Heinrich Boehm

Surgical treatment of cervical spondylodiscitis: a review of 30 consecutive patients.

Study Design. A retrospective study of 30 consecutive cases of pyogenic cervical spine infection, excluding postoperative infections. Objective. To establish a real incidence of the disease and the risk factors associated with its occurrence. Furthermore, to evaluate the different surgical approaches dealing with this condition as well as the complications associated with the disease itself and with the different lines of treatment undertaken. Summary of Background Data. Cervical spondylodiscitis is a quite rare finding regarding the common location of spinal abscesses in the lumbar and thoracic regions. Methods. Between January 2004 and December 2009, 30 patients suffering from cervical spondylodiscitis underwent surgical debridement and reconstruction in our institution. The mean age at presentation was 64.5 years, and 19 patients were male (63.3%). Clinically, 24 patients (80%) had neck pain. Neurological deficit was found in 12 patients (40%), while septicemia was one of the presenting pictures in 12 patients (40%). Radiologically, epidural abscess was found in 24 patients (80%). Another concomitant noncontiguous discitis in the thoracic and/or lumbar spine was found in 14 patients (47%). All patients in this series underwent surgical debridement followed by antibiotic therapy for 8 to 12 weeks. Mean period of follow-up was 28.4 months. Results. Healing of the inflammation was the rule. From the 12 patients with neurological deficit, 7 (58%) improved clinically after surgery. Three patients (10%) died postoperatively due to septicemia. Metal failure occurred in 1 patient in whom corpectomy, grafting, and ventral plating were performed. Esophagus perforation occurred in 1 patient with history of cancer pharynx and total neck dissection. Conclusion. Radical surgical debridement and appropriate antibiotic provide a reliable approach to achieve complete healing of the inflammation in cervical spondylodiscitis. Magnetic resonance imaging of the whole spine is recommended in all cases so as not to miss another infection in the spinal column. Regarding the surgical options, ventral plating after corpectomy for spondylodiscitis should be avoided.

Infection rate after transoral approach for the upper cervical spine.

Study Design. A retrospective review of prospectively collected databases of 139 consecutive patients who underwent transoral surgery for lesions of the upper cervical spine. Objective. To analyze the incidence and risk factors of local infection after transoral surgery for the craniocervical junction in a single institution and to compare the findings with the literature. Summary of Background Data. One of the primary risks associated with transoral approach for lesions in the upper cervical spine is postoperative surgical wound infection. Methods. From April 1994 to December 2012, 139 consecutive transoral surgical procedures were performed at a single referral center. The mean age at presentation was 53.6 years (range: 5–87 yr), and more than half of the patients were males (58.3%). The majority of cases were experiencing rheumatic diseases (43.9%), whereas tumor destruction was the indication for surgery in 23.7% of the cases. A total of 23% had fracture of the upper cervical spine and primary infection was found in 7 patients (5%). The mean follow-up period was 4.5 years. Results. Infection of the pharyngeal wound occurred in 5 patients (3.6%), solely in the rheumatic and tumor groups. The presentation was mostly in the first 4 months. A single patient with cage reconstruction after giant cell tumor C2 presented with a late infection 5 years postoperatively. Debridement and primary closure was possible in 2 patients, whereas flap coverage of the pharyngeal wall was necessary in 3 patients. The presence of implant did not have a statistically significant effect on the occurrence of infection. However, infection in the presence of titanium cage mostly necessitated flap coverage of the pharyngeal wall after removal of the cage. Conclusion. The transoral route has proved to be an invaluable method of approaching pathological lesions in the upper cervical spine. The infection rate in this work was 3.6%. Patients with rheumatic diseases and patients presenting with tumors were more susceptible to postoperative surgical wound infection. Level of Evidence: 4

Infection rate after minimally invasive noninstrumented spinal surgery based on 4350 procedures.

