Biomechanical Effects of a Dynamic Topping off Instrumentation in a Long Rigid Pedicle Screw Construct.

STUDY DESIGN: Biomechanical ex vivo study. OBJECTIVE: To determine if topping off instrumentation can reduce the hypermobility in the adjacent segments when compared with the classic rigid spinal instrumentation. SUMMARY OF THE BACKGROUND DATA: Long rigid instrumentation might increase the mechanical load in the adjacent segments, the resulting hypermobility, and the risk for adjacent segment disease. Topping off instrumentation intends to reduce the hypermobility at the adjacent level by more evenly distributing segmental motion and, thereby, potentially mitigating adjacent level disease. MATERIALS AND METHODS: Eight human spines (Th12-L5) were divided into 2 groups. In the rigid group, a 3-segment metal rod instrumentation (L2-L5) was performed. The hybrid group included a 2-segment metal rod instrumentation (L3-L5) with a dynamic topping off instrumentation (L2-L3). Each specimen was tested consecutively in 3 different configurations: native (N=8), 2-segment rod instrumentation (L3-L5, N=8), 3-segment instrumentation (rigid: N=4, hybrid: N=4). For each configuration the range of motion (ROM) of the whole spine and each level was measured by a motion capture system during 5 cycles of extension-flexion (angle controlled to ±5 degrees, 0.1 Hz frequency, no preload). RESULTS: In comparison with the intact spine, both the rigid 3-segment instrumentation and the hybrid instrumentation significantly reduced the ROM in the instrumented segments (L2-L5) while increasing the movement in the adjacent segment L1-L2 (P=0.002, η=0.82) and in Th12-L1 (P<0.001, η=0.90). There were no ROM differences between the rigid and hybrid instrumentation in all segments. CONCLUSIONS: Introducing the dynamic topping off did not impart any significant difference in the segmental motion when compared with the rigid instrumentation. Therefore, the current biomechanical study could not show a benefit of using this specific topping off instrumentation to solve the problem of adjacent segment disease.

Hybrid Instrumentation in Lumbar Spinal Fusion: A Biomechanical Evaluation of Three Different Instrumentation Techniques.

STUDY DESIGN: Ex vivo human cadaveric study. OBJECTIVE: The development or progression of adjacent segment disease (ASD) after spine stabilization and fusion is a major problem in spine surgery. Apart from optimal balancing of the sagittal profile, dynamic instrumentation is often suggested to prevent or impede ASD. Hybrid instrumentation is used to gain stabilization while allowing motion to avoid hypermobility in the adjacent segment. In this biomechanical study, the effects of two different hybrid instrumentations on human cadaver spines were evaluated and compared with a rigid instrumentation. METHODS: Eighteen human cadaver spines (T11-L5) were subdivided into three groups: rigid, dynamic, and hook comprising six spines each. Clinical parameters and initial mechanical characteristics were consistent among groups. All specimens received rigid fixation from L3-L5 followed by application of a free bending load of extension and flexion. The range of motion (ROM) for every segment was evaluated. For the rigid group, further rigid fixation from L1-L5 was applied. A dynamic Elaspine system (Spinelab AG, Winterthur, Switzerland) was applied from L1 to L3 for the dynamic group, and the hook group was instrumented with additional laminar hooks at L1-L3. ROM was then evaluated again. RESULTS: There was no significant difference in ROM among the three instrumentation techniques. CONCLUSION: Based on this data, the intended advantage of a hybrid or dynamic instrumentation might not be achieved.

Radiation-Induced Intraspinal Chondrosarcoma: A Case Report.

Study Design Case report and review of the literature. Objective To report a unique case of an intraspinal chondrosarcoma that was diagnosed 18 years after radiotherapy for a cervical carcinoma and its remarkably unusual clinical presentation. Methods A retrospective case description of an intraspinal mass lesion that occurred 6 weeks after previous spinal surgery. Results Within ∼9 weeks, the tumor had infiltrated the peritoneal cavity and reached the lumbar subcutaneous tissue. Conclusion Radiation-induced sarcomas are rare, are highly aggressive, and may be difficult to diagnose. Furthermore, the only means of achieving long-term survival is through early and extensive surgery.

Spontaneus bilateral pedicle fracture 30 years after Harrington Instrumentation for idiopathic scoliosis: a case report.

INTRODUCTION: Spontaneous fractures of the spine are a common entity. They usually occur in older people with osteoporosis. This case is presented on account of its rarity. To the best of the authors' knowledge only one case of an osteoporotic pedicle fracture after Harrington Instrumentation has been described before. CASE PRESENTATION: We report the case of a 46-year-old Caucasian woman who underwent surgery due to idiopathic scoliosis with a Harrington Instrumentation (T4 to L3) 30 years ago. During the operation she was infected with hepatitis C while receiving erythrocyte concentrates and has suffered from liver cirrhosis since then. She presented with a sudden pain in her lower back and paraesthesia in both her legs but no other neurological symptoms. A computed tomography scan showed a bilateral pedicle fracture of L3 and an additional compression fracture of L4. In the first session we performed a dorsal stabilization with massive intraoperative bleeding and a postoperative failure of liver synthesis. In a second session an additional ventral augmentation was done. After the second operation she developed a hepatorenal syndrome. Both operations left the patient in a very critical state which led to a prolonged stay in the intensive care and rehabilitation unit. At her 12-month follow-up visit, she was free of complaints. CONCLUSION: The un-physiological load of the spine after Harrington Instrumentation can lead to osteoporosis due to inactivity even in younger patients. Although these implants are not used anymore one should keep this possibility in mind when dealing with patients who have received Harrington rods in surgical procedures.