Radiation Exposure of Patient and Operating Room Personnel by Fluoroscopy and Navigation during Spinal Surgery.

Intraoperative radiography imaging is essential for accurate spinal implant placement. Hazards caused by ionizing radiation raised concern on personnel's work life long exposure in the operating room (OR). To particularize a cumulative risk estimation of radiation of personnel and patient, depending on used methods (C-arm fluoroscopy, O-arm navigation) and patient characteristics during spinal surgery, detailed investigation of radiation exposure in a clinical setting is required. Lumbosacral dorsal spinal fusion was performed in 37 patients (19 navigated, 18 fluoroscopy) during this prospective study. Radiation exposure was measured on several body regions with thermoluminescent dosimeters on patient and OR personnel (surgeon, assistant, sterile nurse, radiology technologist). Comparison between patient characteristics and radiation exposure was included. The highest patients values were measured in the surgery field and gonads area during navigation (43.2 ± 19.4 mSv; fluoroscopy: 27.7 ± 31.3 mSv; p = 0.02), followed by the thoracic region during fluoroscopy (7.7 ± 14.8 mSv; navigation: 1.1 ± 1.0 mSv; p = 0.06), other measured regions can be considered marginal in comparison. Amongst OR personnel exposure of the surgeon was significant higher during fluoroscopy (right hand: 566 ± 560 µSv and thoracic region: 275 ± 147 µSv; followed by thyroid and forehead) compared to navigation (right finger: 49 ± 19 µSv; similar levels for all regions; p < 0.001 in all regions). When compared to the surgeon, other OR personnel had significantly lower radiation doses on all body regions using fluoroscopy, and similar dose during navigation. The highest eye's lens region value was measured during fluoroscopy for the patient (185 ± 165 µSv; navigation: 205 ± 60 µSv; p = 0.57) and the surgeon (164 ± 74 µSv; navigation: 92 ± 41 µSv; p < 0.001). There was a significant correlation between patient BMI and radiation exposure to the surgery field during fluoroscopy. To our knowledge, these data present the first real life, detailed comparison of radiation exposure on OR personnel and patients between clinical use of navigation and fluoroscopy. Although patient's radiation dose is approximately 3-fold during navigation compared to the fluoroscopy, we found that a spinal surgeon could perform up to 10-fold number of surgeries (10.000 versus 883) until maximum permissible annual effective radiation dose would be reached. Especially for a spinal surgeon, who is mainly exposed amongst OR personnel, radiation prevention and protection must remain a main issue.

Navigation versus experience: providing training in accurate lumbar pedicle screw positioning.

PURPOSE: Accurate placement of spinal pedicle screws (PS) is mandatory for good primary segmental stabilization allowing consequent osseous fusion, requiring judgmental experience developed during a long training process. Computer navigation offers permanent visual control during screw manipulation and has been shown to significantly lower the risk of pedicle perforation. This study aims to evaluate whether safety, accuracy, and judgmental skills in screw placement, comparable to an experienced surgeon, can be developed during training using computer navigation. METHODS: Lumbosacral PS were placed in 18 patients in a prospective setting, in one segment side with conventional fluoroscopy by a senior spine-surgeon, and computer navigated on the other side by a trainee without prior experience in the technique. At the beginning and at the end of the study, PS were placed freehand in solid foam models by the trainee. PS placement time, intraoperative placement revisions, PS placement accuracy on postoperative CT scans, and postoperative complications were assessed. RESULTS: Significant improvement of trainee's PS placement accuracy (Sclafani score 8.2-8.83; p = 0.006) and time (13.3-6.8 min per screw; p = 0.005) to a similar level as the experienced surgeon state (5.2-4.1 min per screw; p = 0.39) was explored; similar improvement was explored in the foam models. The number of intraoperative placement revisions kept on a low level for surgeon (3.3-0.0%) and trainee (5.1-2.6%) during the whole study, no postoperative complications occurred. CONCLUSION: Navigated PS insertion allows safe teaching from the early beginning of surgical training, due to steady intraoperative control on PS placement. Adequacy of PS placement is similar to screws placed by an experienced surgeon. Progress in judgmental skills in screw placement can be gained rapidly by the trainee, which can also be transferred to non-computer navigated PS placement.

