Marc Dreimann

Scoliosis and chest cage deformity measures predicting impairments in pulmonary function: a cross-sectional study of 492 patients with scoliosis to improve the early identification of patients at risk.

Study Design. This study examines the correlations between pulmonary function tests (PFTs) and radiographical measures of spinal deformities in patients with scoliosis. Objective. To define the parameters that enable more accurate predictions of restricted pulmonary function (PF) in patients with scoliosis. Summary of Background Data. The early identification of patients with scoliosis who are at risk of developing severe curve progression and restricted PF is critical to improving patient care. Methods. A total of 492 patients with a thoracic/thoracolumbar curve (TC) and preoperative PFTs as well as radiographical analysis of the TC and thoracic kyphosis (TK) were assessed. The forced vital capacity (FVC) was expressed as a percentage of the predicted value (FVC%). According to guidelines for the severity of pulmonary impairments, classifications were used: no impairment (FVC > 80%), mild (65 < FVC ⩽ 80%), moderate (50 < FVC ⩽ 65), and severe impairment (FVC ⩽ 50%). Main radiographical parameters were included and statistical analyses were used to identify radiographical predictors and to develop prediction models. Results. The average age was 17 years, 94% of the patients had adolescent idiopathic scoliosis, 20% had lordoscoliosis (TK <10°). The average FVC% was 75% ± 17%, their average TC was 57° ± 21°, and TK was 26° ± 25°. A total of 38% had no impairment, 37% exhibited mild impairment, 15% had moderate impairments, and 10% were severely impaired. Spinal deformities identified by radiographical analysis (TC, TC-flexibility, apical vertebral rotation, TK, and rib hump) significantly influenced FVC% (P < 0.01). TK logistic regression analysis revealed that 2 factors are predictive for an FVC 50% or less: increased scoliosis with a low TK less than 0° (odds ratio = 7.3) or a high TK more than 60° (odds ratio = 20). A model for predicting FVC values more than 50% was established and shown to achieve a correct classification rate of 94%. Conclusion. Patients with increasing coronal and sagittal plane deformities with a high thoracic scoliosis apex are at the highest risk for reduced FVC%. The models developed provided improved estimations of actual PF based on the magnitude of the radiographical deformity. Level of Evidence: 2

Combined modified en bloc corpectomy with replacement of the aorta in curative interdisciplinary treatment of a large osteosarcoma infiltrating the aorta

PurposeWe report a case of a large three-level spinal osteosarcoma infiltrating the adjacent aorta. This is the first case in which a combined modified three-level en bloc corpectomy with resection and replacement of the adjacent aorta was successful as a part of interdisciplinary curative treatment.MethodsCase report.ResultsThe surgical procedure was performed as a two-step treatment. A heart lung machine (HLM) was not used, in order to avoid cerebral and spinal ischemia and to decrease the risk of hematogenous tumor metastases. Instead, a bypass from the left subclavian artery the distal descending aorta was used. We modified the en bloc corpectomy procedure, leaving a dorsal segment of the vertebral bodies to enable rapid surgery. The procedure was successful and the en bloc resection of the vertebral body with aortal resection could be achieved. Except for pallhypesthesia in the left dermatomes Th7–Th10, the patient does not have any postoperative neurologic deficits.ConclusionCombined corpectomy with aortic replacement should be considered as a reasonable option in the curative treatment of osteosarcoma with consideration of the immense surgical risks. The use of an HLM is not necessary, especially considering the inherent risk of hematogenous tumor metastases. Modified corpectomy leaving a dorsal vertebral body segment was considered a reasonable variation since tumor-free margins could still be expected.

