[Slipped vertebrae (Spondylolysis): the underestimated weak point of the (pre)professional football player-an algorithm]

BACKGROUND

Isthmic spondylolysis represents the most common cause of spinal pain in adolescent athletes. This article provides an overview of the classification, diagnosis, and treatment options for these conditions, including conservative and operative measures. It also provides a treatment pathway to how young athletes with spondylolysis should be treated.

DIAGNOSTICS

Diagnostic imaging techniques are essential for an accurate diagnosis, with CT scans providing additional information for surgical planning.

TREATMENT

Conservative treatment focuses on activity modification and physiotherapy, with a phased approach tailored to individual patient needs. Operative intervention may be considered if conservative measures fail, with minimally invasive techniques such as Buck's screw fixation showing promising results. The decision between conservative and operative management should consider factors of the patients' individual profile. In this paper, we present the first treatment algorithm for the treatment of isthmic spondylolysis. Long-term prognosis varies, with most athletes able to return to sport following treatment.

How Preoperative Closed Reduction and Time to Surgery Impact Postoperative Palmar Inclination in Distal Radius Fractures

Background: The anatomical reconstruction of the wrist is the aim when treating distal radius fractures. Current literature on the importance of preoperative reduction in fractures that are treated operatively is limited. Methods: This study investigated the effect of the preoperative closed reduction of distal radius fractures on the day of trauma and the time to surgery on postoperative palmar inclination. A total of eighty patients (48 females and 32 males, mean age 55.6 years) were studied retrospectively. All patients were treated with an open reduction and internal fixation. The palmar inclination angle was measured using X-rays by two investigators, and the interobservers and pre- and post-reduction parameters were compared. Results: When the surgical management of closed distal radius fractures is required, neither initial repositioning nor a delay of up to 14 days to the surgical treatment influences postoperative palmar inclination. Conclusions: The significance of preoperative reduction of distal radius fractures without neurovascular or extensive soft tissue damage is limited and is not leading to improved outcomes. When surgery is about to be performed, surgeons should carefully consider if reduction is really vital preoperatively. Level of evidence: III.

Economic implications of dural tears in lumbar microdiscectomies: a retrospective, observational study

STUDY DESIGN

Retrospective cohort study. Level of Evidence Level III. Dural tears (DT) are a frequent complication after lumbar spine surgery. With this study we sought to determine the incidence of DT and the related impact on healthcare expenditures after lumbar discectomies. All patients with first-time single level lumbar discectomies at our institution that underwent minimally-invasive surgery from 2015 to 2019 were reviewed. Age, sex, weight, height, body mass index (BMI), costs, revenues, length of stay (LOS), American Society of Anesthesiology (ASA) score, Charlson Comorbidity Index (CCI) and operation time (OT) were assessed. Exclusion criteria were age < 18 years, previous spine surgery, multiple or traumatic disc herniations but also malignant and infectious diseases. The follow-up time was at least 12 months postoperatively. 358 patients with lumbar discectomies were identified and 230 met the inclusion criteria. The DT incidence was 3.5%. The mean costs (p < 0.001), the loss (p < 0.01) and the operation time (p < 0.0001) were found to be significantly higher in the DT group when compared to the control group of patients without a DT. The revenues were not statistically different between both groups (p > 0.05). Further analysis of the control group by profit and loss revealed significantly higher BMI (p < 0.05), LOS (p < 0.0001) and OT (p < 0.0001) in the loss group. DT represent a significant socioeconomic burden in lumbar spine surgery and cause severe secondary complications. The DT-related impact on healthcare expenses is primarily based on significantly higher OT and a higher mean LOS.

Pain alleviation and functional improvement: ultra-early patient-reported outcome measures after full endoscopic spine surgery

OBJECTIVE

Questions regarding anticipated pain improvement and functional recovery postsurgery are frequently posed in preoperative consultations. However, a lack of data characterizing outcomes for the first postoperative days only allows for anecdotal answers. Hence, the assessment of ultra-early patient-reported outcome measures (PROMs) is essential for patient-provider communication and patient satisfaction. The aim of this study was to elucidate this research gap by assessing and characterizing PROMs for the first days after full endoscopic spine surgery (FESS).

METHODS

This multicenter study included patients undergoing lumbar FESS from March 2021 to July 2023. After informed consent was provided, data were collected prospectively through a smartphone application. Patients underwent either discectomy or decompression. Analyzed parameters included demographics, surgical details, visual analog scale scores for both back and leg pain, and the Oswestry Disability Index (ODI) score. Data were acquired daily for the 1st postoperative week, as well as after 2 weeks, 3 months, and 6 months.

RESULTS

A total of 182 patients were included, of whom 102 underwent FESS discectomy and 80 underwent FESS decompression. Significant differences between the discectomy and decompression groups were found for age (mean 50.45 ± 15.28 years and 63.85 ± 13.25 years, p < 0.001; respectively), sex (p = 0.007), and surgery duration (73.45 ± 45.23 minutes vs 98.05 ± 46.47 minutes, p < 0.001; respectively). Patients in both groups reported a significant amelioration of leg pain on the 1st postoperative day (discectomy group VAS score: 6.2 ± 2.6 vs 2.4 ± 2.9, p < 0.001; decompression group: 5.3 ± 2.8 vs 1.9 ± 2.2, p < 0.001) and of back pain within the 1st postoperative week (discectomy group VAS score: 5.5 ± 2.8 vs 2.8 ± 2.2, p < 0.001; decompression group: 5.2 ± 2.7 vs 3.1 ± 2.4, p < 0.001). ODI score improvement was most pronounced at the 3-month time point (discectomy group: 21.7 ± 9.1 vs 9.3 ± 9.1, p < 0.001; decompression group: 19.3 ± 7.8 vs 9.9 ± 8.3, p < 0.001). For both groups, pain improvement within the 1st week after surgery was highly predictive of later benefits.

CONCLUSIONS

Ultra-early PROMs reveal an immediate pain improvement after FESS. While the benefits in pain reduction plateaued within the 1st postoperative week for both groups, functional improvements developed over a more extended period. These results illustrate a biphasic rehabilitation process wherein initial pain alleviation transitions into functional improvement over time.

An investigation into the quality of life improvements after vertebral osteomyelitis depending on the status of pathogen detection

OBJECTIVE

This study aimed to compare clinical characteristics and quality of life (QoL) after vertebral osteomyelitis (VO) based on the status of pathogen detection in microbiological sampling.

METHODS

We conducted a post hoc data analysis from a prospective single-center study in a tertiary referral hospital, including VO patients from 2008 to 2020. Data were collected preoperatively (T0) and 1-year post surgery (T1). The primary outcome was QoL, assessed with the Oswestry Disability Index and Core Outcome Measures Index.

RESULTS

Data from 133 patients with surgically treated thoracic or lumbar VO were evaluated. The pathogen was detected from cultured intraoperative samples in 100 (75.2%) patients (group 1). Culture remained negative in 33 (24.8%) patients (group 2). Quality of life did not differ significantly between the groups at T1. We observed higher preoperative C-reactive protein values and higher rates of spinal empyema at T0 in group 1.

