Development and current use of local antibiotic carriers in spondylodiscitis : Pilot study on reduction of duration of systemic treatment.

BACKGROUND: The current study situation regarding the duration of systemic antibiotic treatment for spondylodiscitis is inhomogeneous and varies between 4-12 weeks. Due to the many undesirable side effects the aim is to achieve complete healing without recurrence or hematogenous scatter within the shortest possible period of time. The present pilot study investigated whether the additional application of a local antibiotic carrier to the surgically treated intervertebral disc space can contribute to a further reduction of treatment duration. MATERIAL AND METHODS: In the pilot study 20 patients with acute spondylodiscitis and indications for surgical intervention were included. Surgical treatment was carried out by dorsal instrumentation, radical debridement of the site of infection, and cage interposition in the affected disc space. The remaining disc space was filled with homologous cancellous bone and antibiotic-loaded calcium sulfate hydroxyapatite pellets. A classification into a long-term and a short-term antibiotic group was performed. Both groups initially received a 10-day parenteral antibiotic administration. This was followed by oral antibiotics for 2 or 12 weeks, depending on the group. During the 12-month follow-up inflammation parameters, the local infection situation as well as the bony fusion and antibiotic tolerance were regularly checked. RESULTS: The average age of the patients was 66.7 ± 11.2 years. Intraoperative detection of pathogens was successful in 65%. In 60% the antibiotic carrier was loaded with gentamicin, in 40% with vancomycin. At follow-up, all patients except one in the short-term antibiotic group had inflammation parameters within the normal range after 3 months. In the long-term antibiosis group, two patients still showed elevated infection values after 3 months, otherwise the values were within the normal range. After 12 months a complete cure of the infection was achieved in all patients. Antibiotic treatment intolerance occurred in 10% of the short-term antibiotic group and in 50% of the long-term group. CONCLUSION: The results of the present pilot study show that with the additional use of absorbable local antibiotic carriers in the surgical treatment of bacterial spondylodiscitis it is possible to shorten the duration of systemic antibiotic treatment to 3 weeks. This can reduce the side effects and incompatibility of treatment and still achieve similar healing results.

[The importance of interspinous spacers in the treatment of lumbar spinal stenosis]. / Stellenwert der interspinösen Implantate in der Therapie der lumbalen Spinalkanalstenose.

INTRODUCTION: In the treatment of lumbar spinal stenosis, interspinous spacers can be used in a tissue and time sparing technique. Relief of low back pain might be achieved by stress reduction of facet joints and limitation of segmental mobility. AIM: Presentation of dynamic stabilization by means of an interspinous spacer with and without decompression and to compare it with the outcome of decompression and fusion. MATERIAL AND METHODS: As part of a PubMed search, randomized controlled trials (RCTs) and non-RCTs from high-quality controlled clinical trials were selected and contrasted with our own experience. RESULTS: The current literature was evaluated, which assesses interspinous spacers with and without decompression in comparison with the "gold standard", the microsurgical interlaminar decompression. CONCLUSION: Published data indicate that the use of interspinous spacers with or without decompression for the treatment of lumbar spinal stenosis is not less effective than stand-alone decompression. The reoperation rate can only be proven for implants without decompression on the basis of Level I studies. However, as a link between decompression alone and fusion, it cannot yet provide a scientifically clear solution.

[Lumbar synovial cysts: literature review and original long-term results after microsurgical resection]. / Die lumbalen Synovialzysten: Literaturreview und originäre Langzeitergebnisse nach mikrochirurgischer Resektion.

BACKGROUND: Intraspinal lumbar vertebral joint cysts are an unusual cause of nerve root compression symptoms and do not differ clinically from the symptoms of a herniated disc. PATHOGENESIS: The cysts originate from the small vertebral joints and, depending on their size, compress the nerval structures. The affected vertebral joints typically show activated arthritic circumstances, which are associated with degenerative spondylolisthesis in about 50% of cases. In the majority of cases, MRT and CT can be used for diagnostic purposes. The exact etiology has not been fully clarified; various factors such as activated arthritis of the vertebral joints appear to be the major cause. TREATMENT: Treatment options include conservative, semi-invasive and surgical therapy. Conservative and semi-invasive treatment methods lead to temporary improvement. The result of surgical treatment, however, is excellent in a complete resection of synovial cysts. In In rare cases, an initial fusion is necessary in rare cases.

[Lumbar spinal canal stenosis : A historical perspective]. / Die lumbale Spinalkanalstenose : Eine historische Perspektive.