Intraocular pressure during neurosurgical procedures in context of head position and loss of cerebrospinal fluid

OBJECTIVEPerioperative visual loss (POVL) is a rare but serious complication in surgical disciplines, especially in spine surgery. The exact pathophysiology of POVL remains unclear, but elevated intraocular pressure (IOP) is known to be part of it. As POVL is rarely described in patients undergoing intracranial or intradural surgery, the aim of this study was to investigate the course of IOP during neurosurgical procedures with opening of the dura mater and loss of CSF.METHODSIn this prospective, controlled trial, 64 patients fell into one of 4 groups of 16 patients each. Group A included patients undergoing spine surgery in the prone position, group B patients had intracranial procedures in the prone position, and group C patients were treated for intracranial pathologies in a modified lateral position with the head rotated. In groups A-C, the dura was opened during surgery. Group D patients underwent spine surgeries in the prone position with an intact dura. IOP was measured continuously pre-, peri-, and postoperatively.RESULTSIn all groups, IOP decreased after induction of anesthesia and increased time dependently after final positioning for the operation. The maximum IOP in group A prior to opening of the dura was 28.6 ± 6.2 mm Hg and decreased to 23.44 ± 4.9 mm Hg directly after dura opening (p < 0.0007). This effect lasted for 30 minutes (23.5 ± 5.6 mm Hg, p = 0.0028); after 60 minutes IOP slowly increased again (24.5 ± 6.3 mm Hg, p = 0.15). In group B, the last measured IOP before CSF loss was 28.1 ± 5.0 mm Hg and decreased to 23.5 ± 6.1 mm Hg (p = 0.0039) after dura opening. A significant IOP decrease in group B lasted at 30 minutes (23.6 ± 6.0 mm Hg, p = 0.0039) and 60 minutes (23.7 ± 6.0 mm Hg, p = 0.0189). In group C, only the lower eye showed a decrease in IOP up to 60 minutes after loss of CSF (opening of dura, p = 0.0007; 30 minutes, p = 0.0477; 60 minutes, p = 0.0243). In group D (control group), IOP remained stable throughout the operation after the patient was prone.CONCLUSIONSThis study is the first to demonstrate that opening of the dura with loss of CSF during neurosurgical procedures results in a decrease in IOP. This might explain why POVL predominantly occurs in spinal but rarely in intracranial procedures, offers new insight to the pathophysiology of POVL, and provides the basis for further research and treatment of POVL.German Clinical Trials Register (DRKS) no.: DRKS00007590 (drks.de).

Basilar impression as complication of Grisel's syndrome

Grisels syndrome presents a rare disease. Here, we present a peculiar case of Grisels syndrome with an unfavorable course developing a basilar impression. This highlights the importance of close clinical and radiological follow‐up even in cases where the course seems uncomplicated.

Circulating Tumour Cell Release after Cement Augmentation of Vertebral Metastases

Cement augmentation via percutaneous vertebroplasty or kyphoplasty for treatment of spinal metastasis is a well-established treatment option. We assessed whether elevated intrametastatic pressure during cement augmentation results in an increased dissemination of tumour cells into the vascular circulation. We prospectively collected blood from patients with osteolytic spinal column metastases and analysed the prevalence of circulating tumour cells (CTCs) at three time-points: preoperatively, 20 minutes after cement augmentation, and 3–5 days postoperatively. Enrolling 21 patients, including 13 breast- (61.9%), 5 lung- (23.8%), and one (4.8%) colorectal-, renal-, and prostate-carcinoma patient each, we demonstrate a significant 1.8-fold increase of EpCAM+/K+ CTCs in samples taken 20 minutes post-cement augmentation (P < 0.0001). Despite increased mechanical CTC dissemination due to cement augmentation, follow-up blood draws demonstrated that no long-term increase of CTCs was present. Array-CGH analysis revealed a specific profile of the CTC collected 20 minutes after cement augmentation. This is the first study to report that peripheral CTCs are temporarily increased due to vertebral cement augmentation procedures. Our findings provide a rationale for the development of new prophylactic strategies to reduce the increased release of CTC after cement augmentation of osteolytic spinal metastases.