CONCLUSION

Quality of life improved significantly for all patients at T1, but scores remained comparable to those reported by patients with chronic back pain. Quality of life was not affected by pathogen detection. However, attempts to detect pathogens are still indicated due to the concomitant findings, including bacteremia and epidural abscesses, along with the advantages of targeted antibiotic therapy. The most critical step for detection may be avoiding pre-sampling antibiotic administration. Cite this article as: Beyer F, Wenk B, Jung N, Bredow J, Eysel P, Yagdiran A. An investigation into quality of life improvements after vertebral osteomyelitis depending on the status of pathogen detection. Acta Orthop Traumatol Turc., 2024; 10.5152/j.aott.2024.23073 [Epub Ahead of Print].

Assessing the impact of obesity on full endoscopic spine surgery: surgical site infections, surgery durations, early complications, and short-term functional outcomes

OBJECTIVE

An increasing number of obese patients undergoing elective spine surgery has been reported. Obesity has been associated with a substantially higher number of surgical site infections and a longer surgery duration. However, there is a lack of research investigating the intersection of obesity and full endoscopic spine surgery (FESS) in terms of functional outcomes and complications. The aim of this study was to evaluate wound site infections and functional outcomes following FESS in obese patients.

METHODS

Patients undergoing lumbar FESS at the participating institutions from March 2020 to March 2023 for degenerative pathologies were included in the analysis. Patients were divided into obese (BMI > 30 kg/m2) and nonobese (BMI 18-30 kg/m2) groups. Data were collected prospectively using an approved smartphone application for 3 months postsurgery. Parameters included demographics, surgical details, a virtual wound checkup, the visual analog scale for back and leg pain, and the Oswestry Disability Index (ODI) as a functional outcome measure.

RESULTS

A total of 118 patients were included in the analysis, with 53 patients in the obese group and 65 in the nonobese group. Group homogeneity was satisfactory regarding patient age (obese vs nonobese: 55.5 ± 14.7 years vs 59.1 ± 17.1 years, p = 0.25) and sex (p = 0.85). No surgical site infection requiring operative revision was reported for either group. No significant differences for blood loss per level (obese vs nonobese: 9.7 ± 16.8 ml vs 8.0 ± 13.3 ml, p = 0.49) or duration of surgery per level (obese vs nonobese: 91.2 ± 57.7 minutes vs 76.8 ± 39.2 minutes, p = 0.44) were reported between groups. Obese patients showed significantly faster improvement regarding ODI (-3.0 ± 9.8 vs 0.7 ± 11.3, p = 0.01) and leg pain (-4.4 ± 3.2 vs -2.9 ± 3.7, p = 0.03) 7 days postsurgery. This effect was no longer significant 90 days postsurgery for either ODI (obese vs nonobese: -11.4 ± 11.4 vs -9.1 ± 9.6, p = 0.24) or leg pain (obese vs nonobese: -4.3 ± 3.9 vs -3.5 ± 3.8, p = 0.28).

CONCLUSIONS

The results highlight the effectiveness and safety of lumbar FESS in obese patients. Unlike with open spine surgery, obese patients did not experience significant increases in surgery time or postoperative complications. Interestingly, obese patients demonstrated faster early recovery, as indicated by significantly greater improvements in ODI and leg pain at 7 days after surgery. However, there was no difference in improvement between the groups at 90 days after surgery.

Smartphone applications for remote patient monitoring reduces clinic utilization after full-endoscopic spine surgery

INTRODUCTION

The rising number of outpatient spine surgeries creates challenges in postoperative management and care. Telemedicine offers a unique opportunity to reduce in-person clinic visits and improve resource allocation. We aimed to investigate the impact of a validated smartphone application on clinic utilization following full-endoscopic spine surgery (FESS).

METHODS

We evaluated patients undergoing FESS from 2020 to 2022 and a pre-COVID control group (CG) from 2018 to 2019. Subsequently, we divided the patients into three groups: one using the application (intervention group, IG), and two CGs (2020-2022, CG and 2018-2019, historical control group (HG)). We analyzed the post-surgical hospitalization rate, all follow-ups, and virtually transmitted patient-reported outcomes.

RESULTS

A total of 115 patients were included in the IG. The CG consisted of 137 and the HG of 202 patients (CG and HG in the following). Group homogeneity was satisfactory regarding patient age (p = 0.9), sex (p = 0.88), and body mass index (p = 0.99). IG patients were treated as outpatients significantly more often [14.78% vs. 29.2% vs. 37.62% (p < 0.001)]. Additionally, IG patients showed significantly higher follow-up compliance [74.78% vs. 40.14% vs. 37.13% (p < 0.001)] 3-month post-surgery and fewer in-patient follow-up visits [(0.5 ± 0.85 vs. 1.32 ± 0.8 vs. 1.33 ± 0.7 (p < 0.001)].

CONCLUSION

Our results underline the feasibility, efficacy, and safety of remote patient monitoring following FESS. Furthermore, they highlight the opportunity to implement a virtual wound checkup, and to substantially improve postoperative follow-up compliance via telemedicine.

Quality of life in lumbar spinal stenosis: Does it correlate with magnetic resonance imaging and spinopelvic parameters?

Purpose

Degenerative lumbar spinal stenosis (LSS) is a common degenerative spinal disorder with debilitating symptoms that can impact quality of life (QoL). However, the anatomical basis for typical complaints has been poorly quantified. This study aims to correlate QoL assessments of patients with LSS with radiographic spinopelvic parameters and magnetic resonance imaging (MRI) measurements.

Methods

We screened 371 patients hospitalized for LSS and excluded those with a history of spine surgery. Ultimately, we analyzed the data of 34 patients retrospectively. Two independent members of our research group evaluated the alignment parameters on preoperative spinal radiographs, MRI, and classified the images according to the Pfirrmann grading. The spinopelvic alignment was then compared with the clinical QoL scores Core Outcome Measures Index (COMI) and the Oswestry Disability Index (ODI) as collected by the Spine Tango registry. In addition, the interobserver reliability was analyzed.

Results

The individual MRI measurements correlated significantly. This correlation could not be found when compared with the spinopelvic parameters on radiographs. Neither the COMI nor the ODI scores showed a significant correlation with the MRI or radiographic imaging.

Conclusions

The severity of LSS related disability according to QoL questionnaires could not be quantified by any MRI or spinopelvic parameter that was measured. There was also no correlation of the MRI and spinopelvic parameters among themselves. Consequently, treatment recommendations for symptomatic LSS should never be based on radiological data only.

Lessons learned? Increasing injury severity of electric-scooter accidents over a period of one year: a monocentric follow-up study at a level 1 trauma center

PURPOSE

After major COVID-19 lockdown measures were suspended in 2021, E-scooter mobility regrew rapidly. In the meantime, multiple studies were published on the potential risks for e-scooter drivers and the necessity for wearing protective equipment. But did the drivers learn their lessons?

METHODS

We observed data of E-scooter-related accidents admitted to the emergency department of a level 1 German trauma center in the year 2021 and compared the data with our previous report (July 2019-July 2020).

RESULTS

N = 97 E-scooter-related accidents were included, marking a 50% increase when compared to the previous observation. Most patients were young adults (28.18 ± 1.13 years) with a notable shift towards a male population (25 vs. 63, p = 0.007). While the injury pattern remained unchanged, injury severity, reflected by a significant increase in shock room treatments (p = 0.005), hospital admissions (p = 0.45), and ICU admissions (p = 0.028), increased. Lastly, we report a higher injury severity of patients driving under the influence of alcohol, expressed by significant differences in hospital admissions, shock room treatments, ICU admissions, intracerebral bleeding (p < 0.0001), and injuries requiring surgery (p = 0.0017).

