[Blood management in complex reconstructive spine surgery in ASD patients : Do effective measures to reduce bleeding exist?] / Blutungsmanagement in der komplexen rekonstruktiven Wirbelsäulenchirurgie bei ASD-Patienten : Gibt es effektive Maßnahmen, um Blutungen zu verringern?

BACKGROUND: Blood management in reconstructive spine surgery is a challenge and must be managed interdisciplinarily. An experienced team of anesthesiologists and spine surgeons needs to work closely together. THERAPY: After optimal preoperative preparation, the patient is given an initial dose of 1000 mg tranexamic acid. The most adequate medium blood pressure is about 80 mm Hg during surgery. The surgeon must watch for subperiosteal preparation and subtle stypsis. A cell saver is used. If the expected blood loss exceeds 1000 ml, additional tranexamic acid of 1000 mg/6 h will be infused. Epidural bleeding as well as bony hemorrhage are challenges for the spine surgeon. Epidural veins should be coagulated under the microscope before they bleed. Bone wax should be used in bony bleeding. If bleeding is uncontrollable, industrially produced hemostyptics can be used. POST-TREATMENT: Postoperatively the risk of bleeding should be minimized under critical observation of coagulation and blood pressure. Also, a critical assessment of the anticoagulation is to be made. The drainage rate should be well documented. The surgeon must decide whether the drain is to be put on suction or on overflow. He must also decide when to remove the drainage.

Lumbosacral spondylodiscitis due to rectal fistula following mesh penetration 7 years after colpopexy.

INTRODUCTION: The primary source of spondylodiscitis cannot always be identified. However, not treating the original focus might preclude successful healing due to further spread of the causative microorganisms. CASE REPORT: An 80-year-old woman presented with lumbar spondylodiscitis. She received surgical debridement and stabilization with transforaminal lumbar interbody fusion and tailored antibiotic therapy after isolation of Enterococcus spp. Despite appropriate treatment, the patient's condition continued to worsen. An extensive search for the primary infection source finally revealed a rectal fistula caused by a synthetic mesh that had been inserted 7 years before for abdominal sacrocolpopexy. Only after removal of the fistula and protective ileostomy did the patient's condition improved, allowing successful healing of the spondylodiscitis. After a follow-up period of one year no infection relapse was observed. CONCLUSION: In cases of spondyodiscitis that are resistant to adequate treatment, a search for infection source must be continued until the focus is found and treated. The presence of uncommon enteric microorganisms causing spondylodiscitis, such as Enterococcus spp., is suggestive of contiguous spread and should therefore be further investigated.

[Thromboprophylaxis and platelet aggregation inhibitors in spinal surgery: perioperative management]. / Thromboseprophylaxe und Aggregationshemmer in der Wirbelsäulenchirurgie: perioperative Management.

BACKGROUND: The perioperative use of anticoagulants (AC) and platelet aggregation inhibitors (PAI) in the field of spinal surgery suggests an increased rate of epidural bleeding. However, evidence is lacking and these medications are most often indispensable in the prevention of thromboembolic complications. Comprehensive recommendations for the correct use of AC and PAI are lacking. OBJECTIVE: The aim of this study was an analysis of the current situation with regards to the use of AC and PAI in spinal surgery and development of new recommendations. MATERIAL AND METHODS: Two independent surveys on the perioperative use of AC and PAI were obtained from centers for spinal surgery in Germany. The study obtained information on the perioperative use of AC and PAI, risk assessment of thromboembolic and hemorrhagic events as well as on the type and extent of the substance groups used. RESULTS: Almost the entire patient collective (98%) received perioperative low molecular weight heparin. In 64% the medical prophylaxis was started before surgery and in 36% after surgery. The period of prophylaxis was determined arbitrarily. Approximately 40% of interviewees employed paravertebral infiltration and 19% injected into the epidural space in patients on PAI medication. Open spinal canal surgery was performed in 30% of PAI medicated patients and closed spinal canal surgery was executed in 40%. The risk assessment of PAI differed significantly between aspirin and receptor blocker medication as well as dual administration of PAI. DISCUSSION: The use of AC and PAI in spinal surgery in Germany is very heterogeneous and large deviations from the guidelines frequently occurred. Therefore, there is a strong need for further studies to accurately assess the perioperative use of AC and PAI and to formulate precise recommendations.

[Benign and semimalignant spinal tumors. Characteristics in children and adults]. / Benigne und semimaligne Tumoren der Wirbelsäule. Besonderheiten im Kindes- und Erwachsenenalter.

