Peer Eysel

Indications and contraindications for vertebroplasty and kyphoplasty.

IntroductionVertebral fractures (VF) are a leading cause of morbidity in the elderly. In the past decade, minimally invasive bone augmentation techniques for VF, such as percutaneous vertebroplasty (VP) and kyphoplasty (KP) have become more widespread. According to the literature, both techniques provide significant pain relief. However, KP is more expensive and technically more demanding than VP. The current study surveyed German surgeons who practice percutaneous augmentation to evaluate and compare decisions regarding the implementation of these techniques. Is there a difference in the indications and contraindications of VP and KP compared with the interdisciplinary consensus paper on VP and KP of the German medical association in the treatment of VF?MethodsA multiple choice questionnaire was designed with questions regarding diagnostic procedures, clinical and radiologic (AO classification) indications, as well as contraindications for both VP and KP. A panel of five experts refined the initial questionnaire. The final version was then sent to 580 clinics registered to practice KP in Germany. The statistical analysis was done by two authors, who collected the questionnaire data and Wilcoxon’s signed ranks test was performed for non-parametric variables with SPSS.Results327 of 580 questionnaires (56.4%) were completed and returned. 151 (46.2%) of participants were performing both procedures, and 176 (53.8%) performed KP only. Median duration from onset of acute pain to intervention was 3xa0weeks. For most participants (95.4%), consistent back pain at the fracture level with a visual analog scale score over 5 was the main clinical indication for VP and KP. A1 and A3.1 fractures from osteoporosis and metastasis were considered indications for KP. Osteoporotic A1.1 fractures were an indication for VP. Traumatic A3.2 fractures were not an indication for either procedure. Major contraindications to both procedures were active infection (94.7%), cement allergy (86.8%), and coagulation disorders (80.3%).ConclusionVertebroplasty and kyphoplasty both have roles in the treatment of vertebral fractures. However, we could see differences in the indications for the two percutaneous techniques. Participants of this study found more indications for KP versus VP in cases of painful A1.2 and A3.1 fractures due to osteoporosis, metastasis, and trauma. About half of the respondents reported that VP is indicated for osteoporotic and pathologic A1.1 fractures. This study offers only limited conclusions. Open questionnaires and prospective data from all clinicians performing these procedures should be analyzed to offer more specific information.

How does spinal canal decompression and dorsal stabilization affect segmental mobility? A biomechanical study

IntroductionWhen decompression of the lumbar spinal canal is performed, segmental stability might be affected. Exactly which anatomical structures can thereby be resected without interfering with stability, and when, respectively how, additional stabilization is essential, has not been adequately investigated so far. The present investigation describes kinetic changes in a surgically treated motion segment as well as in its adjacent segments.Material and methodsSegmental biomechanical examination of nine human lumbar cadaver spines (L1 to L5) was performed without preload in a spine-testing apparatus by means of a precise, ultrasound-guided measuring system. Thus, samples consisting of four free motion segments were made available. Besides measurements in the native (untreated) spine specimen further measurements were done after progressive resection of dorsal elements like lig. flavum, hemilaminectomy, laminectomy and facetectomy. The segment was then stabilised by means of a rigid system (ART®) and by means of a dynamic, transpedicularly fixed system (Dynesys®).ResultsFor the analysis, range of motion (ROM) values and separately viewed data of the respective direction of motion were considered in equal measure. A very high reproducibility of the individual measurements could be verified. In the sagittal and frontal plane, flavectomy and hemilaminectomy did not achieve any relevant change in the ROM in both directions. This applies to the segment operated on as well as to the adjacent segments examined. Resection of the facet likewise does not lead to any distinct increase of mobility in the operated segment as far as flexion and right/left bending is concerned. In extension a striking increase in mobility of more than 1° compared to the native value can be perceived in the operated segment. Stabilization with the rigid and dynamic system effect an almost equal reduction of flexion/extension and right/left bending. In the adjacent segments, a slightly higher mobility is to be noted for rigid stabilization than for dynamic stabilisation. A linear regression analysis shows that in flexion/extension monosegmental rigid stabilisation is compensated predominantly in the first cranial adjacent segment. In case of a dynamic stabilisation the compensation is distributed among the first and second cranial, and by 20% in the caudal adjacent segment.SummaryMonosegmental decompression of the lumbar spinal canal does not essentially destabilise the motion segment during in vitro conditions. Regarding rigid or dynamic stabilisation, the ROM does not differ within the operated segment, but the distribution of the compensatory movement is different.