CONCLUSION

The increase in injury severity and especially the substantial number of accidents due to driving under the influence of alcohol, are alarming for both trauma- and neurosurgeons. As the controversy surrounding the general use of E-scooters will continue, we urge representatives to intensify their efforts regarding prevention campaigns focusing on the potential dangers of E-scooters, especially when driving under the influence of alcohol.

Spinal Deformity, Surgery at the Cervicothoracic Junction, and American Society of Anesthesiologists Class Increase the Risk of Post-surgical Intensive Care Unit Treatment after Dorsal Spine Surgery: A Single-Center Multivariate Analysis of 962 Patients

STUDY DESIGN

This was a retrospective multivariate analysis of preoperative risk factors leading to intensive care unit (ICU) admissions in patients undergoing elective or acute dorsal spine surgery.

PURPOSE

Numerous studies have predicted a substantial increase in spine surgeries within the next decades, potentially overwhelming hospitals' resources, including ICU occupancy. Accurate estimates of whether patients need postsurgical ICU treatment are pivotal for both resource allocation and patient safety.

OVERVIEW OF LITERATURE

Risk factors leading to ICU admissions after dorsal spine surgery have been extensively examined for lumbar elective surgery. Studies including other anatomical segments of the spine and nonelective surgery regarding postsurgical ICU treatment probability are lacking.

METHODS

This study was designed to be a single-center multivariate analysis of data retrospectively collected from a tertiary care university hospital. Patients undergoing dorsal spine surgery from 2009 to 2019 were included in this study. The patients' demographic data were analyzed to determine potential preoperative risk factors for ICU admission after surgery using multiple logistic regression.

RESULTS

In our cohort, 962 patients with a mean age of 71.1±0.55 years were included. Surgeries involved 3.24±0.08 spinal levels on average. The incidence of ICU treatment after surgery was 30.4% (n=292). Multivariate logistic regression showed a markedly increased odds ratio (OR) for patients undergoing surgery of the cervicothoracic junction (OR, 8.86) and those undergoing surgery for spinal deformity treatment (OR, 7.7). Additionally, cervical procedures (OR, 3.29), American Society of Anesthesiologists (ASA) class 3-4 (OR, 2.74), spondylodiscitis (OR, 2.47), fusion of ≥3 levels (OR, 1.94), and age >75 years (OR, 1.33) were associated with an increased risk of postsurgical ICU admission.

CONCLUSIONS

The findings highlight the relevance of anatomical location, preoperative diagnosis, ASA class, and length of surgery regarding the predictability of postoperative ICU admission. Our data allowed for more sophisticated estimates regarding the need for ICU treatment after dorsal spine surgery, guiding the surgeon through patient selection, communication, and ICU admission predictability.

Quality of Life with Respect to Surgically Treated Vertebral Osteomyelitis and Degenerative Spondylolisthesis

Vertebral osteomyelitis (VO) and degenerative spondylolisthesis (SL) are 2 commonly treated spinal conditions. Therefore, in the presented work, the quality of life after surgical therapy of these 2 entities is compared using established scores.In a monocentric study, all patients with VO and SL were prospectively enrolled using the Spine Tango Registry. Surgical procedures included one- or two-stage fusion of the affected segments. Quality of life was assessed using the Core Outcome Measures Index (COMI) and the Oswestry Disability Index (ODI) at time points t0 (0 months), t1 (12 months), and t2 (24 months). Statistical analysis was performed using SPSS. The level of significance was set at 5%.52 patients with VO and 48 patients with SL were included in the analysis. There were no significant differences in age and gender distribution. The length of stay in the SL group was significantly shorter (p < 0.001). ODI at time t0 was significantly higher in the VO group (p < 0.001), whereas COMI scores did not differ significantly (p = 0.155). At time points t1 and t2, the differences between the VO and SL groups were not significantly different for either the ODI score (p = 0.176; p = 0.250) or the COMI score (p = 0.682; p = 0.640).Postoperative quality of life scores after lumbar fusion surgery in SL and VO are comparable despite different indications and medical conditions. In both groups, similar quality of life with in patient with chronic back pain was achieved. This should be considered for the preoperative assessment, as well as for the indication for surgery in SL.

Remote patient monitoring following full endoscopic spine surgery: feasibility and patient satisfaction

OBJECTIVE

The utilization of telemedicine in healthcare has increased dramatically during the recent COVID-19 pandemic. This study aimed to investigate the feasibility to perform remote patient monitoring after full endoscopic spine surgery via a smartphone application that also allows communication with patients.

METHODS

A smartphone application (SPINEhealthie) was designed at the University of Washington and used to collect patient-reported outcome measures (PROMs) and to provide chat communication between patients and their care team. A total of 71 patients were included in the study and prospectively followed for 3 months postoperatively. Patient demographic characteristics, compliance with surveys, and frequency of chat utilization were recorded. The ease of use, the participants' experiences with the app interface design, and the usefulness of the app were assessed by using the mHealth App Usability Questionnaire (MAUQ).

RESULTS

Of all eligible patients, 71/78 (91.0%) agreed to participate. Of these, 60 (85%) patients provided at least 1 postoperative PROM. There was good coverage of the immediate postoperative period with 45 (63.4%) patients providing ≥ 5 PROMs within the 1st week after surgery. The authors observed a 33.2% increase in patient compliance in postoperative PROMs and a 45.7% increase in chat function utilization between the first and last of the three enrollment periods of the study, during which continuous updates were made to improve the app's functionality. Sixty-two (87.3%) patients responded to the user satisfaction survey after using the app for at least 40 days. The MAUQ results revealed excellent rates of satisfaction for ease of use (78.6% of the maximum score), app interface design (71.4%), and usefulness (71.4%), resulting in a total mean MAUQ score of 110 (74.8%). Communication with the doctor (38 votes) was found to be the top feature of the app. Additionally, physical therapy instructions (33 votes) and imaging review (29 votes) were the top two features that patients would like to see in future app versions. Lastly, the authors have presented a case example of a 68-year-old man who used the app for postoperative monitoring and communication after undergoing a two-level lumbar endoscopic unilateral laminotomy for bilateral decompression.

CONCLUSIONS

Postoperative remote patient monitoring and communication after full endoscopic surgery is feasible using the SPINEhealthie app. Importantly, patients were willing to share their medical information using a mobile device, and they were eager to use it postoperatively as a supplementary tool.

Determining threshold values for success after surgical treatment of lumbar spondylodiscitis using quality of life scores

OBJECTIVE

This study aimed to determine threshold values of validated quality of life (QoL) scores, including Oswestry Disability Index (ODI) and Core Outcome Measures Index (COMI), for predicting a successful outcome following surgical treatment of lumbar spondylodiscitis (LS).

METHODS

Patients with lumbar spondylodiscitis (LS) undergoing surgery in a tertiary referral hospital were included prospectively from 2008-2019. Data were collected both before surgery (T0) and one year after surgery (T1). QoL was measured using ODI and COMI. The successful clinical outcome was defined by the combination of the following four criteria: no recurrence of spondylodiscitis, back pain ≤4 on visual analogue scale or relief of ≥3 points, absence of LS-related neurological deficit, and radiological fusion of the affected segment. For subgroup analysis, group 1 consisted of patients with a favorable treatment outcome (meeting all four criteria), while group 2 included patients with unfavorable treatment outcome (meeting ≤3 criteria).

