Preoperative Performance Status Threshold for Favorable Surgical Outcome in Metastatic Spine Disease.

BACKGROUND AND OBJECTIVES: Surgical treatment is an integral component of multimodality management of metastatic spine disease but must be balanced against the risk of surgery-related morbidity and mortality, making tailored surgical counseling a clinical challenge. The aim of this study was to investigate the potential predictive value of the preoperative performance status for surgical outcome in patients with spinal metastases. METHODS: Performance status was determined using the Karnofsky Performance Scale (KPS), and surgical outcome was classified as "favorable" or "unfavorable" based on postoperative changes in neurological function and perioperative complications. The correlation between preoperative performance status and surgical outcome was assessed to determine a KPS-related performance threshold. RESULTS: A total of 463 patients were included. The mean age was 63 years (range: 22-87), and the mean preoperative KPS was 70 (range: 30-100). Analysis of clinical outcome in relation to the preoperative performance status revealed a KPS threshold between 40% and 50% with a relative risk of an unfavorable outcome of 65.7% in KPS ≤40% compared with the relative chance for a favorable outcome of 77.1% in KPS ≥50%. Accordingly, we found significantly higher rates of preserved or restored ambulatory function in KPS ≥50% (85.7%) than in KPS ≤40% (48.6%; P < .001) as opposed to a significantly higher risk of perioperative mortality in KPS ≤40% (11.4%) than in KPS ≥50% (2.1%, P = .012). CONCLUSION: Our results underline the predictive value of the KPS in metastatic spine patients for counseling and decision-making. The study suggests an overall clinical benefit of surgical treatment of spinal metastases in patients with a preoperative KPS score ≥50%, while a high risk of unfavorable outcome outweighing the potential clinical benefit from surgery is encountered in patients with a KPS score ≤40%.

The projected increase of vertebral osteomyelitis in Germany implies a demanding challenge for future healthcare management of aging populations.

PURPOSE: Since an increase in the occurrence of native vertebral osteomyelitis (VO) is expected and reliable projections are missing, it is urgent to provide a reliable forecast model and make it a part of future health care considerations. METHODS: Comprehensive nationwide data provided by the Federal Statistical Office of Germany were used to forecast total numbers and incidence rates (IR) of VO as a function of age and gender until 2040. Projections were done using autoregressive integrated moving average model on historical data from 2005 to 2019 in relation to official population projections from 2020 to 2040. RESULTS: The IR of VO is expected to increase from 12.4 in 2019 to 21.5 per 100,000 inhabitants [95% CI 20.9-22.1] in 2040. The highest increase is predicted in patients over 75 years of age for both men and women leading to a steep increase in absolute numbers, which is fourfold higher compared to patients younger than 75 years. While the IR per age group will not increase any further after 2035, the subsequent increase is due to a higher number of individuals aged 75 years or older. CONCLUSIONS: Our data suggest that increasing IR of VO will seriously challenge healthcare systems, particularly due to demographic change and increasing proportions of populations turning 75 years and older. With respect to globally fast aging populations, future health care policies need to address this burden by anticipating limitations in financial and human resources and developing high-level evidence-based guidelines for prevention and interdisciplinary treatment.

Projections From Surgical Use Models in Germany Suggest a Rising Number of Spinal Fusions in Patients 75 Years and Older Will Challenge Healthcare Systems Worldwide.