Diagnostic radiology and magnetic resonance imaging (MRI) are the most important imaging tools in the evaluation of benign bone tumors. Computed tomography (CT) is an additional tool for bony lesions, such as in cases of confirmation of the diagnosis of osteoid osteomas. For benign bony lesions three-stage skeletal scintigraphy is an optional additional diagnostic tool. The identification of benign or semimalignant bone tumors is not always clear; therefore percutaneous biopsy is necessary in most cases. In benign spinal tumors an intralesional curettage with reconstruction and stabilization is sufficient. In cases of semimalignant tumors, e.g. giant cell tumors localized in the spine, an en bloc resection is necessary because of the high recurrence rate.

[Specific spondylitis]. / Spezifische Spondylitis.

Tuberculosis of the spine usually occurs with a latency period after primary infection with tuberculosis (TB) and the most frequent agent is Mycobacterium tuberculosis. The rate of TB has increased due to the impact of acquired immunodeficiency syndrome (AIDS) and more than 50% of skeletal tuberculosis is localized in the spine. Spinal tuberculosis was discovered by Pott in 1776. Magnetic resonance imaging (MRI) with gadolineum is the most sensitive imaging method. Diagnostic accuracy is given by direct detection of Mycobacterium tuberculosis by punction or biopsy. Granuloma of the spine can lead to abscesses, severe spinal deformity with instability and potentially paraplegia. Chemotherapy is effective with a minimum duration of 6-12 months. In cases with neurological deficits and severe deformity there is an additional indication for surgical therapy. In the acute phase a posterior instrumentation, anterior debridement and reconstruction of the defect is indicated. After recovery of the spinal tuberculosis Pott's kyphosis could remain and operative correction can be managed by pedicle substraction osteotomy.

[Pedicle screw augmentation from a biomechanical perspective]. / Pedikelschraubenaugmentation aus biomechanischer Sicht.

Severe osteoporosis is a serious problem in the instrumentation during spine surgery. Besides kyphosis, adjacent vertebral fractures and of course pedicle screw loosening and implant pullout are frequent challenges in instrumentation of the osteoporotic spine. In addition to screw diameter and length, bone mineral density has the most important impact on the stability of a pedicle screw. In cases of severe osteoporosis cement augmentation increases the stability of a pedicle screw. Pullout force can be increased with augmentation by 96-278%. Nowadays, there are two different procedures for augmentation: cement augmentation of the vertebra before inserting the screw into the soft, fresh cement or augmentation via a perforated screw that has already been inserted.The main problem in augmentation techniques are cement leakages. In both techniques leakages may occur. The problem of leakages seems to be less severe in the augmentation technique via the perforated screw, because cement application can be stopped immediately if the onset of leakage is noticed. Even surgical revision of cement augmented screws is not a major clinical problem based on recent biomechanical studies. The revision screw can be chosen 1 mm thicker and can be cement augmented again without technical problems.

[Selective fusion of idiopathic scoliosis with respect to the Lenke classification]. / Selektive Fusionsmöglichkeiten der idiopathischen Skoliose unter kritischer Würdigung der Lenke-Klassifikation.

Indications for surgical treatment of idiopathic scoliosis are progressive curves greater than 40-50 degrees. In most cases, fusion of only the primary (structural) curve(s) is sufficient due to the flexibility and spontaneous correction of the secondary curves. Therefore, it is crucial to identify both primary and secondary curves. According to the Lenke classification, all curves with a residual curve of more than 25 degrees on the bending films and those with a pathological kyphosis are regarded as structural and should be fused, whereas the nonstructural curves can be left unfused. However, according to reports in the literature and to the author's experience, clinical parameters such as shoulder level and rib or lumbar hump as well as radiometric criteria such as rotation are relevant as well. In summary, the Lenke classification is an important and helpful tool for analysing idiopathic curves and determining fusion length, even though each scoliosis case needs to be evaluated individually, especially taking clinical parameters into account.

[Posterior operative correction of idiopathic scoliosis. Value of pedicle screws versus hooks]. / Dorsale operative Korrektur der idiopathischen Skoliose. Stellenwert von Pedikelschrauben vs. Haken.