RESULTS

Ninety-two LS patients (median age = 66 years; age range = 57-74) were analyzed. QoL scores improved significantly. Threshold values for the ODI and COMI were calculated at 35 and 4.2 points, respectively. The area under curve for the ODI was 0.856 (95%-CI 0.767- 0.945; P<0.001) and 0.839 (95% CI-0.749-0.928; P<0.001) for the COMI score. Eighty percent of patients achieved a favorable outcome.

CONCLUSION

Objective measurement and evaluation of successful surgical treatment of spondylodiscitis require defined thresholds of quality of life scores. We were able to define such thresholds for Oswestry Disability Index and Core Outcome Measures Index. These can be useful to assess clinically relevant changes and therefore allow a more precise estimation of the post-surgical outcome.

LEVEL OF EVIDENCE

Level II, Prognostic study.

A decrease in the neuroprotective effects of acute spinal cord decompression according to injury severity: introducing the concept of a ceiling effect

OBJECTIVE

Acute traumatic spinal cord injury (tSCI) is followed by a prolonged period of secondary neuroglial cell death. Neuroprotective interventions, such as surgical spinal cord decompression, aim to mitigate secondary injury. In this study, the authors explore whether the effect size of posttraumatic neuroprotective spinal cord decompression varies with injury severity.

METHODS

Seventy-one adult female Long Evans rats were subjected to a thoracic tSCI using a third-generation spinal contusion device. Moderate and severe tSCI were defined by recorded impact force delivered to the spinal cord. Immediately after injury (< 15 minutes), treatment cohorts underwent either a decompressive durotomy or myelotomy. Functional recovery was documented using the Basso, Beattie, and Bresnahan locomotor scale, and tissue sparing was documented using histological analysis.

RESULTS

Moderate and severe injuries were separated at a cutoff point of 231.8 kdyn peak impact force based on locomotor recovery at 8 weeks after injury. Durotomy improved hindlimb locomotor recovery 8 weeks after moderate trauma (p < 0.01), but not after severe trauma (p > 0.05). Myelotomy led to increased tissue sparing (p < 0.0001) and a significantly higher number of spared motor neurons (p < 0.05) in moderate trauma, but no such effect was noted in severely injured rats (p > 0.05). Within the moderate injury group, myelotomy also resulted in significantly more spared tissue when compared with durotomy-only animals (p < 0.01).

CONCLUSIONS

These results suggest that the neuroprotective effects of surgical spinal cord decompression decrease with increasing injury severity in a rodent tSCI model.

Full-endoscopic spine surgery diminishes surgical site infections - a propensity score-matched analysis

BACKGROUND CONTEXT

Surgical site infections (SSI) are one the most frequent and costly complications following spinal surgery. The SSI rates of different surgical approaches need to be analyzed to successfully minimize SSI occurrence.

PURPOSE

The purpose of this study was to define the rate of SSIs in patients undergoing full-endoscopic spine surgery (FESS) and then to compare this rate against a propensity score-matched cohort from the National Surgical Quality Improvement Program (NSQIP) database.

DESIGN

This is a retrospective multicenter cohort study using a propensity score-matched analysis of prospectively maintained databases.

PATIENT SAMPLE

One thousand two hundred seventy-seven non-instrumented FESS cases between 2015 and 2021 were selected for analysis. In the nonendoscopic NSQIP cohort we selected data of 55,882 patients.

OUTCOME MEASURES

The occurrence of any SSI was the primary outcome. We also collected any other perioperative complications, demographic data, comorbidities, operative details, history of smoking, and chronic steroid intake.

METHODS

All FESS cases from a multi-institutional group that underwent surgery from 2015 to 2021 were identified for analysis. A cohort of cases for comparison was identified from the NSQIP database using Current Procedural Terminology of nonendoscopic cervical, thoracic, and lumbar procedures from 2015 to 2019. Trauma cases as well as arthrodesis procedures, surgeries to treat pathologies affecting more than 4 levels or spine tumors that required surgical treatment were excluded. In addition, nonelective cases, and patients with wounds worse than class 1 were also not included. Patient demographics, comorbidities, and operative details were analyzed for propensity matching.

RESULTS

In the non-propensity-matched dataset, the endoscopic cohort had a significantly higher incidence of medical comorbidities. The SSI rates for nonendoscopic and endoscopic patients were 1.2% and 0.001%, respectively, in the nonpropensity match cohort (p-value <.011). Propensity score matching yielded 5936 nonendoscopic patients with excellent matching (standard mean difference of 0.007). The SSI rate in the matched population was 1.1%, compared to 0.001% in endoscopic patients with an odds ratio 0.063 (95% confidence interval (CI) 0.009-0.461, p=.006) favoring FESS.

CONCLUSIONS

FESS compares favorably for risk reduction in SSI following spinal decompression surgeries with similar operative characteristics. As a consequence, FESS may be considered the optimal strategy for minimizing SSI morbidity.

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.

The influence of orthopedic surgery on the incidence of post-operative delirium in geriatric patients: results of a prospective observational study

Background

Postoperative delirium (PD) is a major concern in geriatric patients undergoing orthopedic surgery. This prospective observational study aims to examine the incidence of PD, to identify intervention-specific risk factors and to investigate the influence of orthopedic surgery on delirium.

Methods

From 2019 to 2020, 132 patients ≥70 years of age with endoprosthetic (Group E) or spinal surgery (Group S) were included. Upon admission, the ISAR score, the Nursing Delirium Screening Scale, potential risk factors, the ASA score, duration of surgery, type of anesthesia, blood loss, and hemoglobin drop were recorded. For risk factor analysis patients were grouped into Group D (delirium) and Group ND (no delirium). Primary endpoint was the occurrence of PD.

Results

Of 132 patients, 50 were included in Group E and 82 in Group S. Mean age and ISAR score were not significantly different between groups. Delirium rate in Group E and S was 12% vs. 18% (p = 0.3). Differences could be observed between Group D and ND in duration of surgery (173 min vs. 112 min, p = 0.02), postoperative hemoglobin drop (3.2 g/dl vs. 2.3 g/dl; p = 0.026), history of PD (23% vs. 11%, p = 0.039) and use of isoflurane (6 vs. 2). Type of surgery was not an independent risk factor (p = 0.26).

Conclusion

Specific type of orthopedic surgery is not an independent risk factor for PD. Prevention of PD should focus on duration of surgery and blood loss, particularly in patients with a history of PD. A possible delirogenic potential of isoflurane should be further studied.