Clinical Results and Serum Metal Ion Concentrations following Ceramic-on-Metal Total Hip Arthroplasty at a Mean Follow-Up of 60 Months.

Background. Increased metal ion levels following total hip arthroplasty (THA) with metal-on-metal bearings are a highly debated topic. Local soft tissue reactions with chronic pain and systemic side effects such as neuropathy are described. The aim of the current study was to determine the serum metal ion concentrations of Cobalt (Co) and Chrome (Cr) after THA with a ceramic-on-metal (CoM) bearing. Patients and Methods. Between 2008 and 2010, 20 patients underwent THA using a CoM bearing. Clinical function was evaluated by standardized scores systems (Harris Hip Score and WOMAC Score) and radiological examination included X-rays. Patient's blood samples were obtained for metal ion analysis and correlation analysis was done between these results and implant position. Results. Overall, 13 patients with 14 CoM devices were available for the current series. The mean age at time of surgery was 61 years (range, 41 to 85). The postoperative follow-up ranged from 49 to 68 months (mean, 58). Metal ion determination showed mean concentrations of 3,1 µg/L (range, 0,3-15,2 µg/L) for Co and 1,6 µg/L (range, 0,1-5,5 µg/L) for Cr, respectively. A correlation between cup anteversion and Co and Cr concentrations was shown. Conclusion. The current series showed increments for Co and Cr following CoM THA. However, these levels are lower compared to metal ion concentrations in patients with metal-on-metal bearings and the international accepted threshold for revision of MoM devices. We recommend routine follow-up including at least one obligatory evaluation of serum metal ion concentrations and an MRI once to exclude local soft tissue reactions.

Passage of an Anterior Odontoid Screw through Gastrointestinal Tract.

Purpose. Anterior screw fixation has become a popular surgical treatment method for instable odontoid fractures. Screw loosening and migration are a rare, severe complication following anterior odontoid fixation, which can lead to esophagus perforation and requires revision operation. Methods. We report a case of screw loosening and migration after anterior odontoid fixation, which perforated the esophagus and was excreted without complications in a 78-year-old male patient. Results. A ventral dislocated anterior screw perforated through the esophagus after eight years after implantation and was excreted through the gastrointestinal (GI) tract. At a 6-month follow-up after the event the patient was asymptomatic. Conclusion. Extrusion via the GI tract is not safe enough to be considered as a treatment option for loosened screws. Some improvements could be implemented to prevent such an incident. Furthermore, this case is a fine example that recent preoperative imaging is mandatory before revision surgery for screw loosening.

Molecular phenotype is associated with survival in breast cancer patients with spinal bone metastases.

To aid in therapy selection for patients with spinal bone metastases (SBM), predictive models have been developed. These models consider SBM from breast cancer a positive predictive factor, but do not take phenotypes based on estrogen (ER), progesterone (PR) and human epidermal growth factor 2 (HER2) receptors into account. The aim of this study was to ascertain whether receptors are associated with survival, when the disease has progressed up to SBM. All patients who were treated for SBM from breast cancer between 2005 and 2012 were included in this international multi-center retrospective study (n = 111). Reports were reviewed for ER, PR and HER2 status and subsequently subdivided into one of four categories; luminal A, luminal B, HER2 and triple negative. Survival time was calculated as the difference between start of treatment for SBM and date of death. Analysis was performed using the Kaplan-Meier method and log-rank tests. Median follow-up was 3.7 years. Survival times in the luminal B and HER2 categories were not significantly different to the luminal A category and were joined into a single receptor positive category. Eighty-five patients (77 %) had a receptor positive phenotype and 25 (23 %) had a triple negative phenotype. Median survival time was 22.5 months (95 %CI 18.0-26.9) for the receptor positive category and 6.7 months (95 %CI 2.4-10.9) for the triple negative category (p < 0.001). Patients with SBM from breast cancer with a triple negative phenotype have a shorter survival time than patients with a receptor positive phenotype. Models estimating survival should be adjusted accordingly.