Posterior correction and fusion of scoliosis with multisegmental instrumentation systems was developed by Cotrel-Dubousset in the 1980s. Initially correction and instrumentation was performed using hooks only. Later pedicle screws were implemented first for the lumbar and then for the thoracic spine. Nowadays instrumentation based on pedicle screws only is well established for posterior scoliosis surgery. Biomechanical studies demonstrated higher pull-out forces for pedicle than for hook constructs.In clinical studies several authors reported better Cobb angle correction of the primary and the secondary curves and less loss of correction in pedicle screw versus hook instrumentations. Furthermore, pedicle screw instrumentation allows fewer segments to be fused, especially caudally, and thus saving mobile segments. In most of these publications there were no differences in operation time, blood loss and complication rates. In summary, there is better curve correction without an increased risk using multisegmental pedicle screw instrumentation in modern posterior scoliosis surgery.

[Value of adjuvant physiotherapy in postoperative pain management]. / Stellenwert der physikalischen Therapie und Physiotherapie in der postoperativen Schmerztherapie.

In times of limited financial and human resources the application of adjuvant physiotherapy postoperatively in orthopaedic patients requires reevaluation. In the early postoperative course physiotherapy improves the patients' mobility. However, it is not able to reduce the need for pain medication. It is intended to minimize complications and to mobilize and motivate the patients early. In contrast, massages are of minor importance in the immediate postoperative course and are applied only in a few selected cases. Cryotherapy plays a major role especially after shoulder and knee surgery. On the other hand, transcutaneous electrical nerve stimulation (TENS) and acupuncture are applied only in selected patients after orthopaedic surgery, e.g., after limb amputation.

[Surgical treatment of idiopathic scoliosis with anterior dual rod instrumentation]. / Operative Therapie der idiopathischen Skoliose mittels ventraler Doppelstabinstrumentation.

BACKGROUND: In the surgical treatment of idiopathic scoliosis both anterior and posterior correction and instrumentation techniques are available. The aim of the present study was to analyse the results of a new anterior dual rod instrumentation. PATIENTS AND METHODS: Prospective analysis of radiometric and clinical parameters of 93 patients operated on between 1996 and 2004 using the Münster Anterior Dual Rod System. RESULTS: The average curve correction was 65% (fusion length usually Cobb levels) with a preoperative Cobb angle of 59 degrees. Postoperative loss of correction amounted to 1.5 degrees (average follow-up of 36 months). Apical vertebral derotation averaged 45% in the thoracic and 53% in the lumbar spine with a subsequent correction of the rib hump of 66% and the lumbar hump of 81%. There were no revisions or neurological complications. CONCLUSION: Anterior dual rod instrumentation enables an effective and safe three-dimensional curve correction in single structural curves with only minimal loss of correction.

[Lumbar spinal stenosis]. / Lumbale Spinalkanalstenose.

Lumbal spinal stenosis is gaining more and more clinical relevance because of changing population structure and increasing demand on lifequality in the elderly. Current treatment recommendations are based on clinical experience, expert opinions and single studies rather than on proven evidence. The radiologic degree of stenosis does not correlate with the patients' clinical situation. It is not the main factor indicating surgery but rather the typical history and spinal claudication. Symptomatic patients with light to moderate complaints should undergo multimodal conservative treatment. Epidural injections, delordosating physiotherapy and medication are useful. In patients with severe symptomatic stenosis surgery is indicated after a conservative treatment of 3 months. Relevant pareses or a cauda equina syndrome are absolute indications for surgery. The general aim is to decompress sufficiently while maintaining or restoring segmental stability. A laminectomy is not necessarily required. In patients with accompanying degenerative Meyerding grade I-II spondylolisthesis or instability in functional radiographs, fusion or dynamic stabilisation are recommended in addition to decompression, depending on the patient's age and activity level.

Perivascular axillary brachial plexus block and patient positioning: the influence of a lateral, head-down position.

The aim of this study was to examine the effect of a 20 degrees Trendelenburg position on the blockade of nerves that exit the brachial plexus proximally in patients undergoing single-injection axillary brachial plexus block. After a pilot study of eight cadavers suggested that a head-down and lateral position would encourage the proximal spread of local anaesthetic, 72 patients undergoing elective surgery were divided into two equal groups: a Supine group and a Modified Position group (lateral position, 20 degrees head-down tilt). Patients were left in the allocated position for 30 min after an axillary block had been performed with alkalinised mepivacaine 1% 49.5 ml. Sensory and motor blockade evaluation showed that there was a significantly higher proportion of axillary nerve (76% vs. 0%, p < 0.001), thoracodorsal nerve (86% vs. 0%, p < 0.001) and subscapular nerve (89% vs. 0%, p < 0.001) blockade in the Modified Position group. Sensory block of the radial nerve was also improved by the modified position (100% vs. 86%, p < 0.05).

