Late Implant Failure in Cervical Disc Arthroplasty (M6-C, Spinal Kinetics) Causing Radiculopathy and Myelopathy. / Spätes Versagen einer zervikalen Bandscheibenprothese (M6-C, Spinal Kinetics) mit Radikulomyelopathie.

Cervical disc arthroplasty (CDA) is an approved surgical treatment option in selected patients with cervical spinal disc degeneration. Even though CDA is a standard procedure since 20 years, there is a lack of information about long term performance. The published reoperation rates after CDA are low and comparable to anterior cervical fusion. The authors describe a severe failure and dysfunction with a partial core dislocation of a cervical prosthesis into the spinal canal (M6-C, Spinal Kinetics, Sunnyvale, CA, USA). Six years after implantation of a cTDR (cervical Total Disk Replacement) of the M6 type at C4/5 level, a 52 year-old women presented herself with new clinical signs of cervical myelopathy and radicular pain. Complete posterior dislocation of the central core of the implant into the spinal canal was identified as a cause. The failed device was removed completely and an ACCF (anterior cervical corpectomy and fusion) was performed. Intraoperatively, rupture of the posterior portion of the mesh tissue with posterior dislocation of the whole prosthesis core was detected. This is the second described case of a severe implant failure with core dislocation in this type of cTDR device. Even though there are thousands of successful implantations and middle term outcomes, it seems to be necessary to continue with long term radiological follow up to exclude similar failure in this type of prosthesis.

Prospective observational cohort study on epidemiology, treatment and outcome of patients with traumatic brain injury (TBI) in German BG hospitals.

OBJECTIVES: Since 2000/2001, no large-scale prospective studies addressing traumatic brain injury (TBI) epidemiology in Germany have been published. Our aim was to look for a possible shift in TBI epidemiology described in other European countries, to look for possible changes in TBI management and to identify predictors of 1-year outcome especially in patients with mild TBI. DESIGN: Observational cohort study. SETTING: All patients suffering from a TBI of any degree between 1 October 2014 and 30 September 2015, and who arrived in one of the seven participating BG hospitals within 24 hours after trauma, were included. PARTICIPANTS: In total, 3514 patients were included. OUTCOME MEASURES: Initial care, acute hospital care and rehabilitation were documented using standardised documentation forms. A standardised telephone interview was conducted 3 and 12 months after TBI in order to obtain information on outcome. RESULTS: Peaks were identified in males in the early 20s and mid-50s, and in both sexes in the late 70s, with 25% of all patients aged 75 or older. A fall was the most frequent cause of TBI, followed by traffic accidents (especially bicyclists). The number of head CT scans increased, and the number of conventional X-rays of the skull decreased compared with 2000/2001. Besides, more patients were offered rehabilitation than before. Though most TBI were classified as mild, one-third of the patients participating in the telephone interview after 12 months still reported troubles attributed to TBI. Negative predictors in mild TBI were female gender, intracranial bleeding and Glasgow Coma Scale (GCS) 13/14. CONCLUSION: The observed epidemiologic shift in TBI (ie, elderly patients, more falls, more bicyclists) calls for targeted preventive measures. The heterogeneity behind the diagnosis 'mild TBI' emphasises the need for defining subgroups not only based on GCS.

[Spondylodiscitis]. / Spondylodiszitis.

Spondylodiscitis is an infection of the spine that first affects the vertebral endplates ("spondylitis") and then spreads to the adjacent intervertebral disc ("spondylodiscitis"). As it is a potentially life-threatening systemic disease rapid, often surgical treatment is required. Due to the multimorbidity of the patients and the complexity of the therapy, a multidisciplinary approach is essential. The vast majority of the cases heals under conservative therapy. An absolute indication for surgical therapy is given for acute septic courses or if there are new relevant neurological deficits. In addition, urgent surgical treatment is required for epidural abscesses that can be diagnosed by means of magnetic resonance imaging. In developed countries, over 90% of all spondylodiscitis cases come to a complete recovery.

PLIF surgery with titanium-coated PEEK or uncoated PEEK cages: a prospective randomised clinical and radiological study.