[Posttraumatic AV fistula in the upper arm region following a foreign body injury. Sonographic diagnosis - a case report]. / Sonographischer Nachweis einer posttraumatischen AV-Fistel am Oberarm nach Fremdkörpereinsprengung.

This paper reports on the sonographic localisation of a metallic foreign body in the upper arm region and its topographic anatomic position as well as the sonographic diagnosis of an AV fistula due to a lesion of the brachial blood vessels. Ultrasonography is the method of choice for the evaluation and diagnosis of foreign body injuries and possible subsequent complications.

Impaired blood polymorphonuclear leukocyte migration and infection risk in severe trauma.

OBJECTIVES: We investigated the association of impaired blood polymorphonuclear leukocyte (PMN) migration with the incidence of bacterial infections in patients with severe trauma. METHOD: Twenty-six intensive-care patients with different injury severity scores were enrolled in a prospective study. PMN migration was measured daily using 300 microl fresh whole blood in a membrane filter assay. Migration was evaluated in an automated image analyzer that recorded numbers and distribution of the immigrant PMNs within a filter. The relevant parameter was the percentage of PMNs that migrated from the blood samples into the filters upon f-Met-Leu-Phe stimulation. RESULTS: Nine patients developed posttraumatic infections verified microbiologically. These patients showed a reduced PMN migratory capacity in comparison with the 17 patients without infections. A migrating portion of six per cent or less at least three days in succession preceded infections by one to 19 days and indicated infection in eight true positive versus three false positive cases, and 14 true negative versus one false negative case, i.e. specificity was 82.3% and sensitivity 88.8%, p=0.0008. Trauma severity had no influence on PMN migration. CONCLUSIONS: Trauma patients with impaired PMN migration are at risk for bacterial infections. Whole-blood migration tests can define the infection risk and thus may be useful predictive markers for infections.

[Ultrasound diagnosis of the Achilles tendon]. / Sonographische Achillessehnendiagnostik.

Due to the superficial position of the Achilles tendon and the development of high-resolution probes with 7.5, 10, and more MHz, which allow the exact depiction of even very small structures, ultrasonography is the method of choice for the diagnosis of acute and chronic Achilles tendon disorders. Using sonography, both chronic achillodynia (disorders of the tendon itself, peritendinous tissue, bursa, and insertion of the tendon at the calcaneus) and ruptures of the Achilles tendon are exactly diagnosed. By sonographic examination, depiction of changes of the tendon itself (rupture, calcification, thickening) and evaluation of the peritendinous soft tissue with dynamic assessment of the gliding sheath are possible. The risk for the less experienced clinician using ultrasonographic assessment of the locomotor system is not to miss pathologic findings, but to overestimate them, due to artifacts. Sufficient knowledge of ultrasound physics as a reason for typical artifacts and the use of a standardized examination technique are necessary. However, by using high-resolution small ultrasound probes, the depiction of "problem areas" (e.g., musculotendinous junction, insertion of the tendon on the calcaneus) has become easier and more accurate.

[Cervical spine injuries in stable lower cervical spine with spinal stenosis]. / Zervikale Rückenmarkverletzungen bei stabiler unterer Halswirbelsäule mit Spinalkanalstenose.

