and sometimes significant alterations of the NZ can be an essential factor for development of adjacent segment degeneration. A dynamic conclusion of instrumentation in the sense of a topping-off would appear to be useful if pathoanatomical indications for an intervertebral disc prosthesis are present.

[Pyogenic spondylodiscitis of the thoracic and lumbar spine : a new classification and guide for surgical decision-making]. / Pyogene Spondylodiszitis der Brust- und Lendenwirbelsäule : Eine neue Klassifikation zur Entscheidungsfindung bei der Wahl der operativen Therapie.

Despite modern diagnostic imaging options pyogenic infections of the spine are often detected tardily and therefore accompanied by a high mortality rate. To ensure an efficient and adequate therapy it is necessary to identify and treat the focus of inflammation. The recommendations for the operative strategy are still a highly controversial issue. On the other hand no classification and guidelines for surgical treatment and treatment strategies of pyogenic spinal infection have yet been published.Pyogenic spinal infections are often underestimated in frequency of occurrence and severity of symptoms. From 1994 until 2008, 269 patients suffering from an infection of the thoracic and lumbar spine were treated in the Department of Orthopedic Surgery Heidelberg and 221 patients underwent surgery. Within the scope of a clinical trial clinical aspects and therapeutic consequences of patients with pyogenic spinal infections were retrospectively investigated. Based on the study data a classification of pyogenic spinal infections of the thoracic and lumbar spine and a guide for surgical decision-making was developed.

Clinical presentation of spondylodiscitis as a long-term complication in incomplete paraplegia: a report of three cases.

STUDY DESIGN: Case report. OBJECTIVE: Complications in spinal cord injury (SCI) are a challenging problem for the patients and often difficult to manage. Three cases of spondylodiscitis, localized at the lumbosacral junction in long-term paraplegic patients are presented. SETTING: Spinal Cord Injury Center, Orthopaedic University Hospital Heidelberg, Heidelberg, Germany. CLINICAL PRESENTATION: In all three cases, neurological deterioration (ASIA A) was caused by a secondary compression of the spinal cord at the lumbosacral spine. Increase of spasticity and pain, atonic bladder and sphincter function accompanied by vegetative symptoms were present in all patients. Microbiological analysis of the sacral area showed coagulase negative staphylococcus in two cases, whereas in one case no microorganism was found. The diagnosis was made by MRI of the whole spine and surgical treatment was required. At follow-up (6 months), patients showed no AIS (ASIA Impairment Scale) changes. CONCLUSION: If neurological deterioration occurs, spondylodiscitis should be ruled out in paraplegic individuals. The therapeutic goal is to achieve emergent decompression of the spinal cord and to administrate adequate antibiotic therapy to avoid a neurologically complete situation.