Archibald von Strempel

Die vordere Wirbelsäulenbegradigung mit der ventralen Derotationsspondylodese (VDS) nach Zielke

OperationsprinzipDurch Resektion der Bandscheiben wird die Wirbelsäule im Bereich einer skoliotischen Deformität gelockert. Die Korrektur der Seitverbiegung erfolgt durch Verkürzung der Konvexität, die Korrektur der rotatorischen Komponente durch Entwringung der Wirbelsäule in der Horizontalebene mit Hilfe eines speziellen Instrumentariums. Eine großflächige, interkorporelle Spondylodese sichert ein langfristiges Korrekturergebnis.

Dynamische dorsale Stabilisierung mit dem Cosmic-System

OBJECTIVE Stabilization of unstable motion segments with a stable but non-rigid implant system without an additional spondylodesis. INDICATIONS Neurogenic claudication with instability; discogenic pain; in combination with a fusion (hybrid technique); elongation of a preexisting fusion; second recurrence of a herniated disk. CONTRAINDICATIONS Increased instability; correction and reduction; instrumentation of more than three levels. SURGICAL TECHNIQUE Muscle-sparing approach to the posterior lumbar spine under anteroposterior and lateral image control. Use of special instruments with a slotted sleeve connected to the screw head for rod implantation. Alternatively: conventional midline approach with detachment of muscles from the posterior spine. POSTOPERATIVE MANAGEMENT Mobilization on the day after surgery. Limited physical activities and no work load for 6 weeks. RESULTS In 139 patients (77 females, 62 males, average age 55 years) with a follow-up of 2 years, Oswestry score improved from 49.0% preoperatively to 22.5% and VAS (visual analog scale) from 7.3 preoperatively to 2.5 after 2 years. No change of the lordosis. Eleven revisions (7.9%). Two broken screws (0.3%) and 17 screws (2.5%) with a radiolucent halo.ZusammenfassungOperationszielStabilisierung von instabilen Bewegungssegmenten mit Hilfe eines stabilen, aber nicht rigiden Implantatsystems ohne zusätzliche Spondylodese.IndikationenClaudicatio spinalis mit Segmentinstabilität; diskogener Schmerz; in Kombination mit einer Spondylodese (Hybridtechnik); Verlängerung einer vorbestehenden Spondylodese; zweites Rezidiv einer Bandscheibenherniation.KontraindikationenMakroinstabilität; Korrektur und Reposition; Instrumentation über mehr als drei Segmente.OperationstechnikMuskelschonender Zugang zur dorsalen Lendenwirbelsäule unter anteroposteriorer und lateraler Bildverstärkerkontrolle. Verwendung eines speziellen Instrumentariums mit auf die Schrauben gesteckten Hülsen zur Stabimplantation. Alternativ: Konventioneller Zugang mit Ablösen der Muskulatur von den dorsalen Wirbelsäulenstrukturen.WeiterbehandlungMobilisation am 1. postoperativen Tag. Körperliche Schonung und Arbeitsruhe für 6 Wochen.ErgebnisseBei 139 Patienten (77 Frauen und 62 Männer in einem durchschnittlichen Alter von 55 Jahren) verbesserten sich der Oswestry-Score von präoperativ 49,0% auf 22,5% und die analoge zehnteilige Schmerzskala von präoperativ 7,3 auf 2,5 nach 2 Jahren. Keine Veränderung der Lordose. Elf Revisionsoperationen (7,9%). Zwei gebrochene Schrauben (0,3%) und 17 Schrauben (2,5%) mit radiologischer Saumbildung.AbstractObjectiveStabilization of unstable motion segments with a stable but non-rigid implant system without an additional spondylodesis.IndicationsNeurogenic claudication with instability; discogenic pain; in combination with a fusion (hybrid technique); elongation of a preexisting fusion; second recurrence of a herniated disk.ContraindicationsIncreased instability; correction and reduction; instrumentation of more than three levels.Surgical TechniqueMuscle-sparing approach to the posterior lumbar spine under anteroposterior and lateral image control. Use of special instruments with a slotted sleeve connected to the screw head for rod implantation. Alternatively: conventional midline approach with detachment of muscles from the posterior spine.Postoperative ManagementMobilization on the day after surgery. Limited physical activities and no work load for 6 weeks.ResultsIn 139 patients (77 females, 62 males, average age 55 years) with a follow-up of 2 years, Oswestry score improved from 49.0% preoperatively to 22.5% and VAS (visual analog scale) from 7.3 preoperatively to 2.5 after 2 years. No change of the lordosis. Eleven revisions (7.9%). Two broken screws (0.3%) and 17 screws (2.5%) with a radiolucent halo.