The aim of the study was to investigate the neurological outcome of spinal cord injuries in the traumatized cervical spine with a stenosis of the spinal medullary canal. From 1992 to 1999 we treated 145 spinal cord injuries and/or injuries with an unstable cervical spine, 138 were treated operatively, in 7 patients we found an injury of the spinal cord with a stable cervical spine and a stenosis of the spinal medullary canal. The radiological diagnostics consisted of anterioposterior X-rays of the cervical spine, an X-ray view of the dens axis and a stress roentgenogramm in extension and flection. An MRI was performed within the first 12 hours after the accident. The stenosis of the spinal medullary canal was evaluated by the quotient of the mid-sagittal diameter of the spinal medullary canal as well as the vertebral body (Torg-quotient) and ranged from 0.5 to 0.8. Pathological changed values were found in 4 patients within 2 segments and in 3 patients within 3 segments. In the T2-turbospin echo sequence hyperintense lesions of the spinal cord, accordingly to an edema were found in 6 patients. The neurological evaluation was performed according to the "Standard Neurological Classification of Spinal Cord Injuries". Treatment of these 7 patients was performed conservatively, consisting of NSAR as well as Methyl-Prednisolon according to the pattern of NASCIS-II and III. The follow-up was performed after 12 to 18 months. We evaluated the X-rays in anterioposterior and lateral view, stress roentgenogramms and neurological status. Radiological findings showed stable conditions of the cervical spine with block vertebras and increased osteophytes. The neurological outcome was evaluated according to the "Motor-Score" and showed an improvement from 8 to 63 points within 13 months in one case. In 6 cases, the average "Motor-Score" of 78 increased to 100 points within 2 to 5 months after injury. Most defunctionalization symptoms were found in the upper extremities. Disturbances in fine motor movement were unable to be examined with the "Motor-Score". We can conclude that spinal cord injuries in stable cervical spines with stenosis of the spinal medullary canal can be treated conservatively with a good outcome. A regression of the neurological deficiency can be expected within 2 to 5 months, but even after one year, deficiency regression is possible.

[Carbon frames. Positioning and reduction aids in tibial intramedullary nailing with unreamed technique]. / Karbonrahmen. Lagerungs- und Repositionshilfe bei der Unterschenkelmarknagelung in unaufgebohrter Technik.

Intramedullary stabilisation of long bones is an established treatment option since Küntscher. Especially for tibial nailing different methods were proposed in the past, were as the use of a fracture table was more or less the standard procedure. Since 4 years now we are nailing tibial fractures without fracture table. We are now using more and more a simple carbon fibre-frame, easily assembled by parts of the AO external fixator. So we can minimize the additional iatrogenic soft tissue damage during surgery and the logistic preoperative set-up in the operation theatre is shorter.

Pathologic odontoid fracture and benign fibrous histiocytoma of bone.

We present the case of a 44-year-old female patient, who sustained an odontoid fracture after a minor trauma (uncomplicated fall). The radiologic evaluation revealed a skeletal tumor of the second cervical vertebra together with a fracture line at the base of the odontoid process of the axis. The patient underwent surgery, the tumor was resected and the odontoid was stabilised using an autologous cortico-cancellous bone graft and a halo fixator. Histologic examination revealed benign fibrous histiocytoma, which is reported to be a very rare skeletal tumor.

[First experiences with unreamed AO intramedullary nail in treatment of femoral shaft fractures]. / Erste Erfahrungen mit dem unaufgebohrten AO-Marknagel (UFN) in der Behandlung von Oberschenkelfrakturen.

The unreamed femoral nail (UFN) system, with its numerous proximal interlocking options, allows a minimal invasive surgical procedure for the treatment of nearly all femoral fracture patterns. Sixty-six fractures, 5 cases of osteolysis or pathologic fractures, 2 limb shortenings and 1 lengthening (monorail technique) and 3 cases of pseudarthrosis were stabilised with the UFN from July 1994 to December 1996. The fractures were analysed according to the AO classification. We found 31 polytrauma patients with an mean ISS of 21.8 and a mean PTS of 25.4. Most of the multiply injured patients (n = 26) were stabilised with the UFN primarily. Follow-up of 44 patients ranged from 4 to 18 months postoperatively. According to our clinical and radiological score the results were excellent in 34% of cases, good in 36.3%, poor in 20.4% and bad in 9%. Average fracture healing time was about 9.8 weeks.

[The UFN-system (unreamed femoral nail)--avoidable intra- and postoperative complications]. / Das UFN-System--Vermeidbare intra- und postoperative Komplikationen.