BACKGROUND: Spinal fusion is a well-established procedure in the treatment of degenerative spinal diseases. Previous research shows that the use of this operative treatment has been growing in recent decades in industrialized countries and has become one of the most cost-intensive surgical procedures. It seems that in some countries such as Germany-with its large, industrialized, European population-this increase is mainly driven by demographic changes with low fertility rates, increasing life expectancy, and an aging population. Based on current projections, however, Germany faces a population trend that many other countries are likely to follow within a few decades. An increasingly shrinking and aging working population may eventually put the healthcare system under enormous pressure, with greater demands for spinal fusions and associated higher costs. Thus, we aimed to provide reliable projections regarding the future demand for posterior spinal fusion procedures including age- and gender-related trends up to 2060, which will be necessary for future resource planning and possible improvements in actual treatment strategies. QUESTIONS/PURPOSES: (1) How is the use of posterior spinal fusions in Germany expected to change from 2019 through 2060, if currents trends continue? (2) How is the use of posterior spinal fusions in Germany expected to change depending on patients' age and gender during this time period? METHODS: Comprehensive nationwide data provided by the Federal Statistical Office, the official institution for documenting all data on operations and procedures performed in Germany, were used to quantify posterior spinal fusion rates as a function of calendar year, age, and gender. Because there is a lack of evidence regarding future trends in the use of posterior spinal fusions, an autoregressive integrated moving average model on historical procedure rates from 2005 to 2019 in relation to official population projections from 2020 to 2060 was chosen to forecast future absolute numbers and incidence rates of this procedure in Germany. Long-term forecasting is more prone to unexpected disruptions than forecasting over short-term periods; however, longer spans facilitate estimates of how trends may challenge future healthcare systems if those trends continue, and thus are useful for research and planning. RESULTS: The incidence rate of posterior spinal fusion was projected to increase by approximately 83% (95% CI 28% to 139%) to 102% per 100,000 inhabitants (95% CI 71% to 133%) in 2060, with a 1.3-fold higher rate of women undergoing surgery in terms of absolute numbers. The highest increase identified by the model occurred in patients 75 years and older with 38,974 (95% CI 27,294 to 50,653) posterior spinal fusions in 2060, compared with 14,657 in 2019. This trend applied for both women and men, with a 246% (95% CI 138% to 355%) increase in the total number of posterior spinal fusions for women 75 years and older and a 296% (95% CI 222% to 370%) increase for men 75 years and older. At the same time, posterior spinal fusions in all age groups younger than 55 years were projected to follow a constant or even negative trend up to 2060. CONCLUSION: Our findings suggest that increasing use of posterior spinal fusion, particularly in patients 75 years and older, will challenge healthcare systems worldwide if current trends persist. This study may serve as a model for many other industrialized countries facing similar demographic and procedure-specific developments in the future. This emphasizes the need to focus on frailty research as well as appropriate financial and human resource management. Effective perioperative medical management, multidisciplinary treatment, and interinstitutional protocols are warranted, especially in older patients as we attempt to manage these trends in the future. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

When to remove? Evaluation of postoperative drainage volume after single-level posterior lumbar interbody fusion.

Study design: prospective, observational. Background: Wound drainage's indwelling duration and general use are the centre of ongoing discussion. The aim of our prospective observational study was to evaluate the total drainage volume postoperatively and its course after lumbar interbody fusion surgeries to define an ideal point in time for drainage removal. Methods: We included all patients who underwent monosegmental lumbar interbody fusion via transforaminal or posterior lumbar interbody fusion (TLIF/PLIF). After application of the exclusion criteria, 27 patients were included in our study. Drainage volume was measured three times a day and at the time of drain removal. Results: The PLIF group reached higher total drainage volume (337.14 ml) than the TLIF group (215.5 ml) (p = 0.047. Drainage volume's plateau was reached after 33.0 h (±1.8 h) in the TLIF group and 25.3 h (±1.7 h) in the PLIF group following surgery. Conclusions: Our study shows, that drainage volume did not increase significantly after the evening of the first postoperative day at latest. This was on average 33.0 h after surgery. Therefore, extraction of the drainage tube hereafter can be assumed to be safe.

Endoscopic Facet Joint Denervation on the Lumbar Spine: A Retrospective Analysis.

STUDY DESIGN: This single-center retrospective study analyzed patients with chronic low back pain (CLBP) who underwent endoscopic facet joint denervation (EFJD) between April 2018 and May 2019. PURPOSE: This study was designed to investigate the effectiveness of EFJD in treating CLBP. OVERVIEW OF LITERATURE: CLBP is a challenging burden to healthcare systems worldwide. As up to 45% of cases originate from the lumbar facet joints, sufficient therapy strategies must be developed. EFJD offers a precise depiction of the dorsal medial ramus and the facet joint capsule. METHODS: In this study, 64 patients who underwent EFJD were included. The main outcome of interest was patients' Visual Analog Scale (VAS) pain score, which was recorded at 3-time points (i.e., before operation and 6 weeks and 12 months after surgery). RESULTS: EFJD effectively reduced the VAS pain scores by 58% in the short term (6 weeks) and 38% in the long term (12 months). Patients with isolated facet joint osteoarthritis benefited more (p <0.001). CONCLUSIONS: EFJD is a good treatment alternative for CLBP originating from the facet joints, particularly in patients with isolated facet joint osteoarthritis. Moreover, this method can address not only the dorsal medial ramus but also the surrounding tissue (e.g., facet joint capsule, facet joint effusion, and osteophytes) as the origin of CLBP.