Die einzeitige kombinierte Vertebrektomie bei Tumoren der Stammwirbelsäule

GOAL OF SURGERY Resection of tumor as complete as possible without injury to the spinal cord or nerve roots. Maintenance of stability of the spinal column. INDICATION Painful instability or imminent quadriplegia due to primary and secondary malignant tumors. CONTRAINDICATION Multiple metastases, poor general health. POSITIONING AND ANAESTHESIA Lateral, followed by a knee-chest position. SURGICAL TECHNIQUE Through a standard approach for a left thoracophrenotomy resection of the involved vertebra, decompression of the dural sack, insertion of an adjustable intervertebral spreader which will maintain the distance between the vertebrae and serve as replacement for the removed vertebra. After turning the patient into prone position transpedicular fixation of the vertebral segment. (Example is given for resection of the first lumbar vertebra.) POSTOPERATIVE MANAGEMENT: Regular control of sensory and motoric nerve function of the limbs hourly on the day of surgery and two hourly on 1. and 2. postoperative day. Removal of drains 2 to 3 days postoperatively. Pharmacological stimulation of bowels. Daily radiographic control of chest till 1 day after the removal of drains. Mobilization within 1 week without corset. POSSIBLE COMPLICATIONS Injury to lungs, ureters, large vessels, intestines, lumbar plexus, dura, and plexus sympathici. Haemothorax, Chylothorax, Infection. RESULTS Between 1982 and 1993 thirty-seven patients underwent vertebral resection of tumors. For analysis of retrospective results refer to Tables 1 to 3. Average surgical blood loss: 2378 ml (800 to 6500). Average duration of surgery: 238 minutes (120 to 550). COMPLICATIONS 2 bronchopneumonia, 2 deep infections, 2 thrombophlebitis, 3 transient mental confusion, 1 breakage of implant after 18 months.SummaryGoal of SurgeryResection of tumor as complete as possible without injury to the spinal cord or nerve roots.Maintenance of stability of the spinal column.IndicationPainful instability or imminent quadriplegia due to primary and secondary malignant tumors.ContraindicationMultiple metastases, poor general health.Positioning and AnaesthesiaLateral, followed by a knee-chest position.Surgical TechniqueThrough a standard approach for a left thoracophrenotomy resection of the involved vertebra, decompression of the dural sack, insertion of an adjustable intervertebral spreader which will maintain the distance between the vertebrae and serve as replacement for the removed vertebra. After turning the patient into prone position transpedicular fixation of the vertebral segment. (Example is given for resection of the first lumbar vertebra.)Postoperative ManagementRegular control of sensory and motoric nerve function of the limbs hourly on the day of surgery and two hourly on 1. and 2. postoperative day.Removal of drains 2 to 3 days postoperatively.Pharmacological stimulation of bowels.Daily radiographic control of chest till 1 day after the removal of drains.Mobilization within 1 week without corset.Possible ComplicationsInjury to lungs, ureters, large vessels, intestines, lumbar plexus, dura, and plexus sympathici.Haemothorax, Chylothorax, Infection.ResultsBetween 1982 and 1993 thirty-seven patients underwent vertebral resection of tumors.For analysis of retrospective results refer to Tables 1 to 3.Average surgical blood loss: 2378 ml (800 to 6500).Average duration of surgery: 238 minutes (120 to 550).Complications: 2 bronchopneumonia, 2 deep infections, 2 thrombophlebitis, 3 transient mental confusion, 1 breakage of implant after 18 months.