Current Evidence on where to End a Fusion within the Thoracolumbar Junction Most Preferably - A Systematic Literature Review

Proximal junctional kyphosis (PJK) is one main complication in the surgical treatment of adult spinal deformities. Ending within the thoracolumbar junction (TLJ) should but cannot always be avoided to reduce the risk for PJK. With this systematic review we sought to define the most preferable vertebra within the TLJ to minimize the risk for PJK and establish recommendations based on our findings. We conducted a systematic literature review by scanning the MEDLINE database in accordance with the PRISMA criteria. All articles addressing primary long-distance dorsal thoracolumbar fusion of at least three segments to treat adult spinal deformities were included. 1385 articles were identified and three were included to this review. The first study showed significantly higher rates of PJK in patients where the construct was extended to T7 or higher when compared to an ending at T11 to L1. The second article stated that an expansion to the TLJ resulted in significantly less surgical revisions due to PJK reduction. On the other hand, the third article found that a fusion of the whole thoracic spine reduces the PJK incidence postoperatively. Even though the most favorable vertebra within the TLJ to avoid PJK best could not yet be determined, our study identifies several principles that represent the current state of evidence for surgical treatment of adult scoliosis. Proper preoperative decision making based on thorough analysis and interpretation of the patient's sagittal alignment parameters can improve the individual outcome critically.

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 (r_s = −0.515, P < 0.05) and the sagittal rotation (r_s = −0.545, P < 0.05). The sacral slope was significantly associated with the sacral inclination (r_s = 0.637, P < 0.01) and the pelvic incidence (r_s = 0.500, P < 0.05). In addition, the pelvic incidence showed a significant correlation with the pelvic tilt (r_s = 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.

The Burden of Vertebral Osteomyelitis—An Analysis of the Workforce before and after Treatment

Although vertebral osteomyelitis (VO) has a major impact on morbidity, functional status, and quality of life, data concerning the influence on the patient’s ability to work (ATW) are lacking. Therefore, the aim of this study was to analyze the work status after VO-treatment as well as risk factors associated with loss of the ATW. We conducted a post-hoc analysis of data from a prospective VO-registry (2008–2019) supplemented by workforce data. Primary endpoint was the work status after one year (T1). Univariate analysis comparing patients’ characteristics “at-work” versus “not-at-work” at T1 was performed. Of a total of 335 VO-patients, n = 52 (16%) were part of the workforce at time of diagnosis (T0), of which 22 (42%) failed to be part of the workforce at T1. A higher number of comorbidities and a body mass index (BMI) < 25 kg/m² were associated with a reduced ATW. VO in working age patients is a debilitating condition and associated with reduced patients’ ATW. Patients engaged in heavy physical work mostly had a BMI < 25 kg/m² and therefore were more severely affected and no longer able to keep their workforce. More support in retraining should be offered after successful treatment to maintain ATW and reduce the socio-economic burden.

Clinical outcome after lumbar spinal fusion surgery in degenerative spondylolisthesis: a 3-year follow-up

INTRODUCTION

Lumbar spinal fusion surgery is a widely accepted surgical treatment in degenerative causes of lumbar spondylolisthesis. The benefit of reduction of anterior displacement and restoration of sagittal parameters is still controversially debated. Purpose of the underlying publication was to analyze the influence of radiographic sagittal parameters of the spine in aspects of changes in postoperative clinical outcome.

MATERIALS AND METHODS

By prospective analysis, we included patients with low-grade degenerative lumbar spondylolisthesis (Meyerding grades I and II) with mono- or bisegmental fusion surgery with a minimum follow-up data of 3 years. For clinical outcome measures, COMI, ODI and EQ-5D were used. Spinopelvic parameters (sacral inclination, pelvic tilt, sacral slope and pelvic incidence, lumbar lordosis and lumbar index as well as anterior displacement and sagittal rotation) were measured on plain radiographs.

RESULTS

We could observe a significant benefit in clinical outcome after lumbar fusion surgery in low-grade spondylolisthesis in our mid-term follow-up data including 32 patients. By surgical reduction, we could see significant restoration of anterior displacement and sagittal rotation. Interestingly, a significant correlation between restoration of both sagittal rotation and sacral inclination and clinical outcome score was observed in the 3-year follow-up.

CONCLUSION

In low-grade spondylolisthesis, spinal fusion surgery is a well-established surgical procedure; however, the impact of sagittal parameters and reduction of anterior displacement remains controversial. Within our findings, restoration of sagittal parameters showed significant correlation to improvement in clinical outcome in our mid-term follow-up data.

Suggestion of a safe zone for C1 pedicle screws depending on anatomical peculiarities

OBJECTIVE

For surgical treatment of instable upper cervical injuries, the Harms technique using lateral mass screws provides rigid fixation and favourable clinical outcomes. The use of the posterior arch of C1 as a "pedicle" allows for screw anchorage, giving improved biomechanical stability. Therefore, the aim of this study was to introduce a bilateral safe zone for C1 pedicle screws, regarding screw angulation and pedicle height.

MATERIAL AND METHODS

We retrospectively reviewed the CT scans of 500 patients. Three-dimensional reformats were generated for detailed measurements. Centre screw entry point (EP), length of lateral mass as screw trajectory, lateral mass width (LMW), length of screw trajectory (ST), maximal divergence (DI) and maximal convergence (CON) from EP without perforation, and pedicle height (PH) of the posterior arch were measured.

RESULTS

The 500 cases consisted of 335 males and 165 females, with a mean age of 49.5 years. Measurements did not demonstrate significant side-related differences. The mean screw entry point was 22.8 mm from the midline-axis (left 22.6 mm; right 23.0 mm). From this point, a safe zone between 11.6° of divergence and 19.6° of convergence was detected. Measurements of female patients were generally smaller, with significant differences from male patients (p < 0.05). 158 subjects (31.6%) had a PH < 4 mm.

DISCUSSION

C1 pedicle screws were feasible in the majority of patients. Proposing a safe zone for screw angulation may provide safety and avoid screw perforation. However, detailed knowledge of the individual C1 anatomy and the preoperative measurement is essential in the operative planning.

The role of the transversal ligament on the atlantoaxial complex - Bending forces at C1/2 flexion limits in the elderly

INTRODUCTION

Biomechanical functionality as well as trauma mechanisms of the atlantoaxial complex are still an issue of controversy. The transverse atlantal ligament is the strongest stabilizator. The present study aimed to analyze the bending forces of the transverse atlantal ligament and of the base of the odontoid in elderly specimens.

METHODS

In this biomechanical study five cadaveric specimen with a mean age of 72 at death and bone mineral density measuring for 555.3 Hounsfield units on average were used. To analyze the strain of the transverse atlantal ligament and the dense base, strain gauges were used. A custom biomechanical setup was used to test each specimen at C1/2 flexion and the strain of the transverse atlantal ligament and the dens base (μm/m) were measured.

FINDINGS

In four out of five, a rupture of the transverse atlantal ligament was observed, the mean force required for the ligament to fall was 175 N (min. 99.8 N; 249.2 N; SD 64.7) by a mean strain of 2102.9 μm/m (min. 1953.5 μm/m; max. 2272.3 μm/m; SD 189.7). In one specimen with the lowest Hounsfield units (155), the dens base fractured before the transverse atlantal ligament ruptured and no strain could be measured at the transversal ligament during movement afterwards.

INTERPRETATION

The transverse atlantal ligament fails at an average of 175 N in the elderly, which is less than the value reported previously. In osteoporotic specimen the generated force to rupture the transverse atlantal ligament can fracture the dens itself.

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.

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.

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% F_max).

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 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.

Lumbar spinal fusion of low-grade degenerative spondylolisthesis (Meyerding grade I and II): Do reduction and correction of the radiological sagittal parameters correlate with better clinical outcome?

