B. Wiedenhöfer

Kyphoplasty in patients with multiple myeloma a retrospective comparative pilot study

This retrospective study of 73 myeloma patients with painful vertebral lesions compares clinical and radiomorphological outcomes up to 2 years after additional kyphoplasty, radiation therapy or systemic treatment only.

Do Overhead Sports Increase Risk for Rotator Cuff Tears in Wheelchair Users

OBJECTIVE To analyze whether frequent overhead-sports activity increases the risk for rotator cuff disease in patients with spinal cord injuries (SCIs) who are wheelchair dependent. DESIGN Cross-sectional study, risk analysis. SETTING Department of Orthopaedic Surgery, Trauma Surgery and Spinal Cord Injury. PARTICIPANTS Patients (N=296) with SCI requiring the full-time use of a manual wheelchair were recruited for this study. The total population was divided into 2 groups (sports vs no sports), among them 103 patients playing overhead sports on a regular basis (at least 1-2 times/wk) and 193 patients involved in overhead sports less than once a week or in no sports activity at all. The mean age of the sports group was 49.1 years. The mean duration of wheelchair dependence was 26.5 years. The mean age of the no-sports group was 48 years. The mean duration of wheelchair dependence was 25.2 years. Each individual completed a questionnaire designed to identify overhead-sports activity on a regular basis and was asked about shoulder problems. Magnetic resonance imaging scans of both shoulders were performed in each patient and analyzed in a standardized fashion. INTERVENTIONS None. MAIN OUTCOME MEASURES Possible differences in continuous data between patients with and without rotator cuff tear were evaluated. The relative risk of suffering from a rotator cuff tear between patients playing overhead sports and those not playing overhead sports was calculated. RESULTS One hundred three patients played overhead sports regularly and 193 did not. There was no difference between groups regarding age, sex, level of SCI, and duration of wheelchair dependence. The body mass index was significantly lower in the sports group than in the no-sports group (P<.0001). A rotator cuff tear was present in 75.7% of the patients in the sports group and in 36.3% of the patients in the no-sports group (P<.0001). Rotator cuff tears were symptomatic in 92.6% of the patients. The estimated risk increase for the sports group to develop rotator cuff tears was twice as high as for the no-sports group (95% confidence interval, 1.7-2.6; P<.001). Similar results were found for the neurological level of lesion (T2-7/<T7), where the estimated risk was about 2.3 times higher in patients with a high neurological level of lesion (T2-7) than in those with a low neurological level of lesion (<T7) (95% confidence interval, 1.82-3.04; P<.001). CONCLUSIONS Overhead-sports activities have been identified as an additional risk factor, along with age and duration of wheelchair dependence, for developing rotator cuff disease in patients with paraplegia. A high frequency of sports activity shows physiological benefits as well as improves the psychological status and quality of life in patients with SCI. The dilemma is how to increase physical activity to gain physiological and psychological health benefits without further increasing overuse of the upper extremities, particularly the shoulder, in patients with paraplegia. The data from this study may be helpful in elucidating the etiology of rotator cuff tear in athletes with paraplegia and in counseling patients with SCI regarding shoulder and upper extremity activity level and provide support for developing preventive strategies.

„Wirbelkörperstabilität“ im spinalen Metastasenmanagement

BACKGROUND Metastases are responsible for most tumor manifestations of the spine. About 25% are symptomatic; however, due to interdisciplinary management the tumor-associated mortality is regressing. Associated acute spinal cord injury (SCI) syndromes raise patient morbidity with a loss of independence and quality of life associated with a fair potential for recovery. Therefore, the management is focused on the avoidance of SCI. The assessment of mechanical stability of vertebral bodies is a central part of decision-making when considering operative therapy. This review gives an update on the current evidence-based data for metastasis management. DECISION MAKING The NOMS concept is well established. Especially the parameters origin, neurologic symptoms, stability and vascularization are described and illustrated by clinical cases. OPERATIVE THERAPY CONCEPTS Evidence-based operative therapy concepts are shown reflecting palliative and curative approaches. ASSESSMENT OF PARAMETERS FOR THERAPY ALGORITHM Clinical and radiological parameters help to find the individual therapy. Generally a number of scores with significant time expenditure are needed. The spine instability neoplastic score (SINS) simplifies the management. Operative therapy shows the best results for the parameters pain and quality of life. However, potential perioperative and postoperative complications have to be estimated and should be avoided. Using these facts our therapy algorithm is helpful for therapy management. CONCLUSIONS With rising life expectancy operative therapy is of increasing relevance. Decision-making uses information about tumor origin, neurologic symptoms, stability, prognostic factors and vascularisation to determine the individual therapy.