Long-term Radiological and Clinical Outcome after Lumbar Spinal Fusion Surgery in Patients with Degenerative Spondylolisthesis: A Prospective 6-Year Follow-up Study.

OBJECTIVE: To assess which radiological alignment parameters are associated with a satisfactory long-term clinical outcome after performing lumbar spinal fusion for treating degenerative spondylolisthesis. METHODS: This single-center prospective study assessed the relation between radiological alignment parameters measured on standing lateral lumbar spine radiographs and the patient-reported outcome using four different questionnaires (COMI, EQ-5D, ODI and VAS) as primary outcome measures (level of evidence: II). The following spinopelvic alignment parameters were used: gliding angle, sacral inclination, anterior displacement, sagittal rotation, lumbar lordosis, sacral slope, pelvic tilt and pelvic incidence. Furthermore, the length of stay and perioperative complications were documented. Only cases from 2013 to 2015 of low-grade degenerative lumbar spondylolisthesis (Meyerding grades I and II) were considered. The patients underwent open posterior lumbar fusion surgery by pedicle screw instrumentation and cage insertion. The operative technique was either a posterior lumbar interbody fusion (PLIF) or a transforaminal lumbar interbody fusion (TLIF) performed by three different senior orthopedic surgeons. Exclusion criteria were spine fractures, minimally invasive techniques, underlying malignant diseases or acute infections, previous or multisegmental spine surgery as well as preoperative neurologic impairment. Of 89 initially contacted patients, 17 patients were included for data analysis (11 males, six females). RESULTS: The data of 17 patients after mono- or bisegmental lumbar fusion surgery to treat low-grade lumbar spondylolisthesis and with a follow-up time of least 72 months were analyzed. The mean age was 66.7 ± 11.3 years. In terms of complications two dural tears and one intraoperative bleeding occurred. The average body mass index (BMI) was 27.6 ± 4.4 kg/m2 and the average inpatient length of stay was 12.9 ± 3.8 days (range: 8-21). The long-term clinical outcome correlated significantly with the change of the pelvic tilt (rs  = -0.515, P < 0.05) and the sagittal rotation (rs  = -0.545, P < 0.05). The sacral slope was significantly associated with the sacral inclination (rs  = 0.637, P < 0.01) and the pelvic incidence (rs  = 0.500, P < 0.05). In addition, the pelvic incidence showed a significant correlation with the pelvic tilt (rs  = 0.709, P < 0.01). The change of the different clinical scores over time also correlated significantly between the different questionnaires. CONCLUSIONS: The surgical modification of the pelvic tilt and the sagittal rotation are the two radiological alignment parameters that can most accurately predict the long-term clinical outcome after lumbar interbody fusion surgery.

Lumbar Facet Joint Radiofrequency Denervation Therapy for Chronic Low Back Pain: Enhanced Outcome Compared With Chemical Neurolysis (Ethyl Alcohol 95% or Glycerol 20%).

BACKGROUND: It was hypothesized that radiofrequency denervation (RFD) of lumbar facet joints is associated with superior pain abolishment and less complications than chemical neurolysis (with ethyl alcohol or glycerol) in patients with chronic facet joint arthropathy. METHODS: For this prospective cohort study, adult patients with chronic lumbar facet joint arthropathy were prospectively enrolled between 2017 and 2019. The following groups were compared before the intervention and 6 weeks, 6 months, and 12 months after the intervention: RFD, chemical neurolysis with ethyl alcohol 95% (EA-95), or glycerol 20% (Gly-20). Outcome parameters included the Core Outcome Measures Index for the back (COMI-back), World Health Organization (WHO) pain ladder level, and visual analog scale (VAS). P values <0.05 were considered statistically significant. RESULTS: A total of 95 patients with a mean age of 63.7 years were included. Among them, 30 patients underwent RFD, 30 patients were treated with EA-95, and 35 individuals were treated with Gly-20. After 6 weeks, RFD patients had significantly lower VAS scores compared with the EA-95 group. After 6 months, both VAS and COMI were significantly lower in RFD patients than in the Gly-20 group. Twelve months after intervention, VAS scores were significantly lower in the RFD group compared with the Gly-20 group. CONCLUSIONS: This study reveals that RFD is associated with improved pain relief and quality of life compared with chemical neurolysis for facet joint-related chronic lower back pain and should be considered as the treatment of choice in patients with chronic low back pain due to facet joint arthropathy. CLINICAL RELEVANCE: The current study provides information that may improve clinical decision making in the treatment of chronic lumbar facet joint arthropathy and to appropriately counsel such patients about expected outcomes.