Der pararektale, retroperitoneale Zugang zum Promontorium bei Kombinationseingriffen

OperationsprinzipDurch Spaltung des ventralen Blattes der linken Rektusscheide und Beiseitehalten des Musculus rectus abdominis nach medial kann das Peritoneum kaudal der Linea arcuata, an der lateralen Bauchwand beginnend, stumpf abgeschoben werden, bis das Promontorium freiliegt. Mit Hilfe dieses Zuganges, bei dem keine Muskeln verletzt werden müssen und neben der Haut nur das ventrale Blatt der Rektusscheide durchtrennt wird, gewinnt man eine nahezu ventrale Darstellung des Segments L5/S1.

Veraltete thorakolumbale Frakturen mit Gibbusbildung

SummaryIndicationsRemote thoracolumbar gibbosity with painful functional disturbances.ContraindicationsSevere osteoporosis.Poor general health.Positioning and AnaesthesiaInitially prone, using a supporting frame, followed by right lateral decubitus.General anaesthesia.Surgical TechniqueStraightening of gibbosity in one sitting using a posterior and an anterior incision. After resection of the involved vertebrae and the neighbouring intervertebral discs wedge-shaped interlaminar resection of the respective neural arches, transection of the partes interarticulares, correction of the malposition with a bone spreader, and posterior fixation with pedicle screws and rods. Completion of surgery by anterior autogenous fibula graft.Postoperative ManagementTwo-hourly control of motoricity and sensitivity.Prevention of intestinal atony and urinary retention by i. v. administration of Prostigmin.Removal of urinary catheter after 2 days.Initially daily chest radiographs.Patient allowed out of bed after removal of the thorax drain within the first week, and without a brace.No routine implant removal.Possible ComplicationsInjury of lung, intestine, ureter, major vessels, lumbar plexus, dura and sympathetic trunk.Haemo-or/and chylothorax.Infection.ResultsTwelve patients were operated between 1990 and 1995. In 4 patients a rigid rodscrew system was used which led to 2 fatigue fractures of the implant. Despite this bony consolidation was achieved in all patients. 6 patients were symptomfree and 4 were markedly improved, increase of symptoms in 1 patient who suffered the initial fracture during a suicide attempt.Mean duration of surgery: 4 1/2 h.Complications: 1 severe blood loss (3600 ml): 1 haemothorax requiring aspiration, 2 implant fractures, 1 transient loss of sensitivity in the distribution of the fibularis nerve, and 1 dura leak.Implant removal was performed 4 times.

Dynamische dorsale Stabilisierung mit dem Cosmic-System@@@Dynamic Posterior Stabilization with the Cosmic System