To know the history of a disease and its treatment is always instructive and helps us to understand the contexts better. It also shows what unbelievable preliminary work was necessary for us be able to treat patients today in the way we are used to. This article attempts to shed light on spinal canal stenosis from a historical perspective and to identify the pioneers who contributed to the understanding of the epidemiology, anatomy, pathogenesis, classification and diagnostic work-up of spinal canal stenosis. In addition, the efforts of scientists and clinicians who have participated in developing the treatment of lumbar spinal canal stenosis in the last seven decades should be recognized.

[Classification and diagnosis of lumbar spinal stenosis]. / Klassifikation und Diagnostik der lumbalen Spinalkanalstenose.

BACKGROUND: Lumbar spinal stenosis is caused by various pathological conditions. With the diagnostic tools available, a precise classification of the condition should be made, which enables a consistent and appropriate therapeutic approach. OBJECTIVES: In the present article, the currently used classifications of lumbar spinal stenosis are discussed and the diagnostic tools are presented, focussing on the imaging descriptions of morphological changes. MATERIALS AND METHODS: This article is based on a PubMed literature search of the past 60 years and our own experiences. RESULTS: Lumbar spinal stenosis is caused mainly by degenerative changes to the spine. MR tomographic imaging can result in precise anatomical illustration and classification of the stenosis. CONCLUSIONS: Although modern imaging procedures deliver a very precise illustration of lumbar spinal stenosis, clinical symptoms make a considerable contribution to therapeutic decision-making. With the anatomical classification, differentiated surgical decompression of the spinal canal can be planned.

Micro-CT and micro-FE analysis of pedicle screw fixation under different loading conditions.

Anchorage of pedicle screw instrumentation in the elderly spine with poor bone quality remains challenging. In this study, micro finite element (µFE) models were used to assess the specific influence of screw design and the relative contribution of local bone density to fixation mechanics. These were created from micro computer tomography (µCT) scans of vertebras implanted with two types of pedicle screws, including a full region-or-interest of 10 mm radius around each screw, as well as submodels for the pedicle and inner trabecular bone of the vertebral body. The local bone volume fraction (BV/TV) calculated from the µCT scans around different regions of the screw (pedicle, inner trabecular region of the vertebral body) were then related to the predicted stiffness in simulated pull-out tests as well as to the experimental pull-out and torsional fixation properties mechanically measured on the corresponding specimens. Results show that predicted stiffness correlated excellently with experimental pull-out strength (R2 > 0.92, p < .043), better than regional BV/TV alone (R2 = 0.79, p = .003). They also show that correlations between fixation properties and BV/TV were increased when accounting only for the pedicle zone (R2 = 0.66-0.94, p ≤  .032), but with weaker correlations for torsional loads (R2 < 0.10). Our analyses highlight the role of local density in the pedicle zone on the fixation stiffness and strength of pedicle screws when pull-out loads are involved, but that local apparent bone density alone may not be sufficient to explain resistance in torsion.

Transforaminal lumbar interbody fusion using polyetheretherketone oblique cages with and without a titanium coating: a randomised clinical pilot study.

AIMS: We compared the clinical and radiological outcomes of using a polyetheretherketone cage with (TiPEEK) and without a titanium coating (PEEK) for instrumented transforaminal lumbar interbody fusion (TLIF). MATERIALS AND METHODS: We conducted a randomised clinical pilot trial of 40 patients who were scheduled to undergo a TLIF procedure at one or two levels between L2 and L5. The Oswestry disability index (ODI), EuroQoL-5D, and back and leg pain were determined pre-operatively, and at three, six, and 12 months post-operatively. Fusion rates were assessed by thin slice CT at three months and by functional radiography at 12 months. RESULTS: At final follow-up, one patient in each group had been lost to follow-up. Two patients in each of the PEEK and TiPEEK groups were revised for pseudarthrosis (p = 1.00). The rate of complete or partial fusion at three months was 91.7% in both groups. Overall, there were no significant differences in ODI or in radiological outcomes between the groups. CONCLUSION: Favourable results with identical clinical outcomes and a high rate of fusion was seen in both groups. The titanium coating appears to have no negative effects on outcome or safety in the short term. A future study to determine the effect of titanium coating is warranted. Cite this article: Bone Joint J 2017;99-B:1366-72.

Conservative management of osteoporotic vertebral fractures: an update.

PURPOSE: Adequate conservative management of osteoporotic vertebral fractures remains important in an aging population. METHODS: We performed a research of multiple databases and present important studies in this narrative review. RESULTS: The pertinent literature remains scarce and of mixed quality. However, trends are shown to support early mobilization, less rigid bracing and pharmaceutical secondary prevention. CONCLUSION: There is insufficient data to recommend the optimal conservative management for osteoporotic vertebral fractures. As such high-quality studies need to be conducted to establish a solid course of action.