Short-term radiological results after spheroid-based autologous chondrocyte implantation in the knee are independent of defect localisation.

BACKGROUND: Lesions of articular cartilage represent a crucial risk factor for the early development of osteoarthritis. Autologous chondrocyte implantation (ACI) is a well-established procedure in therapy of those lesions in the knee. The aim of the presented study is to detect differences in short-term radiological outcome depending on defect localization (femoral condyle vs. retropatellar) after spheroid-based ACI. OBJECTIVE: This study aimed to demonstrate that radiological outcome after spheroid-based ACI in the knee is independent of defect localization. METHODS: MRI-scans after retropatellar ACI and ACI of the medial/lateral femoral condyle, with a preoperative Outerbridge grade of III or IV were evaluated regarding MOCART 2.0. RESULTS: The mean defect-size was 5.0 ± 1.8 cm2, with a minimum size of 2 cm2 and a maximum size of 9 cm2. Scans were performed 7.7 months (± 3.1 months) postoperatively. The mean MOCART 2.0 score was 78.5 ± 15.6. No statistically significant influence neither of the localization (p= 0.159), the gender (p= 0.124) nor defect size (< 5 cm2 vs. ⩾ 5 cm2; p= 0.201) could be observed. CONCLUSIONS: The presented data demonstrate good to excellent radiological short-term results after spheroid-based ACI. Data indicates, that at least radiological results are independent of gender, defect-size and defect-localization.

Comparison of Different Approaches in Lumbosacral Spinal Fusion Surgery: A Systematic Review and Meta-Analysis.

We aimed to systematically review the literature to analyze the differences in posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusion (ALIF), and transforaminal lumbar interbody fusion (TLIF), focusing on the complications, risk factors, and fusion rate of each approach. Spinal fusion surgery is a well-established surgical procedure for a variety of indications, and different approaches developed. The various approaches and their advantages, as well as approach-related pathology and complications, are well investigated in spinal surgery. Focusing only on lumbosacral fusion, the comparative studies of different approaches remain fewer in numbers. We systematically reviewed the literature on the complications associated with lumbosacral interbody fusion. Only the PLIF, ALIF, or TLIF approaches and studies published within the last decade (2007-2017) were included. The exclusion criteria in this study were oblique lumbar interbody fusion, extreme lateral interbody fusion, more than one procedure per patient, and reported patient numbers less than 10. The outcome variables were indications, fusion rates, operation time, perioperative complications, and clinical outcome by means of Visual Analog Scale, Oswestry Disability Index, and Japanese Orthopaedic Association score. Five prospective, 17 retrospective, and two comparative studies that investigated the lumbosacral region were included. Mean fusion rates were 91,4%. ALIF showed a higher operation time, while PLIF resulted in greater blood loss. In all approaches, significant improvements in the clinical outcome were achieved, with ALIF showing slightly better results. Regarding complications, the ALIF technique showed the highest complication rates. Lumbosacral fusion surgery is a treatment to provide good results either through an approach for various indications as causes of lower back pain. For each surgical approach, advantages can be depicted. However, perioperative complications and risk factors are numerous and vary with ALIF, PLIF, and TLIF procedures, as well as with fusion rates.

Scoliosis and Prognosis-a systematic review regarding patient-specific and radiological predictive factors for curve progression.

INTRODUCTION: Idiopathic scoliosis, defined as a > 10° curvature of the spine in the frontal plane, is one of the most common spinal deformities. Age, initial curve magnitude and other parameters define whether a scoliotic deformity will progress or not. Still, their interactions and amounts of individual contribution are not fully elaborated and were the aim of this systematic review. METHODS: A systematic literature search was conducted in the common databases using MESH terms, searching for predictive factors of curve progression in adolescent idiopathic scoliosis ("adolescent idiopathic scoliosis" OR "ais" OR "idiopathic scoliosis") AND ("predictive factors" OR "progression" OR "curve progression" OR "prediction" OR "prognosis"). The identified and analysed factors of each study were rated to design a top five scale of the most relevant factors. RESULTS: Twenty-eight investigations with 8255 patients were identified by literature search. Patient-specific risk factors for curve progression from initial curve were age (at diagnosis < 13 years), family history, bone mineral status (< 110 mg/cm3 in quantitative CT) and height velocity (7-8 cm/year, peak 11.6 ± 1.4 years). Relevant radiological criteria indicating curve progression included skeletal maturity, marked by Risser stages (Risser < 1) or Sanders Maturity Scale (SMS < 5), the initial extent of the Cobb angle (> 25° progression) and curve location (thoracic single or double curve). DISCUSSION: This systematic review summarised the current state of knowledge as the basis for creation of patient-specific algorithms regarding a risk calculation for a progressive scoliotic deformity. Curve magnitude is the most relevant predictive factor, followed by status of skeletal maturity and curve location.