Vertebral stability in management of spinal metastases. Criteria and strategies for operative interventions

BACKGROUND Metastases are responsible for most tumor manifestations of the spine. About 25% are symptomatic; however, due to interdisciplinary management the tumor-associated mortality is regressing. Associated acute spinal cord injury (SCI) syndromes raise patient morbidity with a loss of independence and quality of life associated with a fair potential for recovery. Therefore, the management is focused on the avoidance of SCI. The assessment of mechanical stability of vertebral bodies is a central part of decision-making when considering operative therapy. This review gives an update on the current evidence-based data for metastasis management. DECISION MAKING The NOMS concept is well established. Especially the parameters origin, neurologic symptoms, stability and vascularization are described and illustrated by clinical cases. OPERATIVE THERAPY CONCEPTS Evidence-based operative therapy concepts are shown reflecting palliative and curative approaches. ASSESSMENT OF PARAMETERS FOR THERAPY ALGORITHM Clinical and radiological parameters help to find the individual therapy. Generally a number of scores with significant time expenditure are needed. The spine instability neoplastic score (SINS) simplifies the management. Operative therapy shows the best results for the parameters pain and quality of life. However, potential perioperative and postoperative complications have to be estimated and should be avoided. Using these facts our therapy algorithm is helpful for therapy management. CONCLUSIONS With rising life expectancy operative therapy is of increasing relevance. Decision-making uses information about tumor origin, neurologic symptoms, stability, prognostic factors and vascularisation to determine the individual therapy.

[Management of spinal metastases, strategies and surgical indications].

ZusammenfassungMetastasen sind die häufigste maligne Läsion der Wirbelsäule unabhängig vom Primarius und Indikator für ein disseminiertes Tumorleiden. Aufgrund der Optimierung der spezifischen onkologischen Therapiestrategien in den letzten Dekaden und der damit assoziierten steigenden Lebenserwartung stellen Wirbelsäulemetastasen ein wachsendes Problem dar. Deshalb muss gerade bei diesen Patienten eine onkologisch optimale, sinnvolle und patientengerechte Wahl des Therapieverfahrens unter Einbeziehung der Tumorbiologie, Prognose der Überlebenszeit, Vorliegen neurologischer Defizite, Instabilität und Allgemeinzustand des Patienten erfolgen. Die Therapie muss die Lebensqualität des Patienten berücksichtigen. Die Therapieoptionen reichen von einer rein konservativen Behandlung bis zu einer En-bloc-Spondylektomie der metastatischen Läsion. Basierend auf prognostischen Scores muss die chirurgische Entscheidungsfindung unter Berücksichtigung der Differenzialindikationen zu verschiedenen chirurgischen Therapieverfahren individuell entschieden werden.AbstractThe number of bone metastases increases with prolonged survival of primary tumors of kidney, breast, prostate and other tumors. The spine is the most frequent site of bone metastases. This leads to high number of patients where the decision has to be made what kind of treatment should be the best. Several scores have been developed to solve this problem. The decision has to include the biology of the metastatic disease according to primary tumor and dissemination of the disease, the general condition of the patient, the residual stability of the spine, the neurologic status and most important the quality of life of the patient. Treatment options range from conservative treatment up to en bloc resection of the metastatic lesion. Therefore, the strategy of treatment always has to be decided on an individual base.

[Pyogenic spondylodiscitis: therapy algorithm and a new classification for therapeutic decision-making].