OBJECTIVE Stabilization of unstable motion segments with a stable but non-rigid implant system without an additional spondylodesis. INDICATIONS Neurogenic claudication with instability; discogenic pain; in combination with a fusion (hybrid technique); elongation of a preexisting fusion; second recurrence of a herniated disk. CONTRAINDICATIONS Increased instability; correction and reduction; instrumentation of more than three levels. SURGICAL TECHNIQUE Muscle-sparing approach to the posterior lumbar spine under anteroposterior and lateral image control. Use of special instruments with a slotted sleeve connected to the screw head for rod implantation. Alternatively: conventional midline approach with detachment of muscles from the posterior spine. POSTOPERATIVE MANAGEMENT Mobilization on the day after surgery. Limited physical activities and no work load for 6 weeks. RESULTS In 139 patients (77 females, 62 males, average age 55 years) with a follow-up of 2 years, Oswestry score improved from 49.0% preoperatively to 22.5% and VAS (visual analog scale) from 7.3 preoperatively to 2.5 after 2 years. No change of the lordosis. Eleven revisions (7.9%). Two broken screws (0.3%) and 17 screws (2.5%) with a radiolucent halo.ZusammenfassungOperationszielStabilisierung von instabilen Bewegungssegmenten mit Hilfe eines stabilen, aber nicht rigiden Implantatsystems ohne zusätzliche Spondylodese.IndikationenClaudicatio spinalis mit Segmentinstabilität; diskogener Schmerz; in Kombination mit einer Spondylodese (Hybridtechnik); Verlängerung einer vorbestehenden Spondylodese; zweites Rezidiv einer Bandscheibenherniation.KontraindikationenMakroinstabilität; Korrektur und Reposition; Instrumentation über mehr als drei Segmente.OperationstechnikMuskelschonender Zugang zur dorsalen Lendenwirbelsäule unter anteroposteriorer und lateraler Bildverstärkerkontrolle. Verwendung eines speziellen Instrumentariums mit auf die Schrauben gesteckten Hülsen zur Stabimplantation. Alternativ: Konventioneller Zugang mit Ablösen der Muskulatur von den dorsalen Wirbelsäulenstrukturen.WeiterbehandlungMobilisation am 1. postoperativen Tag. Körperliche Schonung und Arbeitsruhe für 6 Wochen.ErgebnisseBei 139 Patienten (77 Frauen und 62 Männer in einem durchschnittlichen Alter von 55 Jahren) verbesserten sich der Oswestry-Score von präoperativ 49,0% auf 22,5% und die analoge zehnteilige Schmerzskala von präoperativ 7,3 auf 2,5 nach 2 Jahren. Keine Veränderung der Lordose. Elf Revisionsoperationen (7,9%). Zwei gebrochene Schrauben (0,3%) und 17 Schrauben (2,5%) mit radiologischer Saumbildung.AbstractObjectiveStabilization of unstable motion segments with a stable but non-rigid implant system without an additional spondylodesis.IndicationsNeurogenic claudication with instability; discogenic pain; in combination with a fusion (hybrid technique); elongation of a preexisting fusion; second recurrence of a herniated disk.ContraindicationsIncreased instability; correction and reduction; instrumentation of more than three levels.Surgical TechniqueMuscle-sparing approach to the posterior lumbar spine under anteroposterior and lateral image control. Use of special instruments with a slotted sleeve connected to the screw head for rod implantation. Alternatively: conventional midline approach with detachment of muscles from the posterior spine.Postoperative ManagementMobilization on the day after surgery. Limited physical activities and no work load for 6 weeks.ResultsIn 139 patients (77 females, 62 males, average age 55 years) with a follow-up of 2 years, Oswestry score improved from 49.0% preoperatively to 22.5% and VAS (visual analog scale) from 7.3 preoperatively to 2.5 after 2 years. No change of the lordosis. Eleven revisions (7.9%). Two broken screws (0.3%) and 17 screws (2.5%) with a radiolucent halo.

Posterior instrumentation and fusion for progressive idiopathic scoliosis

Objectives Prevention of progression of an idiopathic scoliosis. Structural improvement of the spinal column and correction of the trunk deformity.