Implant-Associated Infection of Long-Segment Spinal Instrumentation: A Retrospective Analysis of 46 Consecutive Patients.

STUDY DESIGN: This single-center retrospective study analyzed patients with an implant-associated infection of spinal instrumentation (four or more segments) treated between 2010 and 2018. PURPOSE: This study aimed to investigate the treatment of implant-associated infections of long-segment spinal instrumentation and to define risk factors for implant removal. OVERVIEW OF LITERATURE: Implant-associated infection occurs in 0.7%-20% of spinal instrumentation. Significant blood loss, delayed reoperation, and use of effective antibiotics are reported risk factors for implant removal. METHODS: Patients with superficial infections not involving the implant were excluded. All patients received surgical and antibiotic treatments according to our interdisciplinary osteomyelitis board protocol. An infection was considered healed if a patient showed no signs of infection 1 year after termination of treatment. The patients were divided into an implant retention group and implant removal group, and their clinical and microbiological data were compared. RESULTS: Forty-six patients (27 women, 19 men) with an implant-associated infection of long-segment spinal instrumentation and mean age of 65.3±14.3 years (range, 22-89 years) were included. The mean length of the infected instrumentation was 6.5±2.4 segments (range, 4-13 segments). Implant retention was possible in 21 patients (45.7%); in the other 25 patients (54.3%), a part of or the entire implant required removal. Late infections were associated with implant removal, which correlated with longer hospitalization. Both groups showed high postoperative complication rates (50%) and high mortality rates (8.7%). In 39 patients (84.8%), infection was eradicated at a mean follow-up of 18.9±11.1 months (range, 12-60 months). Three patients (6.5%) were lost to follow-up. CONCLUSIONS: Implant-associated infections of long-segment spinal instrumentations are associated with high complication and mortality rates. Late infections are associated with implant removal. Treatment should be interdisciplinary including orthopedic surgeons and clinical infectiologists.

Impact of the Vestibular System on the Formation and Progression to Idiopathic Scoliosis: A Review of Literature.

The physiopathogenesis of adolescent idiopathic scoliosis remains unknown. However, a multifactorial pathogenesis is being assumed. Besides biomechanical, biochemical, and genetic factors, some studies have focused on congenital or acquired abnormalities in the vestibular organ with consecutive development of scoliosis. This study aims to analyze a possible correlation between any vestibular organ congenital or acquired pathologies and scoliosis based on the current literature. Therefore, we conducted a literature search in three databases, with search terms such as "scoliosis," "organ of balance," "idiopathic scoliosis," "vestibular organ," "spine," and "balance." Fifteen studies were selected and used for research. The relationship between scoliosis and vestibular organ abnormalities was recorded from all included works. Seven studies demonstrated a direct correlation between vestibular organ anatomical abnormalities and the form of the scoliotic spine. Another study confirmed the influence of the pathology of the vestibular organ on scoliosis but questioned whether it had an impact on the formation or the progression of the curvature. Others demonstrated a temporal overlap of the embryonic development of the vestibular organ and the beginning of pre-scoliotic characteristics, but their relationship remained questionable. In three studies, the correlation remained unclear, and any context has been denied. It seems unlikely that an isolated vestibular disorder can trigger structural scoliosis. However, the vestibular system pathologies may certainly occur in the multifactorial genesis of idiopathic scoliosis. Whether the correlation refers to the expression or the progression of scoliosis or may even have an influence on both remains unclear. New treatment options could be derived from these findings with a positive influence on the course of the deformity.

Biomechanical effects of posterior pedicle screw-based instrumentation using titanium versus carbon fiber reinforced PEEK in an osteoporotic spine human cadaver model.