The incidence of pyogenic spondylodiscitis is low but has been steadily increasing in recent years. To date there has been no consensus concerning selection of the appropriate treatment, management and strategies and the recommendations for an operative strategy are still a highly controversial issue. In the literature a few statements have been published concerning therapeutic decision-making in pyogenic spondylodiscitis. The classification given in this article is based on clinical experience and retrospective data analysis considering the degree of segmental bony destruction, grade of kyphosis and instability, epidural involvement of the disease and neurological deficits, which are pivotal for therapeutic decision-making. The therapeutic procedure can be defined based on this classification.ZusammenfassungDie Inzidenz der pyogenen Spondylodiszitis ist zwar relativ gering, jedoch in den letzten Jahren stetig steigend. Ein Konsensus bzgl. eines optimalen therapeutischen Managements der pyogenen Spondylodiszitis besteht in der Literatur nicht. Die operative Therapie wird kontrovers diskutiert. Es gibt in der Literatur wenige Angaben zur therapeutischen Entscheidungsfindung und eine darauf basierende Therapiestrategie.Unsere Klassifikation basiert auf unseren eigenen klinischen Erfahrungen und einer retrospektiven Datenanalyse unter Berücksichtigung des Grades der segmentalen knöchernen Destruktion, des Kyphosegrades und der Instabilität, der epiduralen Beteiligung der Erkrankung und des Vorliegens neurologischer Ausfälle, die für die therapeutische Entscheidungsfindung wichtig sind. Basierend auf unserer Klassifikation kann das therapeutische Vorgehen festgelegt werden.AbstractThe incidence of pyogenic spondylodiscitis is low but has been steadily increasing in recent years. To date there has been no consensus concerning selection of the appropriate treatment, management and strategies and the recommendations for an operative strategy are still a highly controversial issue. In the literature a few statements have been published concerning therapeutic decision-making in pyogenic spondylodiscitis. The classification given in this article is based on clinical experience and retrospective data analysis considering the degree of segmental bony destruction, grade of kyphosis and instability, epidural involvement of the disease and neurological deficits, which are pivotal for therapeutic decision-making. The therapeutic procedure can be defined based on this classification.

Rolle und Grenzen der Vertebro-/Kyphoplastie im Metastasenmanagement der Wirbelsäule

ZusammenfassungDie Wirbelsäule ist die häufigste Region für Skelettmetastasen. Nicht selten entwickeln die Patienten mit einem disseminierten Tumorleiden metastasenassoziierte Schmerzen, Dysfunktion und pathologische Wirbelkörperfrakturen. Bei einem Teil der Patienten können aufgrund des palliativen Therapieansatzes keine konventionellen chirurgischen Eingriffe durchgeführt werden. Gerade bei dieser Patientenpopulation konnte gezeigt werden, dass die minimal-invasive perkutane Wirbelkörperzementaugmentation eine effektive Therapieoption darstellt und eine wichtige Rolle einnimmt. Trotzdem hat die Wirbelkörperzementaugmentation ihre Grenzen und sollte nur bei entsprechender Indikation durchgeführt werden.AbstractThe spine is the most common site for skeletal metastases. Tumor-induced osteolysis may lead to pain, dysfunction and ultimately vertebral fracture. In some patients conventional surgery is not suitable because of the palliative therapy approach. Just for this patient population it was shown that cement augmentation of the vertebra is an effective therapy option and plays an important role. Nevertheless, cement augmentation of the vertebra has its limitations and should only be applied by appropriate indications.The spine is the most common site for skeletal metastases. Tumor-induced osteolysis may lead to pain, dysfunction and ultimately vertebral fracture. In some patients conventional surgery is not suitable because of the palliative therapy approach. Just for this patient population it was shown that cement augmentation of the vertebra is an effective therapy option and plays an important role. Nevertheless, cement augmentation of the vertebra has its limitations and should only be applied by appropriate indications.

Neurological and functional recovery in multiple injured patients with paraplegia: outcome after 1 year.