Study Design. Retrospective review of a prospectively collected database. Objective. To assess the rate of postoperative infection associated with minimally invasive noninstrumented spinal surgery. Summary of Background Data. Infection after spinal surgery results in significant morbidity, extended hospital stay, and significant costs. Minimally invasive spinal techniques require smaller incisions and less dissection, minimizing the risk of postoperative infection. Methods. Inclusion criteria were patients undergoing posterior spinal surgery using a tubular retractor system with the aid of operative microscope between June 1998 and November 2013. The analysis revealed a total number of 4350 procedures performed in 4037 patients (mean age = 53.2 yr). Sixty percent of the patients were male. The majority of procedures were performed in the lumbar spine (98.4%), and the indication was mostly degenerative in nature (96.9%). The databases were then reviewed for any infectious complications. Results. Postoperative infection was recorded in 4 patients (0.09%). All of them occurred in the lumbar region after discectomy. These patients presented with discitis and underwent revision in the form of open debridement and fusion. The time lapse between the index surgery and revision was 56 days. All 4 patients recovered, with a mean follow-up of 7.5 years. Conclusion. Infection rate after posterior transtubular microscopic assisted spinal surgery is very low (0.09%). Surgical debridement with fusion was the method of choice in treating such complications. This minimally invasive technique reduces markedly the risk of postoperative infection when compared with other large series published in the literature. Level of Evidence: 4

Corpectomy of the fifth lumbar vertebra, a challenging procedure.

Study Design: A retrospective study of 25 consecutive cases undergoing L5 corpectomy and reconstruction. Summary of Background Data: Corpectomy of L5 is a challenging procedure because of the unique biomechanical and anatomic properties of this level. Objective: To report the clinical and radiographic outcomes and to stress the technical difficulties encountered with L5 corpectomy, reconstruction of the resulting defect together with posterior stabilization. Methods: Between 2003 and 2008 25 consecutive cases (13 females and 12 males, mean age 54.5 y) underwent L5 corpectomy, followed by titanium cage implantation and posterior stabilization. The indications for surgery were fracture (44%), bony destruction by tumor (44%), and spondylodiscitis (12%). Results: The mean amount of intraoperative blood loss was 3.4 L. The cage was implanted through a posterior approach in a single patient with lymphoma. In the remaining 24 patients, an expandable cage was implanted through a ventral approach. Intraoperative complications occurred in 2 patients presenting with fracture. This was in the form of injury to the left common iliac vein in one patient and extensive epidural bleeding reaching 10 L in the other patient. Five patients died within 2 years after surgery: 2 of them were presenting with spondylodiscitis and died later due to sepsis, whereas the remaining 3 patients had advanced malignancy. In the remaining 20 patients, the mean follow-up period was 3.4 years. Local recurrence of infection occurred in 1 patient necessitating change of the cage. Recurrence of metastasis occurred in 2 patients; one of them underwent posterior decompression and the other one was treated successfully with local irradiation. Conclusions: L5 corpectomy is a demanding procedure because of the vascular anatomy at that level. Large amount of blood loss should be expected. In case of complication or recurrence of the pathology, revision surgery is more demanding and necessitates a wide experience.

Management of burst thoracic and thoracolumbar fractures with thoracoscopically assisted anterior corpectomy and posterior short segment percutaneous stabilization

Study design This was a prospective observational study. Objective The aim of this study was to evaluate the role of thoracoscopically assisted corpectomy of burst thoracic and thoracolumbar fractures combined with posterior percutaneous transpedicular instrumentation. Summary of background data Because of the associated morbidities related to the combined open anterior and posterior approaches to thoracic and thoracolumbar spine, some surgeons prefer either the anterior-only or the posterior-only approach that is sometimes not sufficient to achieve the goals of surgery. The combination of two minimally invasive techniques enables the achievement of treatment goals and minimizes the associated morbidities. Patients and methods Between January 2008 and December 2008, 26 patients with acute burst spinal fractures were operated upon in our hospital. These patients underwent posterior percutaneous stabilization plus anterior thoracoscopically assisted corpectomy and fusion in the prone position. Clinical and radiological outcomes were evaluated after a minimum follow-up period of 2 years. The Oswestry Disability Index combined with clinical examination was used for clinical evaluation. Plain radiography in two views was used for the radiological evaluation. Results The mean operative time was 240 min. The average blood loss was 745 ml. Ten patients had preoperative neurological deficits ranging from Frankel A to Frankel D. One patient did not show any neurological improvement at the final follow-up. The mean Oswestry Disability Index at the final follow-up was about 7. The mean preoperative kyphosis angle was 26.2°, and improved to 9.2° postoperatively and to 14° at the final follow-up. One patient had a superficial wound-healing problem. Conclusion Thoracoscopic decompression and fusion plus short segment posterior percutaneous instrumentation showed good clinical outcomes and can be considered as an alternative to open procedures, with decreased rates of morbidities in the management of burst thoracic and thoracolumbar fractures.

Is inclusion of the occiput necessary in fusion for C1–2 instability in rheumatoid arthritis?