BACKGROUND: Aim of this biomechanical investigation was to compare the biomechanical effects of a carbon fiber reinforced PEEK and titanium pedicle screw/rod device in osteoporotic human cadaveric spine. METHODS: Ten human fresh-frozen cadaveric lumbar spines (L1-L5) have been used and were randomized into two groups according to the bone mineral density. A monosegmental posterior instrumentation (L3-L4) using titanium pedicle screws and rods was carried out in group A and using carbon fiber reinforced PEEK in group B. A cyclic loading test was performed at a frequency of 3 Hz, starting with a peak of 500 N for the first 2000 cycles, up to 950 N for 100,000 cycles under a general preload with 100 N. All specimens were evaluated with regard to a potential collapse of the implanted pedicle screws. A CT supported digital measurement of cavities around the pedicle at 3 defined measuring points was performed. Finally, the maximum zero-time failure load of all specimens was determined using a universal testing machine (80% Fmax). FINDINGS: Regarding maximum axial force (group A: 2835 N, group B: 3006 N, p = 0.595) and maximum compression (group A: 11.67 mm, group B: 15.15 mm, p = 0.174) no statistical difference could be shown between the two groups. However, significant smaller cavity formation around the pedicle screws could be observed in group B (p = 0.007), especially around the screw tip (p < 0.001). INTERPRETATION: Carbon fiber reinforced PEEK devices seem to be advantageous in terms of microscopic screw loosening compared to titanium devices.

Impact of lordotic cages in the restoration of spinopelvic parameters after dorsal lumbar interbody fusion: a retrospective case control study.

PURPOSE: Aim of this study was to compare the reconstruction of radiological sagittal spinopelvic parameters between lordotic (10°) and normal cages (0°) after dorsal lumbar spondylodesis. METHODS: This retrospective monocentric study included patients who received dorsal lumbar spondylodesis between January 2014 and December 2018. Inclusion criteria were degenerative lumbar diseases and mono- or bi-segmental fusions in the middle and lower lumbar region. Exclusion criteria were long-distance fusions (3 segments and more) and infectious and tumour-related diseases. The sagittal spinopelvine parameters (lumbar lordosis, segmental lordosis, sacral slope, pelvic incidence, and pelvic tilt) were measured pre- and post-operatively by two examiners at two different times. The patients were divided into 2 groups (group 1: lordotic cage, group 2: normal cage). RESULTS: One hundred thirty-eight patients (77 female, 61 male) with an average age of 66.6 ± 11.2 years (min.: 26, max.: 90) were included in the study based on the inclusion criteria. Ninety-two patients (66.7%) received 0° cages and 46 (33.3%) lordotic cages (10°). Segmental lordosis was increased by 4.2° on average in group 1 and by 6.5° in group 2 (p = 0.074). Average lumbar lordosis was increased by 2.1° in group 1 and by 0.6° in group 2 (p = 0.378). There was no significant difference in the correction of sagittal spinopelvic parameters. Inter- and inter-class reliability was between 0.887 and 0.956. CONCLUSION: According to the results of our study, no advantages regarding sagittal radiological parameters for the implantation of a lordotic cage could be demonstrated.

Probe versus drill: A biomechanical evaluation of two different pedicle preparation techniques for pedicle screw fixation in human cadaveric osteoporotic spine.

BACKGROUND: Aim of this biomechanical study was to investigate the anchorage of pedicle screws in osteoporotic vertebrae using two different preparation techniques (probe versus drill-assisted). METHODS: Twelve thoracic vertebrae were used for the study. The right and left pedicles of the vertebra were prepared with a thoracic probe or a 3.2 mm drill bit and divided into two groups. A standard titanium (diameter: 5.5 mm, length: 45 mm) pedicle screw was then inserted. All pedicle screws were initially loaded with -25 N to +25 N in the cranio-caudal direction. The load was increased by 5 N every 500 cycles up to a maximum load of 10,000 cycles. Loosening was defined as a displacement of the pedicle screw head of >5 mm. The two groups were compared in terms of maximum number of cycles and maximum force until loosening. FINDINGS: The pedicle screws prepared with the thoracic probe failed on average after 3819 cycles (SD 3281) and the pedicle screws prepared with the 3.2 mm drill after 3335 cycles (SD 3477). There was no significant difference between the two preparation techniques (P = .797). With regard to the maximum force until loosening, there was also no significant difference between the two techniques (thoracic probe: 61 N (SD 33), 3.2 mm drill bit: 56 N (SD 34), P = .791). INTERPRETATION: Preparation of the pedicle screw hole either with a probe or drill bit doesn't seem to have an influence on pedicle screw loosening rates in the osteoporotic spine.