We give an account of the first Austrian clinical results of a prospective study dealing with fractures of the femoral shaft treated with the UFN-system, the intraoperative handling especially considering the intra- and postoperative complications. The UFN-system combines the advantages of numerous proximal interlocking options for the treatment of nearly all femoral fracture patterns with that of the unreamed nailing (biological osteosynthesis, primary stability with individual after-treatment, high patient's comfort and early mobilisation). Within two years (VII/94-VII/96) sixty closed and four second degree open fractures were stabilized with the unreamed femoral nail. In twelve cases we used the spiral blade interlocking technique. Five times we changed from external fixator to the UFN. The fractures were classified according to the AO-classification. In 64 implanted UFN there occurred twelve intraoperative and four postoperative complications. In five cases reoperation was necessary. Failings in the operative technique, numerous different experienced surgeons and a deficient after_treatment led to our pitfalls.

Influence of age on the release of reactive oxygen species by phagocytes as measured by a whole blood chemiluminescence assay.

Polymorphonuclear and mononuclear phagocytes play an important role in host defense, but may also cause tissue injury through excessive inflammation. Reactive oxygen species (ROS) are not only directly ore indirectly involved in a wide variety of clinical disorders, such as atherosclerosis, reperfusion injury, pulmonary toxicity and cancer, but they are also important in the aging process. This process is associated with increasing susceptibility to infection. In this study we investigated the influence of age and sex on phagocyte activation by means of a whole blood chemiluminescence (CL) assay. Circulating phagocyte activity was measured in 55 healthy volunteers (24 females, 31 males) aged from 6 to 92 years. Using an automated luminescence system, phagocytes were stimulated by polystyrene beads and Luminol-enhanced CL was determined in terms of peak height and peak time in freshly withdrawn, peripheral venous whole blood. An extremely significant positive correlation (p < 0.0001) between the maximum of light emission after stimulation and increasing age was found. This finding is true for the total population of blood phagocytes as well as for a single cell. In contrast the time of the appearance of the maximum of light emission showed an extremely significant inverse correlation (p < 0.0003) with increasing age. The influence of sex on the CL-parameters showed no significant difference between women and men. It is concluded that the increased susceptibility of circulating phagocytes to oxidative burst in elderly subjects may be the consequence of several biological events. Senescent cells express more and also have new antigens on their surfaces that trigger an autoimmune response. Cellular senescence appears earlier in old organisms. Therefore phagocytes in aging individuals may be increasingly involved in their scavenger tasks that grow with the catabolic bias in cell turnover. Moreover, atherosclerotic alterations in the intima and endothelial lesions are physiologic concomitants of age and may lead to a stimulation of circulating phagocytes.

Unstable fractures of the upper thoracic spine.

Unstable fractures of the upper thoracic spine are a therapeutic challenge because of the high rate of associated injuries and frequent occurrence of spinal cord lesions. This study focuses on the operative treatment of these injuries. We present nine patients with unstable injuries of the upper thoracic spine. According to the classification of Magerl et al., there are seven type C and two type B fractures. Eight patients had complete transverse lesions of the cord and one had no evidence of spinal cord injury. All patients presented associated injuries: nine patients had fractured ribs, three a fractured sternum and three a severe haemothorax. All underwent operative treatment: six posterior fusions only, two anterior interbody fusions only after thoractotomy owing to severe bleeding from ruptured intercostal arteries, and one a combined fusion after failure of posterior fusion. The treatment of these patients should be individualized, depending on the associated injuries, loss of blood owing to fractured spine and ruptured vessels and depending on the back pain resulting from an unstable thorax. In general, we prefer the posterior approach to unstable fractures of the upper thoracic spine.

The influence of trauma on changes in neutrophil granulocyte function assessed by an analysis of granulocyte migration.

