C.H. Fürstenberg

Tokuhashi Prognosis Score: An Important Tool in Prediction of the Neurological Outcome in Metastatic Spinal Cord Compression? : A Retrospective Clinical Study

Study Design. Retrospective clinical study. Objective. The aim of this study was to examine whether the Tokuhashi score correlates with the neurologic outcome in early surgical treatment in metastatic spinal cord compression (MSCC). A retrospective analysis of 35 consecutive incomplete tetraplegic and paraplegic patients with vertebral metastases (VM) and spinal cord compression (SCC) was performed. Summary of Background Data. MSCC is a challenging problem in VM and constitutes an oncologic emergency. The Tokuhashi score has been modified recently and seems to constitute the best method of prediction for real survival in patients with VM. Until now the influence of the neurologic status as a prognostic factor has been discussed controversially. Methods. Data of 35 patients with VM and incomplete tetraplegia or paraplegia, who underwent surgical treatment, were reviewed retrospectively from 2005 to 2006 at our hospital. All patients were classified among the American Spinal Injury Association (ASIA) Impairment Scale (AIS) before and after surgery and at the follow-up. Data were analyzed with SPSS 15.0® and correlation coefficients (Spearman rho) were computed. Results. Analysis showed that 19 patients (54.3%) with an average Tokuhashi score of 9 showed an improvement in the AIS, whereas 12 (34.3%) patients with an average score of 8 had no change and 4 (11.4%) patients with a score of 7 had deterioration. AIS changes showed a positive correlation with Tokuhashi score (r = 0.33; P = 0.048). Conclusion. Our clinical observation suggests that patients with spinal metastases and a high Tokuhashi score benefit from surgical treatment with moderate improvement in sensomotoric function even in a heterogenic collective.

Malignant cord compression: A critical appraisal of prognostic factors predicting functional outcome after surgical treatment

Objectives: Advanced tumor disease and metastatic spinal cord compression (MSCC) are two entities with a high impact on patients’ quality of life. However, prognostic factors on the outcome after primary decompressive surgery are less well-defined and not yet standardized. The aim of this review was to identify prognostic variables that predict functional or ambulatory outcomes in surgically treated patients with symptomatic MSCC. Materials and Methods: We conducted MEDLINE database searches using relevant keywords in order to identify abstracts referring to prognostic factors on ambulatory outcomes in surgically treated MSCC patients. Details of all selected articles were assembled and the rates of ambulation were stratified. Results: Evidence from five retrospective comparative trials and one observational prospective study summarizes different prognostic factors with a positive or negative influence on postoperative ambulatory status. Ambulatory patients maintaining ambulation status after decompression of the spinal cord constituted 62.1%. The overall rate of MSCC patients losing the ability to ambulate was 7.5% compared to 23.5 % who regained ambulation. Preoperative ambulation status, time to surgery, compression fracture and individual health status seem to be the most relevant prognostic factors for ambulatory outcome. Conclusions: There is a lack of standardized prognostic tools which allow predicting outcome in surgically treated patients. A quantitative score consisting of reliable prognostic tools is essential to predict loss and/or regain of ambulation and requires validation in future prospective clinical trials.

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.

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.

Dreidimensionale Korrekturprinzipien einer dreidimensionalen Deformität

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.

[Collagen hydroxyapatite (Healos) saturated with gentamicin or levofloxacin. In vitro antimicrobial effectiveness - a pilot study].

BACKGROUND The functions of synthetic bone graft substitutes include not only structural support to provide bone healing and osseous ingrowth but also the ability to serve as a local antibiotic delivery system to prevent or treat infections of the spine. MATERIAL AND METHODS The impregnation and antibiotic efficiency of gentamicin and levofloxacin with Healos was investigated in vitro and compared with Healos without an antibiotic additive. These antibiotic-loaded bone graft substitutes were examined without dilution and with 10-fold and 100-fold dilution for activity against spondylodiscitis-causing bacteria on different agar plates using an agar diffusion method. RESULTS All hydroxyapatite (HA)/collagen-saturated diluted antibiotics showed elliptical inhibition zones on the corresponding agar plates. For both antibiotics, there was a linear correlation between dilution and area of the inhibition zone. CONCLUSION The analysis showed that the antimicrobial activity of HA/collagen-saturated antibiotics corresponded to the antimicrobial dilutions. These results should be further analyzed using in vivo studies to determine the remaining antibiotic efficiency after implantation of bone graft substitutes.

Mit Gentamicin oder Levofloxacin gesättigter Kollagenhydroxyapatit (Healos

BACKGROUND The functions of synthetic bone graft substitutes include not only structural support to provide bone healing and osseous ingrowth but also the ability to serve as a local antibiotic delivery system to prevent or treat infections of the spine. MATERIAL AND METHODS The impregnation and antibiotic efficiency of gentamicin and levofloxacin with Healos was investigated in vitro and compared with Healos without an antibiotic additive. These antibiotic-loaded bone graft substitutes were examined without dilution and with 10-fold and 100-fold dilution for activity against spondylodiscitis-causing bacteria on different agar plates using an agar diffusion method. RESULTS All hydroxyapatite (HA)/collagen-saturated diluted antibiotics showed elliptical inhibition zones on the corresponding agar plates. For both antibiotics, there was a linear correlation between dilution and area of the inhibition zone. CONCLUSION The analysis showed that the antimicrobial activity of HA/collagen-saturated antibiotics corresponded to the antimicrobial dilutions. These results should be further analyzed using in vivo studies to determine the remaining antibiotic efficiency after implantation of bone graft substitutes.