Impact of lumbar pedicle screw positioning on screw stability - A biomechanical investigation.

BACKGROUND: Screw loosening is a major complication following spondylodesis. While several modifications increase screw stability, some, such as screw augmentation, are associated with potential complications; new techniques are needed to minimize the risk of screw loosening without increasing complication rates. METHODS: 13 fresh-frozen human lumbar vertebral bodies (L1 to L5) were dissected. In group 1 (n = 7), pedicle screws were implanted conventionally, while in group 2 (n = 6), the screws were positioned divergent in the sagittal pathway. Screw stability was tested under cyclic axial load; one testing-cycle included 1000 repetitions. The first cycle started with a load of 100 N while the load was increased by +20 N in each following cycle until failure. Failure was defined by either a >5 mm movement of the screw heads or triggering of the switch-off threshold. FINDINGS: Average number of cycles until failure was increased in group 2 compared with group 1 (12,046 vs 9761 cycles), as was the average load to failure (Fmax 313 N vs 260 N). Overall, in group 2, the number of cycles until screw loosening or failure increased by 23% (p = 0.28), while the required force increased by 20% (p = 0.3). Statistically significant correlation between BMD and increased number of cycles completed as well as with increased load (p < 0.01) could be observed. INTERPRETATION: The results demonstrate, that divergent screw-drift of pairs of screws in the sagittal plane tends to increase stability, especially in vertebral bodies with lower bone density. Moreover, we could demonstrate a correlation between BMD and stability of screw-fixation.

Anatomical investigation of the segmental vessels for the right-sided anterior surgical approach to the thoracic spine: a human cadaver study.

PURPOSE: Anterior surgical approaches to the thoracic spine are common procedures for the treatment of many diseases of the thoracic spine. Purpose of this anatomic study is to investigate the course of the segmental vessels of the thoracic spine for the anterior and lateral transthoracic approach from the right side. METHODS: 26 formalin-fixed human cadavers (20 femaless/6 male) with an average age of 84.9 ± 8.3 (range 67-97) were included. The segmental arteries and veins of the right thoracic cavity coursing between the third and twelfth thoracic vertebral body have been investigated. To define the localization of the vessels in accordance with the associated vertebral bodies, the distance between the endplates and vessels was measured in the ventral, middle and dorsal parts. RESULTS: The results of the study reveal that not only one, but also two segmental arteries and veins may course over the right hemi-vertebral body, especially in the upper and middle thoracic spine. Furthermore, in the middle and lower thoracic spine (T7-T12) the vessels course over the middle and lower third of the craniocaudal extent of the vertebral body. On the contrary, in the upper thoracic spine (T3-T6), the vessels may course over the entire extent of the vertebral body. CONCLUSION: Due to these common anatomic variations and variability of the course of the segmental vessels, spinal surgeons should remain careful in the identification of the segmental vessels in order to minimize risk of vascular injury in case of right-sided anterior and lateral approach to the thoracic spine.

Quality of life and functional outcomes after surgery for spinal metastases: Results of a cohort study.