OBJECT The atlantoaxial joint is the location most and earliest affected in patients with rheumatoid arthritis (RA). In longstanding disease, ligamentous and osseous destruction can progress and involve all cervical segments. If surgical intervention is necessary, some prefer, to be safe, undertaking fusion to the occiput, whereas others advocate 1-level fusion of C1-2. Sparing the occiput (Oc)-C1 segment would allow retention of a considerable amount of physiological range of motion and seems beneficial against subaxial overload. Previous clinical studies on this topic have provided only nonspecific data after short-term follow-up, rendering a segment-sparing approach questionable. The purpose of the present investigation was to assess long-term progression of inflammatory or degenerative destruction in the Oc-C1 segment after isolated C1-2 fusion for RA. METHODS In a series of 113 consecutive patients with RA-related destruction restricted to the craniocervical junction, 14 individuals underwent Oc-C2 fusion and 99 underwent surgery exclusively at the C1-2 level. After a mean follow-up period of 9.4 years (range 4.9-14.7 years), 46 patients were available for clinical and radiographic examination, including CT imaging. RESULTS None of the 46 patients needed additional surgery to extend the fusion to the occiput. Despite marked deterioration in the subaxial cervical spine, in general there were little or no changes in the atlantooccipital region. All but one patient presented with bony fusion of the fixed C1-2 level at follow-up. CONCLUSIONS The results of this investigation suggest that if the Oc-C1 joint is free of osseous destructions on conventional radiographs and free of abnormalities on MRI scans at the time of surgery (for transarticular fixation and fusion of C1-2), there is a very low risk for relevant destruction in the following 5-14 years. Thus, no prophylactic oligosegmental approach, but rather a segment-sparing monosegmental approach, is preferred, even in patients with high inflammatory levels.

Adjacent segment disease after cervical spine fusion: Evaluation of a 70 patient long term follow-up

Study Design. A retrospective study of 70 patients undergoing surgical treatment for adjacent segment disease (ASD) after anterior cervical decompression and fusion (ACDF). Objective. To analyze the risk factors for the development of ASD in patients who underwent ACDF. Summary of Background Data. ACDF has provided a high rate of clinical success for the cervical degenerative disc disease; nevertheless, adjacent segment degeneration has been reported as a complication at the adjacent level secondary to the rigid fixation. Methods. Between January 2005 and December 2012, 70 consecutive patients underwent surgery for ASD after ACDF in our institution. In all patients thorough clinical and radiological examination was performed preoperatively, postoperatively, and at the final follow-up. The clinical data included the Neck Disability Index (NDI) and the Visual Analogue Scale (VAS). The radiological evaluation included x-rays and magnetic resonance imaging (MRI) for all patients. The duration of follow up after the adjacent segment operation ranged from 3 to 10 years. Results. Surgery for ASD was performed after a mean period of 32 months from the primary ACDF. ASD occurred after single level ACDF in 54% of cases, most commonly after C5/6 fusion (28%). Risk factors for ASD were found to be preexisting radiological signs of degeneration at the primary surgery (74%) and bad sagittal profile after the primary ACDF (90%). Conclusion. ASD occurred predominantly in the middle cervical region (C4–6); especially in patients with preexisting evidence of radiological degeneration in the adjacent segment at the time of primary cervical fusion, notably when this surgery failed to restore or maintain the cervical lordosis. Level of Evidence: 4

OP0242 Fatty lesions detected on mri scans in patients with ankylosing spondylitis are based on the deposition of fat in the vertebral bone marrow