Management of Pharyngeal Fistulas After Anterior Cervical Spine Surgery: A Treatment Algorithm for Severe Complications.

Study Design: This study is a retrospective database query to identify all anterior spinal approaches. Objectives: The objectives were to assess all patients with pharyngocutaneous fistulas (PCFs) after anterior cervical spine surgery. Summary of Background Data: Patients with the diagnosis of PCFs were treated at the University of Heidelberg Spine Medical Center, Spinal Cord Injury Unit and Department of Otolaryngology (Germany), between 2005 and 2011. Methods: We conducted a retrospective study on 5 patients with PCF after anterior cervical spine surgery between 2005 and 2011 and analyzed their therapy management and outcome on the basis of the radiologic data and patient charts. Results: Upon presentation, 4 patients were paraplegic. Two patients had PCF arising from 1 piriform sinus, 2 patients had PCF arising from the posterior pharyngeal wall and piriform sinus combined, and 1 patient had PCF arising only from the posterior pharyngeal wall. Two patients previously underwent unsuccessful surgical repair elsewhere and 1 patient underwent a prior radiation therapy. In 3 patients, speech and swallowing could be completely restored. Two patients died, both of whom were paraplegic. The patients were needed to undergo an average of 2 or 3 procedures for complete functional recovery of primary closure with various vascularized regional flaps and refining laser procedures supplemented with the negative pressure wound therapy wherever needed. Conclusions: On the basis of our experience, we are able to provide a treatment algorithm that indicates that chronic, as opposed to acute, fistulas require a primary surgical closure combined with a vascularized flap that should be accompanied by the immediate application of a negative pressure wound therapy. We also conclude that particularly in paraplegic patients suffering from this complication the risk for a fatal outcome is substantial.

Dreidimensionale Korrekturprinzipien einer dreidimensionalen Deformität@@@Multiplan correction of a 3D deformity: Möglichkeiten und Relevanz der operativen Optimierung der Thorakalkyphose in der Skoliosechirurgie@@@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.

Auswirkung der lumbalen Hybridinstrumentierung und der rigiden Fusion auf das versorgte und anschließende Segment@@@Effect of lumbar hybrid instrumentation and rigid fusion on the treated and the adjacent segments: Eine biomechanische Untersuchung@@@A biomechanical study

BACKGROUND Degeneration of the upper adjacent segment after operative treatment of degenerative spinal diseases of the lumbar spine (degenerative disc disease DDD) is an unsolved problem. There is also no consensus on whether a rigid or dynamic treatment of DDD should be carried out to protect the segments. This study was carried out to evaluate the effect of bisegmental rigid 360° fusion and bisegmental hybrid fusion on the treated segment as well as on the upper adjacent segment under the aspect of segment protection. MATERIAL AND METHODS A total of six human spinal column preparations (L2-5) were tested under native conditions (NAT), with bisegmental rigid fusion (RIG 360°) and with hybrid fusion (Hybrid) in all three movement directions under physical load and with an preload. The range of motion (ROM) and neutral zone (NZ) were evaluated. The intradiscal pressure (IDP) was measured in the upper adjacent segment (OAS). RESULTS The RIG 360° led to a significant reduction in movement in all directions compared to NAT but Hybrid only in lateral bending (LB). In the OAS the NZ was showed a much greater increase than the ROM. The RIG 360° showed an increase of the NZ in flexion-extension of 86.8% and in LB of 49.6% as well as a significant increase in axial rotation of 52.5%. The increase in the Hybrid was not significant compared to NAT in all directions. Pressure measurements in OAS showed no significant differences for RIG 360° and for Hybrid compared to NAT for both load scenarios. DISCUSSION The range of motion of the treated segments for Hybrid were close to NAT in comparison to RIG 360° indicating a segment-protective effect. The hypothesis that rigid fusion has a significant effect on intersegmental mobility and the increase in intradiscal pressure in the upper adjacent segment could not be confirmed. The data indicate that the primary effect of fusion on the adjacent segment is very low but the fusion-linked increased frequency of extreme loads of the OAS falling within the significance level leads to degeneration. Even if the NZ values for Hybrid and RIG 360° do not significantly differ from NAT, the NZ alterations between the instrumentations tend to be strongly shifted in favor of Hybrid. CONCLUSIONS The data confirm that the clear and sometimes significant alterations of the NZ can be an essential factor for development of adjacent segment degeneration. A dynamic conclusion of instrumentation in the sense of a topping-off would appear to be useful if pathoanatomical indications for an intervertebral disc prosthesis are present.