PURPOSE: This study aimed to compare clinical results and fusion rates of uncoated polyetheretherketone (PEEK) cages with titanium-coated PEEK cages in posterior lumbar interbody fusion (PLIF) surgery. METHODS: A prospective randomised study including 60 patients with one- or two-segment lumbar degenerative diseases. Patients received either titanium-coated PEEK cages (group A) or uncoated PEEK cages (group B). Fusion rates were evaluated on plain X-rays and CT scans after 6 and 12 months. Clinical follow-up (visual analogue scale, VAS; Oswestry Disability Index score, ODI; EQ-5D) was performed for 24 months. RESULTS: Fifty-five patients (92%) (36 female, 19 male) had a complete follow-up. There were no statistically significant differences in demographic, peri- or intraoperative data between groups A and B. ODI, VAS and EQ-5D improved significantly (p < 0.001) after surgery without statistically significant differences between the two groups. Overall, 65 operated segments could be evaluated for fusion (group A: 29 segments, group B: 36 segments, p = 0.6). Osseous integration of the cage surface improved significantly (p < 0.001) in both groups between 6 and 12 months after surgery. At 12-month follow-up, neither radiolucency nor signs of instability or dislocation were noted. Fusion was present in CT scans as follows: (a) bone growth through cage pores (A: 100%, B: 100%); (b) bone growth outside the cages (A: 48%, B: 61%; p = 0.3). CONCLUSIONS: PEEK and titanium-coated PEEK cages for PLIF produce equally favourable clinical and radiological results up to 24 months post-surgery. The fusion rate was not different.

Surgical and Non-surgical Treatment of Vertebral Fractures in Elderly. / Operative und konservative Behandlung von Wirbelfrakturen im Alter.

Demographic development in Germany has led to an aging of the population. Particularly for these patients, osteoporosis-induced vertebral fractures represent a significant decrease in quality of life and level of activity. According to current guidelines, the initial treatment of stable osteoporotic vertebral fractures is conservative management with analgesic, anti-osteoporotic, physical therapy, and orthotic measures as first line options. Personal experience, however, suggests that patients benefit from timely surgical treatment through rapid improvement of pain symptoms and thus, more rapid mobilization. The poor bone quality of elderly patients presents the treating spine surgeon a challenge in achieving stable spinal fusion with or without support, for example, through augmentation. Minimally invasive procedures have increasingly established themselves for such purposes in recent years. With over 1000 fracture treatments in the last 3.5 years, we have developed a differentiated treatment concept depending on patient age and fracture morphology, which we would like to introduce. Unstable fractures with posterior edge involvement are stabilized from posterior with a percutaneous fixator. Patients over 60 years were treated percutaneously with a polyaxial screw system. Increased stability was achieved by PMMA cement augmentation of the fenestrated screws. In elderly patients with Magerl A3 fractures without neurologic deficit, the index vertebra is supplementally treated with kyphoplasty (hybrid treatment). In acute, stable osteoporotic vertebral fractures with severe pain despite analgesics, we perform kyphoplasty, which is possible even in high thoracic fractures to T3 with smaller balloons and thinner trocars. Vertebroplasty is another option in the lumbar and lower thoracic spine. Because of invasiveness, extended posterior-anterior correction procedures are generally avoided in this population, which has frequent multiple comorbidities.

Treatment of Atlas Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU).

STUDY DESIGN: Narrative review and expert recommendation. OBJECTIVES: To establish treatment recommendations for atlas fractures based on the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma. METHODS: Neither high-level evidence studies comparing conservative and operative management nor studies matching different operative treatment strategies exist. This recommendation summarizes the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma with regard to the treatment of atlas fractures. RESULTS: Most atlas fractures are the result of compression forces. A valuable morphological classification system has been described by Gehweiler. For an adequate diagnosis, a computed tomography is mandatory. To distinguish between stable and unstable type 3 injuries, it is necessary to evaluate the integrity of the transverse atlantal ligament (TAL) with magnetic resonance imaging and to classify the TAL lesions. The majority of atlas fractures are stable and will be successfully managed conservatively. Unstable atlas fractures (type 3b and sagittal split type 4 fractures) should be treated by surgical stabilization. Unstable atlas fractures (type 3b) with a midsubstance ligamentous disruption or severely dislocated ligamentous bony avulsions of the TAL can successfully be treated by a C1/2 fusion. Unstable atlas fractures (type 3b) with a moderately dislocated ligamentous bony avulsion of the TAL and sagittal split type 4 fractures may be treated by atlas osteosynthesis only. CONCLUSIONS: Whereas the majority of atlas fractures can be managed conservatively, in specific fracture patterns surgical treatment strategies have become the standard of care.