Spondylodiscitis in the elderly patient: clinical mid-term results and quality of life

IntroductionFocusing on spondylodiscitis in elderly patients current literature does not contain much information.MethodWe performed a retrospective case series (nxa0=xa032) comparing conservative (group 1; nxa0=xa016) versus operative (group 2; nxa0=xa016) treated spondylodiscitis patients aged ≥65xa0years (mean age 74.9xa0years) from January 2002 to April 2004. The review of the medical records provided information about the pre-hospital time, the inpatient course and the time after discharge. At follow-up (FU) (mean 3.6xa0years) disease specific and general quality of life (QOL) questionnaires (COMI back patient self-assessment, ODI and SF-36) were administered.ResultsAltogether, 71.9% of the patients could be contacted; 12.5% had died since hospitalisation and 15.6% could not be contacted anymore. At FU based on the visual analogue scale, patients indicated an average of 3.2 for back pain and 2.5 for leg pain. ODI scoring yielded minimal disability for 38.9%, a moderate disability for 22.2%, a severe disability for 22.2% and for 11.1% a crippled situation; 5.6% were bed-ridden or exaggerated their symptoms. The SF-36 PCS amounted to an average of 38.2, the MCS 50.6. Owing to additional surgery-associated risks, operative treatment of spondylodiscitis feature a complication rate twice as high in the respective group, but general complications do not differ. At FU, no statistically remarkable difference concerning QOL and remaining pain became evident between the groups, the operated patients being more satisfied with regard to the treatment of spondylodiscitis.ConclusionUltimately, if surgery is indicated the operative risks should be borne in mind, but advanced age should not be the crucial factor in decision-making.

Clinical Outcomes and Quality of Life 1 Year after Open Microsurgical Decompression or Implantation of an Interspinous Stand-Alone Spacer

BACKGROUNDnInterspinous stand-alone implants are inserted without open decompression to treat symptomatic lumbar spinal stenosis (LSS). The insertion procedure is technically simple, low-risk, and quick. However, the question remains whether the resulting clinical outcomes compare with those of microsurgical decompression, the gold standard.nnnMATERIAL AND METHODSnThis prospective, comparative study included all patients (n=36) with neurogenic intermittent claudication (NIC) secondary to LSS with symptoms improving in forward flexion treated operatively with either interspinous stand-alone spacer insertion (Aperius (®); Medtronic, Tolochenaz, Switzerland) (group 1) or microsurgical bilateral operative decompression (group 2) between February 2007 and November 2008. Data (patient data, operative data, COMI, SF-36 PCS and MCS, ODI, and walking tolerance) were collected preoperatively as well as at 6 weeks, at 3, 6, and 9 months, and at one year follow-up (FU). All patients had complete FU over 1 year.nnnRESULTSnCompared to preoperative measurements, surgery led to improvements of all parameters in the entire collective as well as both individual groups. There were no statistically relevant differences between the 2 groups over the entire course of FU. However, improvements in the ODI and SF-36 MCS were not significant in group 1, in contrast to those of group 2. Also, although in group 1 the improvements in leg pain (VAS leg) were still significant (p<0.05) at 6 months, this was no longer the case at 1 year FU. In group 1 at 1 year FU an increase in leg pain was observed, while in group 2, u2009minimal improvements continued. Walking tolerance was significantly improved at all FU times compared to preoperatively, regardless of group (p<0.01). At no time there was a significant difference between the groups. In group 1, admission and operative times were shorter and blood loss decreased. The complication rate was 0% in group 1 and 20% in group 2, however reoperation was required by 27.3% of group 1 patients and 0% of group 2.nnnCONCLUSIONnImplantation of an interspinous stand-alone spacer yields clinical success comparable to open decompression, at least within the first year of FU. The 1-year conversion rate of 27.3% is, however, decidedly too high.