[ALIF and PLIF interposition in low-grade isthmic spondylolisthesis L5/S1 : Longterm-Comparison of interbody fusion techniques (ALIF - PLIF)]. / ALIF- und PLIF-Interposition bei low-grade isthmischen Spondylolisthesen L5/S1 : Langzeitvergleich der interkorporellen Fusionstechnik (ALIF - PLIF).

INTRODUCTION: For the treatment of isthmic spondylolisthesis two alternative interbody fusion techniques are available, the dorsoventral interposition in ALIF technique and the dorsal access interposition in PLIF technique. Due to the complications of anterior lumbar surgery and in order to avoid a second operation, the dorsoventral fusion technique is becoming uncommon and mainly a pure dorsal supply is performed. The aim of the study was to compare the clinical long-term results of both treatment techniques. MATERIALS AND METHODS: 138 patients were treated surgically between 2003 and 2012 in symptomatic isthmic spondylolysis in L5/S1 with a Meyerding degree of I-III. 72 patients were evaluated finally (ALIF n = 25 and PLIF n = 47). The average follow-up period was 7.9 years for the ALIF group and 5.6 years for the PLIF group. In both groups the average drug consumption, duration of recovery, resumption of work and resumption of sport activities was recorded. RESULTS: The results showed an extended time of surgery and a prolonged hospitalization of 5.4 days for the ALIF group. The ODI had a greater improvement in the PLIF group but this difference was not significant. The VAS was reduced in both groups. 36.8 % of the ALIF group and 44.7 % of the PLIF group reported a reduced pain medication postoperatively. The average recovery was 16 weeks for both groups. 29 % of PLIF and 9 % of ALIF patients had no pain relief. ALIF patients were able to get back to work after 149 days and the PLIF patients after 178 days. 31 % of the PLIF group and 13 % of the ALIF group were not able to return back to work. Revisions of fusion and the rate of wound revisions were increased in the PLIF group, adjacent segment diseases occurred more frequently in the ALIF group. CONCLUSION: Both treatment and fusion techniques (ALIF/PLIF) were able to achieve a significant pain relief and reduced consumption of pain medication postoperatively. The recovery period was similar in both groups, but there were differences regarding the date of return to work, hospitalization, duration of surgery and ODI score. Neither of the two methods could show a definite advantage.

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

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

[Hybrid stabilization technique with spinal fusion and interlaminar device to reduce the length of fusion and to protect symptomatic adjacent segments : Clinical long-term follow-up]. / Hybridversorgung mit Fusion und interlaminärem Implantat zur Verkürzung der Spondylodesestrecke und Protektion der symptomatischen Anschlussdegeneration : Klinisches Langzeit-Follow-up.

INTRODUCTION: Determination of the extent of spinal fusion for lumbar degenerative diseases is often difficult due to minor pathologies in the adjacent segment. Although surgical intervention is required, fusion seems to be an overtreatment. Decompression alone may be not enough as this segment is affected by multiple factors such as destabilization, low grade degeneration and an unfavorable biomechanical transition next to a rigid construct. An alternative surgical treatment is a hybrid construct, consisting of fusion and implantation of an interlaminar stabilization device at the adjacent level. The aim of this study was to compare long-term clinical outcome after lumbar fusion with a hybrid construct including an interlaminar stabilization device as "topping-off". MATERIALS AND METHODS: A retrospective analysis of 25 lumbar spinal fusions from 2003 to 2010 with additional interlaminar stabilization device was performed. Through a matched case controlled procedure 25 congruent patients who received lumbar spinal fusion in one or two levels were included as a control group. At an average follow-up of 43 months pre- and postoperative pain, ODI, SF-36 as well as clinical parameters, such as leg and back pain, walking distance and patient satisfaction were recorded. RESULTS: Pain relief, ODI improvement and patient satisfaction was significantly higher in the hybrid group compared to the control group. SF-36 scores improved in both groups but was higher in the hybrid group, although without significance. Evaluation of walking distance showed no significant differences. DISCUSSION: Many outcome parameters present significantly better long-term results in the hybrid group compared to sole spinal fusion. Therefore, in cases with a clear indication for lumbar spinal fusion with the need for decompression at the adjacent level due to spinal stenosis or moderate spondylarthrosis, support of this segment with an interlaminar stabilization device demonstrates a reasonable treatment option with good clinical outcome. Also, the length of the fusion construct can be reduced allowing for a softer and more harmonic transition.

[Therapy of scoliosis from a historical perspective]. / Therapie der Skoliose aus historischer Sicht.