INTRODUCTION

Lumbar and lumbosacral spinal fusion is an established procedure for the treatment of degenerative spondylolisthesis. However, the impact of reduction in the affected segment and of improvement in the radiological sagittal parameters on the clinical outcome remains unclear. Purpose of the study is to analyze the correlation between the radiological sagittal parameters and clinical outcome after lumbar spinal fusion in low-grade degenerative spondylolisthesis.

MATERIALS AND METHODS

In a monocentric prospective, clinical study, patients with low-grade degenerative spondylolisthesis of a single lumbar segment have been included. All patients received a lumbar spinal fusion according to the pathology of the treated segment. Patients attended clinical and radiological follow-up examination 1 and 2 years postoperatively. Clinical outcome was assessed using the Core Outcome Measurement Index (COMI), the Oswestry Disability Index (ODI) and the EuroQol 5D. The sagittal spinopelvic radiological parameters, sagittal rotation and anterior displacement of the affected segment and lumbar lordosis were assessed. The correlation between the sagittal radiological parameters and clinical outcome was analyzed using Spearman-Rho bi-serial test.

RESULTS

Sixty-two patients (35 female and 27 male) with an average age of 59.3 years were included in the study. All patients completed the follow-up examinations. Significant improvement in COMI, ODI and EuroQol 5D scores was shown in all follow-up examinations. Significant reduction in the anterior displacement was measured postoperatively, which was preserved during the follow-up. However, no correlation could be demonstrated between reduction in anterior displacement and improvement in clinical outcome. Nonetheless, correlation between correction of sagittal rotation and clinical outcome was shown.

CONCLUSIONS

Reduction in anterior displacement of the affected segment in the surgical treatment of low-grade degenerative spondylolisthesis does not have an impact on the clinical outcome.

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 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.

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.

The sacral screw placement depending on morphological and anatomical peculiarities

PURPOSE

Various pathologies of the lumbosacral junction require fusion of the L5/S1 segment. However, pseudarthroses, which often come along with sacral screw loosening, are problematic. The aim of the present investigation was to elaborate the morphological features of the L5/S1 segment to define a so-called "safe zone" for bi- or tricortical screw placement without risking a damage of the iliac vessels.

METHODS

A total of one hundred computed tomographies of the pelvis were included in this investigation. On axial and sagittal slices, pedicle morphologies, the prevertebral position of the iliac vessels, the spinal canal and the area with the largest bone density were analyzed.

RESULTS

Beginning from the entry point of S1-srews iliac vessels were located at an average angle of 7° convergence, the spinal canal at 38°. Bone density was significantly higher centrally with a mean value of 276 Hounsfield Units compared to the area of the Ala ossis sacri. The largest intraosseous screw length could be achieved at an angle of 25°. The average pedicle width was 20 mm and the pedicle height 13 mm.

CONCLUSIONS

A "safe-zone" for bicortical screw placement at S1 with regard to the course of the iliac vessels could be defined between 7° and 38° convergence. Regarding the area offering the largest bone density and the maximal possible screw length, a convergence of 25° is recommended at S1 to reduce the incidence of screw loosening. Screw diameter, as a further influence factor on screw holding, is limited by pedicle height not pedicle width.

Evaluation of Absorbent Versus Conventional Wound Dressing

BACKGROUND

Lower-limb endoprosthetic operations and spinal operations are among the more common types of orthopedic procedures. Postoperative woundhealing disturbances and infections can lead to longer periods of hospital stay and recovery as well as to higher morbidity and mortality.

METHODS

209 patients who had been judged to have an indication for a primary knee or hip endoprosthesis or for a primary spinal operation were included in this randomized trial (ClinicalTrials.gov: NCT01988818) over the period June 2014- February 2015. After randomization, patients in the intervention group were given a trial dressing (Mepilex-Border Post-Op) and those in the control group were given a conventional adhesive dressing (Cosmopor). The primary endpoint was blister formation.

RESULTS

In the overall study population, only a single case of blister formation was seen. The affected patient belonged to the intervention group but was mistakenly given a control dressing and developed blisters on the 6th day after surgery. Dressings were changed less frequently in the intervention group, and this difference was statistically significant (p<0.001). The patients, nurses, and physicians all expressed greater satisfaction with the trial dressings than with the control dressings (p<0.001).

CONCLUSION

The intervention group did not differ from the control group with respect to the primary endpoint, postoperative blister formation. The patients, nurses, and physicians all judged the dressing used in the intervention group more favorably than the conventional dressing.

[Postoperative management of weight bearing and rehabilitation after lumbar spinal surgery]

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.

First results of multicortical screw anchoring compared with conventional bicortical screw placement in the sacrum: A biomechanical investigation of a new screw design

BACKGROUND

Bicortical screw fixation is an established technique to increase screw strength in vertebral bodies, although it is associated with several complications, for example screw-loosening. Cement augmentation can increase stability of screw-fixation but can also cause various complications, such as cement-leakage or cement embolism. In this study, we tested a new, multicortical screw fixation technique in the sacrum.

METHODS

Four fresh-frozen sacrums were used. In group 1, standard screw insertion, with sagittal parallel and axial convergent screw-drive was performed. In group 2, the screw-drive of the first screw was similar to the screw-drive in group 1. In addition, a second screw was inserted descending into the intended hole in the head of the screw and at a stable angle. Therefore, the screws of the multiloc humerus nail-system (Synthes) were used. The specimens were connected to a testing-machine and underwent cyclic axial loading with an increase in the load after each completed stage.

FINDINGS

Multicortical screw fixation leads to a significant increase in the number of completed cycles and a significantly increased load until failure.

INTERPRETATION

Multicortical screw fixation in the sacrum offers a stronger attachment of the screws. In the future, multicortical implants, which fulfil the criteria demanded in spine surgery, can offer higher stability and may decrease the loosening rates of the implanted screws.

Correction to: Does increased femoral antetorsion predispose to cartilage lesions of the patellofemoral joint?

Unfortunately, the following reference was not included in the original publication of the article.

Injuries in equestrian vaulting: results of a prospective study

BACKGROUND

Equestrian vaulting is a sport, particularly popular among children and adolescents, in which gymnastic and dance routines are performed on horseback. Current data regarding injuries and thus, the risks of this sport, is meager and based only on retrospective studies.

METHODS

In the current prospective study, 233 active members of a vaulting club were questioned monthly from November 2014 until October 2015. In addition to general information (training, competitions), the questionnaire collected the number of competitions, the competitive class, the discipline (single, team, Pas-de-Deux), and injuries (type, localization, treatment).

RESULTS

There were 102 documented events resulting in 125 injuries, yielding an average 31.64 days of training lost. Each vaulter suffered an average 0.44 injuries per year. Frequency of injury was 2.15 injuries per 1000 training hours. Injuries occurred most often to the lower and upper extremities. Most common were bruises and muscle injuries. Injury risk increased with increasing age, number of falls from the horse, increasing competitive level, number of tournament entries and events (P=0.006), and previous injuries (P=0.010).

CONCLUSIONS

Our study found that vaulting has a low risk of injury comparable to non-contact sports. The best focus for injury prevention strategies is on older vaulters at higher competitive levels performing more complex routines.