Safe management of acute cervical spine injuries.

Cervical spine injuries are frequent and often caused by a blunt trauma mechanism. They can have severe consequences, with a high mortality rate and a high rate of neurological lesions.Diagnosis is a three-step process: 1) risk assessment according to the history and clinical features, guided by a clinical decision rule such as the Canadian C-Spine rule; 2) imaging if needed; 3) classification of the injury according to different classification systems in the different regions of the cervical spine.The urgency of treatment is dependent on the presence of a neurological lesion and/or instability. The treatment strategy depends on the morphological criteria as defined by the classification. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170076.

Erratum to: Transthoracic mini-open approach for anterior monosegmental stabilization and fusion.

Unfortunately, the title of the above mentioned article was incorrectly published on the original version. The complete correct title should read as follows: "Transthoracic mini-open approach for anterior monosegmental stabilization and fusion".

Traumatic Spondylolisthesis of the Axis Vertebra in Adults.

Study Design Narrative review. Objective To elucidate the current concepts in diagnosis and treatment of traumatic spondylolisthesis of the axis. Methods Literature review using PubMed, Google Scholar, and Cochrane databases. Results The traumatic spondylolisthesis of the axis accounts to 5% of all cervical spine injuries and is defined by a bilateral separation of the C2 vertebral body from the neural arch. The precise location of the fracture line may vary widely. For understanding the pathobiomechanics, the involvement of the C2-C3 disk is essential. Although its synonym "hangman's fracture" suggests an extension moment as primary injury mechanism, flexion moments are also proven to cause such fracture morphology. The axial force vector (distraction versus compression) is thought to have a significant effect on the neurologic involvement. The most widely accepted classifications, according to Effendi and modified by Levine, regard the displacement of the C2 vertebral body and possible locking of the facet joints. For decisions on conservative versus surgical therapy, a definitive statement about the stability is essential. The stability is determined by involvement of the C2-C3 disk and longitudinal ligaments, which frequently cannot be assessed by X-ray or computed tomography alone. The assessment of this soft tissue injury therefore requires additional imaging either by magnetic resonance imaging to display the disk and longitudinal ligaments or dynamic fluoroscopy to assess functional behavior of the C2-C3 motion segment. If stability is proven, an immobilization of the cervical spine in a semirigid cervical collar is sufficient. Unstable lesions require surgical stabilization. The standard procedure is an anterior C2-C3 diskectomy and fusion, because of the lower morbidity of the anterior approach and the motion preservation between C1 and C2. In rare cases (irreducible locked facet joints, the necessity of decompression of the vertebral artery, contraindication for anterior approach), a posterior approach is sometimes necessary. Isolated direct screw osteosynthesis is of little value, because it only makes sense in cases with an intact C2-C3 disk, which is usually regarded as stable and therefore might be treated conservatively. Conclusions Overall, the clinical evidence regarding traumatic spondylolisthesis of the axis is very low and mainly based on small case series, expert opinion, laboratory findings, and theoretical considerations.

A cervical "zero-profile" cage with integrated angle-stable fixation: 24-months results.

The purpose of this prospective mono-centric case series study is to investigate the mid-term (minimum follow-up 24 months) safety and efficacy using a new "zero-profile" stand-alone cage with integrated angle-stable fixation in single- and multilevel anterior cervical fusions. 53 consecutive patients with radiculopathy/myelopathy at one to three levels underwent an anterior cervical discectomy and fusion procedure using the "zero-profile" implant (97 levels operated). A CT-scan at 12-months was taken to assess fusion status, implant failure, subsidence and migration. The overall fusion rate was 97%. 3 out of 45 patients (6.6%) complained about mild dysphagia related symptoms at 24 months follow-up . There was no recorded incidence of hardware failure. The new cervical stand-alone anterior fusion device allows a safe anterior cervical decompression and stabilisation, a low rate of chronic dysphagia and achieves a high fusion rate. Prospective randomised trials are necessary to confirm these results.