Scoliosis can be considered as one of the classical orthopedic diseases of the spine. The history of orthopedics is closely connected to the development of the therapy of scoliosis. In the eighteenth and the beginning of the nineteenth centuries the therapy of scoliosis was mainly a conservative corrective orthopedic treatment with a variety of corset forms and extension bed treatment. In the middle of the nineteenth century physiotherapy (movement therapy) became established as an supplementary active treatment. The first operations for treatment of scoliosis were carried out in 1839. The real success with surgical procedures for improvement in corrective options was connected to the introduction of metal spinal implants in the early 1960s.

[History of vertebral body replacement]. / Geschichte des Wirbelkörperersatzes.

BACKGROUND: Vertebral body replacement after corpectomy is nowadays a standard procedure in spinal surgery. OBJECTIVE: Description of the developmental process of vertebral body replacement. METHOD: Historical description of the innovations in vertebral body replacement. RESULTS: The first serious attempts to perform vertebral body replacement were initiated approximately 50 years ago. Over several decades spinal surgeons used bone grafts, polymethyl methacrylate, titanium and glass-ceramics containing apatite and wollastonite. Known vertebral surgeons, including Scoville, Polster, Kaneda and Harms, to name but a few, were involved in the continuous development of vertebral body replacement. CONCLUSION: Many different expandable and non-expandable implants are now available and both types of implant can still be justified. This article describes the historical development of these implants and shows how this innovational process has significantly increased the therapy options for surgeons.

[Posterior lumbar interbody fusion implants. Software assisted planning--preliminary results]. / Posteriore lumbale interkorporelle Fusionscages. Softwarebasierte Operationsplanung--erste Ergebnisse.

BACKGROUND: Sagittal imbalance, adjacent segment degeneration, and loss of correction due to cage sintering are the main reasons for revision surgery after lumbar fusion. Based on the experience from hip and knee replacement surgery, preoperative software-assisted planning combined with the corresponding cages is helpful to achieve better long-term results. OBJECTIVES: Evaluation of the procedure regarding intraoperative application of preoperative planning and examination to what extent the planning was correct. MATERIALS AND METHODS: In all, 30 patients were included in the period from September 2012 to May 2013 in an observational study, planned preoperatively with the planning software, and treated with the corresponding PLIF cages. The radiological evaluation was performed by thin-layer CT after 3 months. RESULTS: A total of 24 (80%) patients were followed up after 3 months. In these 24 patients, the preoperative planning actually was correct in 17 cases with the intraoperatively implanted cage, which corresponds to a match of about 71%. The fusion rate for these 24 patients who underwent full examinations was 91.7%. CONCLUSION: The results of this observational study to evaluate the planning of intervertebral cages show positive experience with this novel therapeutic concept. Despite the limited number of participants, good results were observed for the intraoperative implementation of the planned cages and an adequate fusion rate was obtained. Irrespective of this, a software-based surgical planning must be questioned critically any time. Ultimately, it is the surgeon's responsibility to modify the planned procedure intraoperatively if necessary. Currently, the influence of this planning regarding the long-term course and the important question of adjacent segment instability remains unanswered.

[The PLIF and TLIF techniques. Indication, technique, advantages, and disadvantages]. / PLIF- und TLIF-Verfahren. Indikation, Technik, Vor- und Nachteile.

BACKGROUND: Posterior fusion procedures (posterior lumbar interbody fusion, PLIF; transforaminal lumbar interbody fusion, TLIF) are long-established surgical techniques for lumbar interbody fusion. They differ from anterior lumbar interbody fusion (ALIF) and extreme lateral interbody fusion (XLIF) procedures by approach and associated complications. OBJECTIVES: The posterior fusion procedures PLIF and TLIF are presented and compared with other fusion methods, including advantages and disadvantages. Furthermore, the surgical technique and their complications are described. Based on the current literature, it is discussed which surgical techniques can be used in various cases. MATERIALS AND METHODS: A PubMed search of "posterior spinal fusion treatments" and the clinical experience of the authors are summarized in this review article. RESULTS: PLIF and TLIF procedures reduced back and leg pain, restored the sagittal profile of the lumbar spine, and achieved good fusion rates and long-term stability. Advantages of the TLIF procedure include shorter operative times, less blood loss, less intraoperative risk of injury to neural structures, and shorter convalescence. Compared with the interposition of a cage in the ALIF technique, a further step with the risk of vascular injury is eliminated. CONCLUSIONS: The PLIF and TLIF procedures are almost equivalent posterior fusion procedures with high fusion rates, good long-term clinical outcomes, and low risk of complications. The TLIF procedure is slightly advantageous: lower nerve irritation rates, shorter operative times, and less extensive operation. Thus, the TLIF procedure is available for cases with single-sided pathologies and the PLIF procedure is available for bilateral compressions.