Biomechanical Comparison of Fixation With a Single Screw Versus Two Kirschner Wires in Distal Chevron Osteotomies of the First Metatarsal: A Cadaver Study

Distal chevron osteotomy is a common procedure for surgical correction of hallux valgus. Osteosynthesis with 1 screw or 2 Kirschner wires has been commonly used. We compared the stability of the 2 techniques in distal chevron osteotomy. Sixteen first metatarsals from fresh-frozen human cadaver feet (9 different cadaveric specimens) were used. A standardized distal chevron osteotomy was performed. One first metatarsal from each pair was assigned to group 1 (3.5-mm cortical screw; n = 8) and one to group 2 (two 1.6-mm Kirschner wires; n = 8). Using a materials testing machine, the head of the first metatarsals was loaded in 2 different configurations (cantilever and physiologic) in succession. In the cantilever configuration, the relative stiffness of the osteosynthesis compared with intact bone was 59% ± 27% in group 1 and 68% ± 18% in group 2 (p = .50). In the physiologic configuration, it was 38% ± 25% in group 1 and 35% ± 7% in group 2 (p = .75). The failure strength in the cantilever configuration was 187 ± 105 N in group 1 and 259 ± 71 N in group 2 (p = .21). No statistically significant differences were found in stability between the 2 techniques. The use of 1 screw or 2 Kirschner wires had no significant differences in their biomechanical loading capacity for osteosynthesis in distal chevron osteotomies for treatment of hallux valgus.

Influence of calibration on digital templating of hip arthroplasty

INTRODUCTION

Digital templating for total joint replacement is the current standard. For image calibration, external calibration markers (ECM) are used. However, there are concerns regarding the precision of the method. This study aimed to identify the direct influence of calibration errors on digital templating.

PATIENTS AND METHODS

A retrospective analysis of 100 post-operative radiographs with unilateral total hip arthroplasty was performed. The magnification factor of the ECM and of the internal prosthetic femoral head (ICM) as a reference value was calculated for each radiograph. Two blinded observers performed templating of the contralateral hip using a randomized list for all radiographs and both markers. The component size templated by the ECM magnification was compared to the reference by the ICM magnification.

RESULTS

Mean magnification factors of ICM and ECM differed significantly (p = 0.006). The absolute difference was 5.2% (range 0.0-23.3%, SD 4.8%). Templating of the acetabular or the femoral component showed no significant differences (p = 0.120, p = 0.599). Differences of more than one size were found in 26% of the acetabular components and 14% of the femoral components and differences over two sizes in 10% respectively 3%. Correlation coefficients for magnification error and size differences of acetabular components were - 0.645 (p < 0.001) and for the femoral component - 0.607 (p < 0.001).

INTERPRETATION

The calibration error of external calibration markers in digital templating for hip replacement influences component sizes significantly. Thus, correct positioning of ECM is of utmost importance.

Factors affecting operative time in primary total hip arthroplasty: A retrospective single hospital cohort study of 7674 cases

BACKGROUND

Total hip arthroplasty (THA) is one of the most common orthopedic procedures in developed countries, and the high volume of surgery and the socioeconomic burden of failures demand continuous optimization. Operative time has been identified as a significant independent factor influencing the clinical outcome of THA.

OBJECTIVE

The aim of this study was to analyze factors influencing the operative time for THA in a large, single-center cohort.

METHODS

A consecutive series of 7,674 cases undergoing primary THA was identified, and after multiple imputation of missing values, univariable and multivariable linear regression analyses were performed.

RESULTS

In the univariable analysis, all factors showed significant influences on operative time, while multivariable regression analysis revealed that sex, a diagnosis of hip dysplasia and small femoral component size did not reach significance. Younger age, an underlying diagnosis other than osteoarthritis or hip dysplasia, a large stem size, usage of a conventional stem rather than a short stem, a larger cup size and a cemented fixation technique, however, remained significantly influential in terms of a longer operative time.

CONCLUSIONS

This study identified risk factors for longer operative time that in turn is associated with a higher rate of periprosthetic joint infection and impaired clinical outcome. Our findings could help to refine scheduling of total hip arthroplasty procedures in times of increasing cost and efficiency pressure.

Dual-position calibration markers for total hip arthroplasty: theoretical comparison to fixed calibration and single marker method

PURPOSE

Digital templating is considered a standard for total hip arthroplasty. Different means for the necessary calibration of radiographs are known. While single marker calibration with radiopaque spheres is the most common, it is associated with possible significant deviations from the true magnification of the hip. Notably, fixed magnification factors showed better results. Therefore, a dual-position calibration marker method was simulated and compared to the established methods.

METHODS

First, an empirical fixed magnification factor was identified and applied to a series of radiographs. Second, three magnification factors were generated based on sagittal patient data of 398 CT scans. These methods were compared to the fixed factor.

RESULTS

The fixed factor was 122.6%. In the clinical application, the error of the fixed factor was 2.5% while the error of the single marker was 5.2%. In the CT cohort, the mean reference factor was 120.5% in females and 120.3% in males. The reference factor was compared to sex-specific means, sex-specific linear functions, and sex-specific cubic functions. The best results were found for the linear regression model with a mean difference of 0.8% from the reference value. No proportional bias was found (p = 0.623).

CONCLUSION

The simulation of the dual-position marker method using the linear regression model showed promising results, superior to all other methods. In future studies, its clinical application should be tested.

Recovery-test or immunoradiometric measurement of anti-thyroglobulinautoantibodies

The determination of thyroglobulin (Tg) in the follow-up of differentiated thyroid carcinomas (DTC), is routinely used in nuclear medicine, although some problems, like a disturbed recovery-test (RT) or autoantibodies to thyroglobulin (TgAb), are well known. But it is a controversial issue in literature, whether the determination of TgAb should be performed beside or instead of the RT. Objective: The study compares the clinical value of the determination of both TgAb and RT with sensitive assays. Methods: 356 patients (pts) were investigated. The results were compared to the concentration of Tg in the sera of the pts. 288 pts stayed tumor-free, the remaining 68 pts showed a recurrence (local and/or metastatic) of their DTC. We measured Tg (with RT) using an immunoradiometric assay (Tg-IRMA; SELco® Tg; Fa. Medipan Diagnostica GmbH) and TgAb using a direct assay (CentAK® anti-Tg; also from Fa. Medipan). Results: The prevalence of TgAb, and of disturbed RT respectively, in the whole population of DTC-pts was 7,6%, in the subgroup of tumor-free pts 6,6%, and in the remaining pts with tumor-recurrence 11,8%, respectively 2,0%, 1,7% and 2,9%. In a significantly higher percentage of pts with local/metastatic recurrence, both a positive TgAb (p <0,001) and a disturbed RT (p <0,05) were found. 7/68 pts with tumor-recurrence but Tg <1 ng/ml showed positive TgAb, only 2/7 had a disturbed RT. In this group, no patient with Tg >1 ng/ ml demonstrated either positive TgAb or disturbed RT (p <0,001 and p <0,05). Conclusion: The determination of TgAb in the follow-up of DTC is necessary, because it supports a suspicion to tumor-recurrence in pts with negative Tg. Also the RT is of great value because of a possibly High dose hook-effect.