Background Fatty lesions (FL), similar to bone marrow oedema (BME) and sclerosis (SCL), are characteristic findings in MRI examinations of patients with ankylosing spondylitis (AS) and degenerative disc disease (DDD). It has recently been shown that FL are associated with syndesmophyte formation in AS. The anatomic correlate of FL has not been studied to date. Current assumptions are solely based on non-invasive data. Objectives To examine the cellular composition of FL in the edges of vertebral bodies of patients with AS or DDD by histology. Methods Patients with AS or DDD undergoing planned kyphosis correction surgery by spinal osteotomy (in AS) or surgery to correct spinal stenosis (in DDD) were included into this biopsy study. The spinal surgeon (HB) took all biopsies mainly in the area close to the vertebral edge in many of which FL had been seen by MRI (figure 1a for AS and 1b for DDD). Biopsies were decalcified, embedded in paraffin, cut and stained by hematoxylin and eosin. The marrow composition was analysed and the cellularity graded (% surface area) by two different investigators blinded to patients’ diagnosis. Four different marrow compositions could be differentiated: (i) fat, (ii) fibrosis, (iii) inflammation and (iv) hematopoiesis (normal). Results A total of 60 biopsies mostly obtained from the lower thoracic spine and the lumbar spine of 21 AS patients (mean age 51.7 years, mean disease duration 24.6 years) and of the lumbar spine in 18 DDD patients (mean age 60.1 years) were available. On the patient level, the histological appearance of MRI-FL was different between the groups: fat marrow was present in biopsies of 19 AS (90%) but in only 5 DDD (28%) patients. Inflammatory marrow changes, resembling mononuclear infiltrates, were found in 8 AS (38.1%) and 14 DDD (77.8%) patients at areas with concomitant FL and BME on MRI, while marrow fibrosis was seen in 6 AS (28.6%) and 4 DDD (22.2%) patients at areas with concomitant FL and SCL on MRI. In the semiquantitative histopathological analysis, the mean distribution (±standard deviation) of the various bone marrow tissue types in the biopsies differed between the AS vs DD in a similar way, with 43% (±26.3%) vs 16% (±30.3%) for fatty marrow, 11% (±15.5%) vs 55% (±42%) for inflammatory marrow and 9% (±16.1%) vs 13% (±27.8%) for fibrotic marrow, respectively. Conclusions The presence of FL on MRI corresponds to fat deposition in the bone marrow of patients with advanced AS. These data show that the MRI change termed ‘fatty lesion’ is indeed based on the deposition of fat in the vertebral bone marrow in AS. Since vertebral bone marrow is physiologically harbouring hematopoiesis, AS seems to lead to a change in the bone marrow microenvironment with local disruption of hematopoiesis and replacement by fat. The link between fat and new bone formation should be studied in earlier disease stages. Disclosure of Interest None declared

What an orthopaedic surgeon should know about vertebral cement augmentation

In the past 3 decades percutaneous vertebroplasty and percutaneous kyphoplasty have widely gained acceptance as a line of treatment in symptomatic osteoporotic vertebral compression fractures and osteolytic primary or secondary lesions in the spinal column. With an ever aging world population these minimal invasive techniques are expected to gain more importance in improving the medical care and quality of life. This review deals with the current techniques and advances of vertebral cement augmentation, their complications, cost efficiency, and effect on pain control.

Value of Combination of Two Minimal Invasive Techniques in Elderly Patients with Multisegmental Lumbar Canal Stenosis and Spondylosis. Midterm Results

Introduction Lumbar canal stenosis (LCS) and spondylosis are the major causes of morbidity among the elderly. LCS remains the most common indication for spinal surgery in elderly patients. These patients are complaining from neurogenic claudication as well as back complaint. LCS remains the most common indication for spinal surgery in elderly patients. These patients are complaining from neurogenic claudication as well as back complaint. Although the decompression Procedures improve the claudication, the back complaint persist or even increase. We assess the efficacy of combination of microscopic assisted percutaneous decompression (MAPD) and percutaneous transpedicular screw fixation (TPSF) with PEEK rod. Material and Methods Prospective study. Between 2009 and June 2012, 20 Patients with LCS and lumbar spondylosis were included in this study. We reviewed demographic information, preoperative (preop.) and postoperative (postop.) Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). Results 20 patients (14 males and 6 females; mean age 69.2 years), mean follow-up 14.2 months, co-morbidities are found in patients (cardiac 8, DM in 4, renal insufficiency in 4), ASA Score (Class I in 8, III in 10, III in 2). BMI; normal weight (7), overweight (6) and Obesity (7). Mean preop. VAS (back and leg) was 5.5 and 5.6 respectively; ODI was 57.2%, 3 months postop. VAS (2.65 and 1.3), ODI 26.4% and 18.2% at the last follow-up. The operated levels were (one level in 2 patients, two levels in 7, three levels in 7 and four levels in 4), eight patients with degenerative scoliosis (more than 10°) with mean cobb- angle of 15.4° preop. and postop. 5.75°. Mean Lumbar lordosis was 35.6° preop. and 39.5° postop. Sacral Slope was 27.8°preop. and postop. 30.3°. Mean operative time was 196 minutes and blood loss was 233.5 ml. Intraop. complications included 2 patients with dural injuries, no wound healing, Follow-up complications included one case with screw loosening. Conclusion Elderly patients are considered good candidates for lumbar surgical decompression using minimally invasive techniques. MAPD is a minimally invasive treatment option that affords a high level of safety, improved functions and decreased pain score. The spinal stabilization using PEEK rod possesses a good solution for spondyolotic back pain not