[Recommendations on sport activities for patients with idiopathic scoliosis]. / Empfehlungen zur Sportausübung bei Patienten mit idiopathischer Skoliose.

The idiopathic scoliosis is a three dimensional spinal deformity mostly occurring in female adolescents. Untreated it can progress and result in back pain, impaired lung capacity and psychosocial disorders due to the cosmetic appearance of the deformed trunk. The treatment depends on the severity of the curve and ranges from physiotherapy and observation, brace treatment to surgical treatment with partial correction and fusion of the primary curve. Patients with an idiopathic scoliosis should be encouraged to actively take part in sports activities. Positive influences on the general fitness including the lung function, on the trunk muscles and on the psyche can be expected. There are no scientific data indicating that any kind of sport activities alter the natural history of idiopathic scoliosis.

[Lumbar disc arthroplasty. Established technique or experimental procedure?]. / Lumbale Bandscheibenprothesen. Etablierte Technik oder experimentelles Vorgehen?

Lumbar interbody fusion used to be the most common surgical treatment for painful lumbar disc degeneration. With the technical development of total disc prostheses, replacement of the degenerated disc by a motion preserving implant has become a widely discussed alternative. The advantages of such replacement appear to include the prevention of adjacent segment disease as well as less perioperative morbidity. Three types of total disc prostheses are currently in common use. Although numerous studies have been made, a review of the literature reveals only two multicenter randomized studies comparing the outcome of disc prostheses with a control group of fusion patients. After 2 years, the available results show similar improvement after both types of surgery without significant differences. However, there is a trend towards faster recovery and improvement in disc arthroplasty patients. The long-term results of current and future randomized studies, including studies comparing results after disc arthroplasty, with results of standardized conservative therapies will determine the fate of lumbar disc prostheses.

[Corrective osteotomy of the humerus using perivascular axillary anesthesia according to Weber in a patient suffering from McCune-Albright syndrome]. / Oberarmkorrekturosteotomie bei einem Patienten mit McCune-Albright-Syndrom unter perivaskulärer axillärer Plexusanästhesie nach Weber.

We report on a 20-year-old patient with McCune-Albright syndrome suffering from global respiratory insufficiency who required continuous mask ventilation and where intubation had to be avoided. Perivascular axillary anesthesia according to Weber was performed for a double corrective osteotomy of the humerus. During plexus anesthesia the patient was positioned on the non-anesthesized side in a 15 degrees Trendelenburg position. An extension of analgesia was observed up to the complete upper arm region. Using the modified positioning an extension of brachial plexus anesthesia is possible.

[Prospective evaluation of braces as treatment in idiopathic scoliosis]. / Prospektive Untersuchung zur Korsettbehandlung bei idiopathischen Skoliosen.

AIM: To prospectively evaluate the results of brace treatment in idiopathic scoliosis and to define risk factors of treatment failure. METHOD: Fifty-two patients with a Cobb angle of between 25 and 40 degrees were included in the study. Prior to initiation of brace treatment with the Chêneau-Toulouse-Muenster orthesis, skeletal age and flexibility of the curve (bending films) were evaluated. The average follow-up after weaning of the brace was 42 months (36-78 months). RESULTS: An average initial Cobb angle of 31 degrees was corrected to 18 degrees (43 %) under brace treatment with a flexibility to 6 degrees Cobb angle on bending films. Three years after weaning there was an overall increase of the Cobb angle to 37 degrees on average. The apical vertebral rotation was corrected from 16 degrees to 11 degrees (31 %) and increased to 20 degrees during follow-up. Thoracic kyphosis changed from 24 degrees to 18 degrees during treatment. At the latest follow-up kyphosis had returned to the pre-treatment angle again. Twenty-two patients had a curve progression during or after brace treatment of more than 5 degrees. In 14 patients surgical correction and fusion have been indicated. There was a positive correlation between flexibility and Cobb angle correction during brace treatment and a negative correlation between Cobb angle correction during brace treatment and curve progression (p < 0.05). CONCLUSIONS: Curve progression was prevented in 58 %. Prognostic risk factors are a young age at initiation of brace treatment, a thoracic curve, unsatisfactory curve correction in the brace and a male gender.

Titanium cages in the surgical treatment of severe vertebral osteomyelitis.