We examined the effects of trauma on polymorphonuclear leucocyte (PMN) migratory parameters and PMN elastase release, with the aim of tracing an acute inflammatory reaction from its very beginning to the phase of recovery. Fifteen patients who underwent monotrauma surgery, followed by uneventful healing, served as inflammation model. PMN activation was studied by measuring their readiness to migrate (TMI) and their penetration potency (DC) in a whole blood membrane filter device, in which a chemoattractant depot (FMLP) was integrated. Control chambers lacking FMLP provided parameters of the spontaneous migration. In healthy controls (n = 64), the numbers of invading PMNs decreased continuously from the outermost layer towards the interior of the filter device. FMLP did not influence the mobilization rate of PMNs immigrant from the blood into the filter, but those cells that did migrate penetrated deeper (P < 0.05). After trauma, the spontaneous and FMLP-stimulated DC was increased (P < 0.05). Trauma also tended to inhibit PMN migratory activity episodically; depression of the unspecific immune function (low TMI values) was found on the 3rd (P < 0.0001) and 12th (P < 0.01) postsurgical days. There was no correlation between the migratory parameters and the inflammation parameter, PMN elastase release. Preliminary results indicate that analyses of PMN migratory parameters by a whole blood membrane filter assay could provide a valuable adjunct in monitoring trauma-associated immunologic changes.

[UFN system. A method of minimal invasive surgical management of femoral shaft fractures]. / UFN-System. Eine Methode der minimalinvasiven chirurgischen Versorgung von Oberschenkelschaftfrakturen.

The aim of this study is to present our early clinical experience using the Unreamed AO Femoral Nail (UFN). The UFN system combines the advantages of numerous proximal interlocking options for the treatment of nearly all femoral fractures patterns with those of unreamed nailing (biological osteosynthesis, preservation of the cortical blood supply, closed mediate reduction, primary stability, high degree of patient comfort). Operation time and blood loss are reduced by eliminating the reaming procedure. The risk of infection is minimized by avoiding dead space. The positioning of the patient on the operating table without the use of traction allows for a minimally invasive surgical procedure. Our report deals with intraoperative handling, intra- and postoperative complications and the prospective clinical outcome in using the solid femoral nail system in Austria. Within nearly 2 years (August 1994-April 1996) 52 closed fractures and four second-degree open fractures were stabilized using the unreamed femoral nail. In 12 cases we used the spiral blade interlocking technique. Four times we changed from external fixation to the UFN. According to the AO classification, we found 8 fractures of the proximal femur (A 1/1: 1; A3/1: 2; A3/3: 5) and 48 diaphyseal fractures (A1:4; A2: 7; A3: 16; B1: 5; B2: 6; B3: 6; C1: 1; C2: 2; C3: 1). Thirty patients were followed up over an average period of 9.1 months postoperatively. The clinical and radiological results were excellent in 20 cases; average fracture healing time was about 10.6 weeks.

Assay of phagocyte activation by means of malondialdehyde and luminol-enhanced chemiluminescence during uneventful wound healing following trauma surgery.

The purpose of the study was the assessment of the acute inflammatory response in patients (N = 12) with comparable trauma severity and uneventful wound healing courses in the postsurgical period as a contribution to the search for objectifiable criteria in the monitoring of wound healing. Whole blood chemiluminescence (CL) on the one hand and the lipid peroxidation product malondialdehyde (MDA) on the other hand as tools for the detection of the respiratory burst activity of phagocytes were used as inflammation markers and were compared with the established marker PMN elastase. Blood samples were withdrawn daily from the day of surgery to the 14th postsurgical day. CL-parameters and PMN elastase increased postoperatively reflecting surgical trauma, while MDA remained within the normal range during the whole time of observation. A decrease of CL-activity in the postsurgical period correlated with decreasing PMN elastase levels (r = 0.52, P<0.0001) as well as with the tapering of local inflammation signs concerning the wound situs. MDA values neither correlated with PMN elastase nor with any CL-parameters. The results indicate that the measurement of the phagocytic activation by CL, used for the first time in traumatology to monitor wound healing, represents a promising marker for the assessment of the actual inflammatory status.