BACKGROUND Injuries of thoracic vertebrae in multiple trauma patients are often accompanied by severe thoracic injuries and sensorimotor deficits. However, until now, it is not clear whether and how the severity of trauma influences the neurologic and functional outcome in paraplegic patients during the first year after the trauma. The aim of the study was to compare two cohorts of multiple injured paraplegic patients with and without conversion in the American Spinal Injury Association Impairment Scale (AIS) with regard to the severity of spinal trauma, the severity of thorax trauma, the type of fracture, and the functional outcome 1 year after the date of injury. METHODS Twenty-one traumatic paraplegic patients (neurologic level T1-T12) were included in the study based on a retrospective analysis of the Heidelberg European Multicenter Study about Spinal Cord Injury database (www.emsci.org) from 2002 to 2007. In all patients, the Polytraumaschluessel (PTS), the AO classification, the AIS, and the Spinal Cord Independence Measure were collected. Patients with no change in the AIS (group 1, n=14) were compared with patients with AIS changes (group 2, n=7), and t test and χ test were performed (p<0.05). RESULTS Differences in both groups concerning fracture classification were confirmed (p=0.046). A relation between neurologic improvement in the AIS and the severity of trauma (p=0.058) after 1 year was not found. The subitem PTST in the thoracic area showed statistical significance comparing the two groups (p=0.005). Both groups significantly improved functionally (Spinal Cord Independence Measure, p=0.035) during the first year but with no significant difference between the groups after 1 year. CONCLUSIONS Our data suggest that functional improvement is achieved independently from neurologic recovery. The combined assessment of the PTS, the AO classification, and the AIS in multiple-injured paraplegic patients can contribute to provide a better prognostication of the neurologic changes during rehabilitation and the outcome after 1 year than the AIS alone.

Osteointegration and Resorption of Intra- and Extravertebral Calcium Phosphate Cement.

Study Design: Eleven patients with painful osteoporotic vertebral fractures who underwent kyphoplasty using calcium phosphate (CaP) cement were followed up for 1 week, 1, 2, and 3 years in a monocentric, nonrandomized, noncontrolled retrospective trial. Objective: This study investigates long-term radiomorphologic features of intraosseous CaP cement implants and of extraosseous CaP cement leakages for up to 3 years after implantation by kyphoplasty. Summary of Background Data: Kyphoplasty is frequently used for the treatment of painful osteoporotic fractures. Of the materials available, CaP is frequently used as a filling material. Resorption of this material is frequently observed, although clinical outcome is comparable with other cements. Methods: Kyphoplasty utilizing CaP cement was performed in 11 patients with painful osteoporotic vertebral fractures. All patients received a pharmacological antiosteoporosis treatment consisting of calcium, vitamin D, and a standard dose of oral bisphosphonates. Radiomorphologic measurements, pain, and mobility were assessed. Results: Intraosseous and extraosseous CaP cement volumes decreased significantly over 3 years. However, vertebral stability as determined by a constant vertebral body height and the sagittal index was not impaired. Pain improved significantly 2 years after implantation and the mobility scores 1 year after kyphoplasty at least until the third year. Conclusions: Intravertebral CaP cement implants are resorbed slowly over time without jeopardizing stability and clinical outcomes most likely because of a slowly progressing osseous replacement. Extraosseous CaP cement material because of leakages during the kyphoplasty procedure is almost completely resorbed as early as 2 years after the leakage occurred. Therefore, CaP cement is an important alternative to PMMA-based cement materials utilized for kyphoplasty of osteoporotic vertebral fractures.

Multiplan correction of a 3D deformity. Options and relevance of optimizing the thoracic kyphosis in reconstructive scoliosis surgery

BACKGROUND There is presently still no consensus on how to operatively treat adolescent idiopathic scoliosis (AIS), i.e. a clearly reduced thoracic kyphosis. For a long time the primary focus was mostly on correcting the coronal plane while neglecting the sagittal profile. Based on the current literature and own retrospective data a comprehensive review will be given on the optimal correction of the spine and how to avoid secondary complications. Different operative standard procedures are demonstrated with special attention to the sagittal balance and the special parameters sagittal vertical axis (SVA), lumbar lordosis (LL), thoracic kyphosis (TK), pelvic tilt (PT), sagittal slope (SSL) and pelvic incidence (PI). RESULTS A total of 24 patients (2 groups of 12 patients) with AIS and posterior fusion with (group A) and without (group B) additional osteotomy were analyzed with respect to the impact on spinopelvic balance and health-related quality of life (HRQoL) parameters. Patients in group A had a significant reduction of TK, LL and SSL and an increase in PT whereas patients in group B showed the opposite. Correlation analysis revealed a significant dependence of HRQoL on PT. DISCUSSION Both the results from the literature and own data confirm that operative correction of AIS needs a careful planning including sagittal spinopelvic parameters. Rigid thoracic hypokyphosis require additional osteotomy.