Dorsale Korrekturspondylodese der progredienten idiopathischen Skoliose

ZusammenfassungOperationsziel Verhinderung des Fortschreitens einer idiopathischen Skoliose. Verbesserung der Wirbelsäulenstatik und Korrektur der Rumpfdeformität. Indikationen Progrediente idiopathische Skoliosen über 45° nach Cobb. Kontraindikationen Reduzierter Allgemeinzustand, inakzeptables Narkoserisiko, ausgeprägte Osteoporose. Operationstechnik Mit Hilfe nur eines Stabes wird die Seitverbiegung durch Distraktion und Reposition korrigiert und stabilisiert. Am kaudalen Ende der Instrumentierung sichern zwei Pedikelschrauben die notwendige Rotationsstabilität. Die Distraktion entspricht der Wirbelsäulenverlängerung auf der Cotrel-Röntgenextensionsaufnahme. Mit sublaminären Drähten im Scheitel der Skoliose wird die deformierte Wirbelsäule an den entsprechend dem angestrebten sagittalen Profil vorgebogenen Stab herangezogen. Ergebnisse 67 von 75 Patienten konnten nach einem Mindestbeobachtungszeitraum von zwei (zwei bis vier) Jahren untersucht werden. Bei 16 Patienten mit doppelbogiger Skoliose (“double major”) wurde zuvor die lumbale Krümmung mit einer ventralen Korrekturspondylodese aufgerichtet. Bei einem durchschnittlichen präoperativen Winkelwert von 71,3° nach Cobb konnte zwei Jahre postoperativ ein Skoliosewinkel von 41,4° gemessen werden. Neurologische Komplikationen traten nicht auf. Eine Patientin verstarb nach unauffälligem intraoperativen Verlauf infolge einer disseminierten intravasalen Gerinnungsstörung. Zwei Pseudarthrosen (mit Stabbruch), ein symptomloser Stabbruch, drei Stablagerinfekte, ein Frühinfekt und drei Hämatomausräumungen wurden als Komplikationen beobachtet.SummaryObjectives Prevention of progression of an idiopathic scoliosis. Structural improvement of the spinal column and correction of the trunk deformity. Indications Progressive idiopathic scoliosis with a Cobb angle > 45° in adolescents and adults. ContraindicationsPoor general health, high anesthetic risk, severe osteoporosis. Surgical Technique The lateral deviation is straightened through distraction and correction and stabilized with 1 rod. Two pedicle screws implanted at the caudal end of the rod assure its rotational stability. The amound of distraction corresponds to the lengthening of the spinal column as visualized on extension films according to Cotrel. Sublaminar wires inserted at the apex of the scoliosis help to approximate the deformed spine to the contoured rod. Results We followed up 67 out of 75 patients for at least 2 years (2 to 4 years). In 16 patients with a double major curve, the lumbar curve had been previously corrected with an anterior fusion. An average preoperative Cobb angle of 71.3° could be improved to 41.1°. No neurologic complications were noted. One patient died of a disseminated intravascular coagulopathy after an uneventful intraoperative course. Among complications we noted 2 pseudarthroses (with breakage of the rod), 1 asymptomatic rod breakage, 3 infections around the rod, 1 early infection, and 3 hematomas necessitating evacuation.

Veraltete thorakolumbale Frakturen mit Gibbusbildung@@@Correction of remote posttraumatic gibbosity and of resulting functional disturbances of the thoracolumbar spine

SummaryIndicationsRemote thoracolumbar gibbosity with painful functional disturbances.ContraindicationsSevere osteoporosis.Poor general health.Positioning and AnaesthesiaInitially prone, using a supporting frame, followed by right lateral decubitus.General anaesthesia.Surgical TechniqueStraightening of gibbosity in one sitting using a posterior and an anterior incision. After resection of the involved vertebrae and the neighbouring intervertebral discs wedge-shaped interlaminar resection of the respective neural arches, transection of the partes interarticulares, correction of the malposition with a bone spreader, and posterior fixation with pedicle screws and rods. Completion of surgery by anterior autogenous fibula graft.Postoperative ManagementTwo-hourly control of motoricity and sensitivity.Prevention of intestinal atony and urinary retention by i. v. administration of Prostigmin.Removal of urinary catheter after 2 days.Initially daily chest radiographs.Patient allowed out of bed after removal of the thorax drain within the first week, and without a brace.No routine implant removal.Possible ComplicationsInjury of lung, intestine, ureter, major vessels, lumbar plexus, dura and sympathetic trunk.Haemo-or/and chylothorax.Infection.ResultsTwelve patients were operated between 1990 and 1995. In 4 patients a rigid rodscrew system was used which led to 2 fatigue fractures of the implant. Despite this bony consolidation was achieved in all patients. 6 patients were symptomfree and 4 were markedly improved, increase of symptoms in 1 patient who suffered the initial fracture during a suicide attempt.Mean duration of surgery: 4 1/2 h.Complications: 1 severe blood loss (3600 ml): 1 haemothorax requiring aspiration, 2 implant fractures, 1 transient loss of sensitivity in the distribution of the fibularis nerve, and 1 dura leak.Implant removal was performed 4 times.

Die kombinierte totale Sakrektomie bei Tumoren des Os sacrum

OperationsprinzipÜber einen transperitonealen Zugang werden die den Tumor ernährenden Gefäße unterbunden. Der Tumor wird stumpf von den Eingeweiden des kleinen Beckens getrennt. Der Wirbelkörper und/oder die Zwischenwirbelscheibe werden in Höhe der Resektionslinie durchtrennt. Nach Verschluß der Bauchwunde wird der Tumor dann von dorsal “entwickelt” und entfernt.