The role of spinal implants in the presence of infection is critically discussed. In this study 20 patients with destructive vertebral osteomyelitis were surgically treated with one-stage posterior instrumentation and fusion and anterior debridement, decompression and anterior column reconstruction using an expandable titanium cage filled with morsellised autologous bone graft. The patients' records and radiographs were retrospectively analysed and follow-up clinical and radiographic data obtained. At a mean follow-up of 23 months (range 12-56 months) all cages were radiographically fused and all infections eradicated. There were no cases of cage dislocation, migration or subsidence. Local kyphosis was corrected from 9.2 degrees (range -20 degrees to 64 degrees ) by 9.4 degrees to -0.2 degrees (range -32 degrees to 40 degrees ) postoperatively and lost 0.9 degrees during follow-up. All five patients with preoperative neurological deficits improved to Frankel score D or E. Patient-perceived disability caused by back pain averaged 7.9 (range 0-22) in the Roland-Morris score at follow-up. In cases of vertebral osteomyelitis with severe anterior column destruction the use of titanium cages in combination with posterior instrumentation is effective and safe and offers a good alternative to structural bone grafts. Further follow-up is necessary to confirm these early results.

[Selective ventral derotation spondylodesis in idiopathic thoracic scoliosis: a prospective study]. / Selektive ventrale Derotationsspondylodese bei idiopathischen Thorakalskoliosen: eine prospektive Studie.

AIM: Radiometric curve analysis of instrumented primary and spontaneous secondary curve correction after anterior correction and fusion of idiopathic thoracic scoliosis. METHOD: Sixty-four patients with idiopathic thoracic scoliosis were prospectively evaluated. All patients were operated either with the Zielke-VDS or with a primary stable double rod instrumentation with selective fusion of the thoracic curve from end-to end-vertebra. Follow-up averaged 29 months (24 - 52 months). RESULTS: The Cobb angle of the primary curve averaged 63.2 degrees preoperatively and was corrected to 21.4 degrees postoperatively with an average loss of correction of 5.3 degrees (58 % final curve correction). Apical thoracic vertebral rotation was corrected by 48 %. The secondary lumbar curve measured 38.2 degrees preoperatively (72 % correction on the bending films) and was spontaneously corrected by 57 % to 16.4 degrees without significant loss of correction in the final follow-up. Apical vertebral rotation averaged 11.3 degrees in the lumbar curve and was corrected spontaneously by 24 % to 8.6 degrees without significant loss of correction. Lumbar apex vertebra deviation showed no significant reduction. There was no case of lumbar curve decompensation in either frontal or sagittal plane. Implant related complications were observed in 7 patients (rod breakage), but no pseudarthrosis occurred. There were no neurological complications noted. CONCLUSION: Selective anterior correction and fusion in idiopathic thoracic scoliosis enables a satisfactory correction of both primary and lumbar secondary curves. The advantage of selective anterior correction and fusion of thoracic scoliosis is the short fusion length, better derotation and satisfactory correction of the secondary lumbar curve. The disadvantages of single threaded rod techniques in terms of lack of primary stability and a kyphogenic effect have been eliminated by the development of a primary stable, small size double rod instrumentation.

[Technique and results of monosegmental transpedicular subtraction osteotomy in patients with ankylosing spondylitis and fixed kyphotic deformity of the spine]. / Technik und Ergebnisse der monosegmentalen transpedikulären Wirbelkörpersubtraktionsosteotomie bei Patienten mit Spondylitis ankylosans und fixierter kyphotischer Deformität.

AIM: The posterior extension osteotomy leads to a lengthening of the anterior column, which is associated with neurological complications and the risk of injuring retroperitoneal structures. Especially in high-grade syndesmophytosis the results are dissatisfactory. In this study we report on the results of an alternative procedure named the transpedicular subtraction osteotomy. METHOD: After resection of the posterior elements of the vertebra at the level of the osteotomy, a wedge of the vertebral body including the pedicles with posterior basis is resected followed by an instrumented closing wedge, which leads to relordosation. 12 patients were treated with this method and reexamined with a minimum follow-up of 2 years (2 - 6 years). The level of osteotomy ranged from T12 to L3. RESULTS: The mean segmental correction averaged 30.1 degrees (25 - 36 degrees ). The overall relordosation averaged 35.9 degrees and was related to additional correction in the adjacent segments. With this dissatisfactory a sufficient correction of spinal balance and visual axis was obtained. All patients were satisfied with the result of the operation and would undergo surgery again from a retrospective point of view. CONCLUSION: With the transpedicular subtraction osteotomy fixed kyphotic deformities of the spine in patients with ankylosing spondylitis can be corrected produce safely. The level of osteotomy is discussed and should depend upon the apex of kyphosis.