BACKGROUND: Spinal metastases are being diagnosed more frequently because of increasing life expectancies and advances in the diagnosis and therapy of primary tumours. OBJECTIVE: This aim of this study was to assess the quality of life (QoL) and functional outcomes after surgical intervention for spinal metastases in a large cohort. METHODS: A single-centre, prospective, observational study was conducted from June 2016 to February 2018. Patients treated surgically for spinal metastasis were included. Primary endpoints were the Core Outcome Measure Index (COMI), Oswestry Disability Index (ODI), and QoL questionnaire (EuroQoL-5D) scores recorded preoperatively, 6 weeks postoperatively, and 3, 6, and 12 months postoperatively. RESULTS: Ninety-two patients (mean age, 62.7 ± 12.8 years) were included. The most frequent neoplasms were multiple myeloma (n= 18; 19.6%), lung cancer (n= 16; 17.4%), prostate cancer (n= 14; 15.2%), and breast cancer (n= 11; 12.0%). During the observation period, 44.6% of patients died. The COMI score improved significantly from preoperatively (mean, 7.1; 95% CI, 6.6-7.6) to 3 months (mean, 5.5; 95% CI, 4.8-6.2; p= 0.01) and 12 months (mean, 4.6; 95% CI, 3.7-5.5; p= 0.001) postoperatively. The ODI showed a significant improvement from preoperatively (mean, 52.9; 95% CI, 48.5-57.4) to 6 weeks (mean, 43.4; 95% CI, 37.1-49.6; p= 0.03), 3 months (mean, 37.0; 95% CI, 31.0-42.9) 6 months mean, 40.5; 95% CI, 34.2-46.8; p= 0.01), and 12 months (mean, 31.9; 95% CI, 24.8-39.1; p= 0.005) postoperatively. Improvements in the COMI at 6 weeks (p= 0.05), and 6 months (p= 0.05) postoperatively were not statistically significant. QoL improved from preoperatively to 6 weeks (mean, 0.48; 95% CI, 0.38-0.59; p= 0.002), 3 months (mean, 0.50; 95% CI, 0.38-0.61; p= 0.009), and 12 months (mean, 0.61; 95% CI, 0.51-0.71; p= 0.001) postoperatively. After 6 months, the difference was not significant (p= 0.08). CONCLUSION: Short-term and long-term improvements in functional outcomes and QoL were observed after surgical treatment of spinal metastases. Surgery is a good option for patients with an estimated life expectancy of more than 3 months.

[Postoperative management of weight bearing and rehabilitation after lumbar spinal surgery]. / Postoperatives Management der Belastung und Rehabilitation nach lumbalen Wirbelsäulenoperationen.

BACKGROUND: Because of the growing trend of lumbar spinal surgery, it is essential for physicians and physiotherapists to develop standardized postoperative treatment. However, currently postoperative treatment after lumbar spinal surgery is controversial. PURPOSE OF THE STUDY: The purpose of this review article is to make recommendations for the postoperative treatment of lumbar intervertebral disc surgery, lumbar decompression surgery and lumbar spinal fusion surgery regarding mobilization, weight bearing and rehabilitation. These recommendations are based on current evidence and experience in our institution. MATERIALS AND METHODS: A selective literature research of relevant publications was conducted in Pubmed. The studies are presented in tabular form. RESULTS: Patient training, accurate information about the postoperative course, information about limitations and stress possibilities as well as pain management seem to have an important role in the final outcome of the operation. Ideally, these procedures should be performed preoperatively or at the latest or repeatedly from the first postoperative day after lumbar spine surgery. Physiotherapy can have a positive impact on the clinical and functional outcome after lumbar disc, decompression and fusion surgery. DISCUSSION: Due to the heterogeneity of the intensity, duration and form of physiotherapy or rehabilitation, which are listed as interventions in the various studies, it is only possible to draw limited conclusions about general instructions for action on "physiotherapy" after spinal surgery.

Insertion Angle of Pedicle Screws in the Subaxial Cervical Spine: The Analysis of Computed Tomography-Navigated Insertion of Pedicle Screws.

STUDY DESIGN: Four orthopedic spine surgeons measured the radiological parameters of pedicle screws in the cervical spine using a postoperative computed tomography (CT) scan. PURPOSE: This study analyzed the insertion angle of CT-navigated insertion of pedicle screws in the subaxial cervical spine and classified them according to their position. OVERVIEW OF LITERATURE: Overall, a pedicle transverse angle of 33.6°-50.2° with a mean angle of 45° relative to the midline has been reported in the literature. METHODS: The insertion angles of 87 pedicle screws inserted using CT-based navigation in the subaxial cervical spine were measured in the postoperative CT. The screw positioning was determined according to the modified Gertzbein and Robbins classification. RESULTS: Total 89.3% (n=78) of the pedicle screws inserted using CT-based navigation showed good placement. The mean insertion angle of the pedicle screws that showed good positioning was 29.9°±9.9°. The pedicle screws showing bad positioning had a mean insertion angle of 26.8°±10.5° (p=0.157). The interobserver reliability showed a reliable measurement intraclass correlation coefficient: 0.994 (95% confidence interval, 0.992-0.996). CONCLUSIONS: The present results show that the insertion angle of the pedicle screws in the subaxial cervical spine was smaller than the actual pedicle transverse angle, as per the literature. One reason for this discrepancy could be that the navigation systems allow the insertion of cervical pedicle screws with a lower convergence.