Therapy of malignant ascites in vivo by 211At-labelled microspheres

Aim: Determination of the biological effect of the alpha emitter 211At on cellular level as well as the assessment of dosimetric data in a tumour model in vivo. Methods: Transplantation of malignant ascitic cells in mice intraperitoneally and estimation of tumour characteristics (doubling time of the cells, mean survival of the animals following an i.p. application of a defined tumour cell number). 211At labelled human serum albumine microspheres B-20 (MSP) of variing activity were injected into tumour bearing mice intraperitoneally. The effectiveness of the therapy was evaluated by means of determination of the duration of cell cycle arrest as well as the microscopic analysis of the rate of abnormal mitotic cells due to radiation induced damage. Furthermore, dose dependence of survival was evaluated. Results: Three days following the intraperitoneally application of 8 x 106 tumour cells, 50-600 kBq 211At-MSP were applied into the abdominal cavity. Considering the volume of ascites at this time and the administered activity, dose calculations were performed. An activity of 50 kBq caused a dose of 0.84 Gy. The increase of radiation induced effect on ascitic tumour cells was correlated with the dose. Between the duration of the cell cycle arrest and the administered activity, a directly proportional correlation was found. The mean survival of non-treated animals was 16.9 ± 3.7 days. The prolongation of the survival was proportional to the activity administered. Using a dosage of 10 Gy, five animals out of 16 survived. Conclusion: Therapy of malignant ascitic cells using 211At-MSP was effective in vivo. For tumour therapy, the 211At represents a highly effective alternative to usually applied beta emitters.

[Influence of Osseous and Ligamentous Injuries on the Stability of the Atlantoaxial Complex]

Background The odontoid process and the transverse ligament are the most important structures stabilising the atlantoaxial complex. It has not been fully elucidated how injuries of these structures contribute towards instability and a potential narrowing of the spinal canal. Therefore, our investigation aimed to perform a biomechanical analysis of spinal width and dislocation of the odontoid process depending on injuries of the aforementioned structures. Methods In 10 fresh human cadaveric specimens, physiologic flexion and extension were simulated under fluoroscopy in intact specimens and after application of an odontoid process fracture and transverse ligament rupture in a crossover design. The width of the spinal canal and the dislocation of fragments were measured. Results In the intact condition, values of 19.8/19.5/19.8 mm (neutral/flexion/extension) were observed regarding spinal width. After an isolated fracture, values were 18.5/18.9/17.9 mm. With additional ligamentous injury, values changed to 20.3/19.4/22.6 mm. In the second group, values after initial ligament injury were 18.6/16.2/17.3 mm and 16.6/14.1/18.7 mm after fracture. Dislocation of fragments after an isolated fracture averaged 2.2/2.5/2.5 mm; an additional ligamentous injury led to 2.6/2.2/2.2 mm. In the second group, where a ligamentous injury preceded the fracture, a dislocation of 1.5/1.9/3.5 mm was detected after the fracture. Conclusion Neurological disorders have been observed starting at a spinal canal constriction of 2.0 mm. Our results demonstrate that a relevant constriction of the spinal canal may be due to isolated or combined injuries of the bone and the transverse ligament. Furthermore, our results show the importance of posttraumatic immobilisation of the spine with a view to the role of the transverse ligament for stabilisation of the atlantoaxial complex.

Non-operative treatment of lumbar spinal stenosis

BACKGROUND AND OBJECTIVE

Non-operative treatment is widely accepted for early stages of lumbar spinal stenosis. In general, a trial of conservative treatment is recommended prior to surgery. However, there is an ongoing debate regarding benefits from non-operative treatment and their duration.

METHODS

Thirty-eight patients were included in this prospective study. All patients received repeated epidural injections and facet joint injections as well as physiotherapy during a one week hospitalization. Patient characteristics, VAS scores, COMI and ODI scores and SF-36 were assessed prior to and immediately after treatment as well as after six, twelve, and 26 weeks. For six weeks after treatment, patients were asked to record a pain diary.

RESULTS

Back and leg pain scores improved significantly on VAS up to three months follow-up. COMI score improved significantly over the entire follow-up. Regarding quality of life, mental sub-scores showed no improvement. Physical component summary scores improved for the first three months.

CONCLUSIONS

Non-operative treatment offers pain relief and improves physical function for three months. COMI scores improve up to six months follow-up. Spine Tango registry offers standardized instruments for outcome evaluation of non-operative treatment.

Lebensqualität und funktionelles Ergebnis nach mikrochirurgischer Dekompression bei lumbaler Spinalkanalstenose – eine Registerstudie

Einleitung Die lumbale Spinalkanalstenose (SKS) hat sich in den letzten Jahren durch die gestiegene Lebenserwartung und die höheren Ansprüche an die Lebensqualität zu einer der häufigsten degenerativen Wirbelsäulenveränderungen entwickelt. Bei therapierefraktären Patienten der konservativen Therapie ist die mikrochirurgische Dekompression der Goldstandard in der operativen Behandlung der degenerativen lumbalen Spinalkanalstenose. Ziel der vorgelegten Studie ist die Bewertung der Lebensqualität nach mikrochirurgischer Dekompression bei lumbaler Spinalkanalstenose anhand der Instrumente des DWG-Registers (vorher Spine Tango).

Methode 36 Patienten wurden in diese monozentrische prospektive Beobachtungsstudie von Januar 2013 bis Juni 2014 eingeschlossen. Die Datenerhebung erfolgte über das Spine Tango- bzw. DWG-Register. Es wurden der Core Outcome Measure Index (COMI), Oswestry Disability Index (ODI) und der Lebensqualitätsfragebogen EuroQoL-5D erhoben. Dies erfolgte vor der Operation sowie 6 Wochen, 6 Monate und 12 Monate nach der Operation.

Ergebnisse Im untersuchten Kollektiv fanden sich 13 weibliche und 23 männliche Patienten (36,1 vs. 63,9 %). Für 21 Patienten konnte ein vollständiges Follow-up über den 12-Monats-Zeitraum erhoben werden. Der COMI-Score besserte sich von 8,1 ± 1,5 präoperativ signifikant über das gesamte Follow-up (6 Wochen: 4,5 ± 3,1 (p < 0,001), 6 Monate: 4,8 ± 3,1, 12 Monate: 3,8 ± 3,2). Auch die Beeinträchtigung der Rückenfunktion gemessen im ODI-Score war gegenüber den präoperativen Werten (47,5 ± 17,3) nach 6 Wochen (29,1 ± 22,4; p < 0,005), 6 Monaten (30,0 ± 19,3) und 12 Monaten (23,8 ± 18,2) signifikant besser. Gleichermaßen verhielt es sich mit der Lebensqualität (präoperativ: 0,36 ± 0,38; 6 Wochen: 0,57 ± 0,34 (p < 0,019), 6 Monate: 0,62 ± 0,28, 12 Monate: 0,67 ± 0,31).

Schlussfolgerung Unsere Untersuchung zeigt, dass Patienten ohne Voroperationen und neurologisches Defizit mit lumbaler Spinalkanalstenose eine erhebliche Linderung von Schmerzen und eine Steigerung der Lebensqualität bereits nach 6 Wochen nach stabilitätserhaltender Dekompression erwarten dürfen. Dieser positive postoperative Effekt zeigt sich über 12 Monate weiter progredient. Das DWG-Register bietet eine standardisierte und validierte Möglichkeit, konservative wie operative Behandlungen an der Wirbelsäule langfristig vergleichbar zu machen.