Mid-range outcomes in 64 consecutive cases of multilevel fusion for degenerative diseases of the lumbar spine

In the treatment of multilevel degenerative disorders of the lumbar spine, spondylodesis plays a controversial role. Most patients can be treated conservatively with success. Multilevel lumbar fusion with instrumentation is associated with severe complications like failed back surgery syndrome, implant failure, and adjacent segment disease (ASD). This retrospective study examines the records of 70 elderly patients with degenerative changes or instability of the lumbar spine treated between 2002 and 2007 with spondylodesis of more than two segments. Sixty-four patients were included; 5 patients had died and one patient was lost to follow-up. We evaluated complications, clinical/radiological outcomes, and success of fusion. Flexion-extension and standing X-rays in two planes, MRI, and/or CT scans were obtained pre-operatively. Patients were assessed clinically using the Oswestry disability index (ODI) and a Visual Analogue Scale (VAS). Surgery performed was dorsolateral fusion (46.9%) or dorsal fusion with anterior lumbar interbody fusion (ALIF; 53.1%). Additional decompression was carried out in 37.5% of patients. Mean follow-up was 29.4±5.4 months. Average patient age was 64.7±4.3 years. Clinical outcomes were not satisfactory for all patients. VAS scores improved from 8.6±1.3 to 5.6±3.0 pre- to post-operatively, without statistical significance. ODI was also not significantly improved (56.1±22.3 pre- and 45.1±26.4 post-operatively). Successful fusion, defined as adequate bone mass with trabeculation at the facets and transverse processes or in the intervertebral segments, did not correlate with good clinical outcomes. Thirty-five of 64 patients (54%) showed signs of pedicle screw loosening, especially of the screws at S1. However, only 7 of these 35 (20%) complained of corresponding back pain. Revision surgery was required in 24 of 64 patients (38%). Of these, indications were adjacent segment disease (16 cases), pedicle screw loosening (7 cases), and infection (one case). At follow-up of 29.4 months, patients with radiographic ASD had worse ODI scores than patients without (54.7 vs. 36.6; P<0.001). Multilevel fusion for degenerative disease still has a high rate of complications, up to 50%. The problem of adjacent segment disease after fusion surgery has not yet been solved. This study underscores the need for strict indication guidelines to perform lumbar spine fusion of more than two levels.

Computed tomography measurements of the lumbar spinous processes and interspinous space

PurposeThis study examines the anatomic proportions of the interspinous space and the spinous processes, considering the optimal placement of an interspinous spacer.MethodsBetween January 2008 and December 2009, 565 patients undergoing computed tomography (CT) scans of the abdomen for various reasons were collected retrospectively for the study. Using the CT scan data, spinous processes of the lumbar spine L1–5 and the interspinous spaces T12–L5 were measured.ResultsThe average measured interspinous space was 9.1xa0±xa02.5xa0mm. This space became significantly (pxa0<xa00.001) smaller from anterior to posterior. Average cortical thickness of all lumbar spinous processes was 2.5xa0±xa00.5xa0mm. Cortical thickness decreased significantly (pxa0<xa00.001) from anterior to posterior. The cortex of the spinous processes from L2 (2.67xa0±xa00.45xa0mm) and L3 (2.66xa0±xa00.94xa0mm) was significantly thicker (pxa0<xa00.001) than that of the others. The spinous process of L5 had the thinnest (pxa0<xa00.001) cortex (2.10xa0±xa00.41xa0mm), as well as the smallest (pxa0<xa00.001) volume (3.0xa0±xa01.0xa0ml) and the shortest (pxa0<xa00.001) height (16.6xa0±xa03.6xa0mm).ConclusionsThe spinous processes of L2 and L3 are the largest and sturdiest, and that of L5 is the weakest. The L4/5 segment features the smallest interspinous space with the thinnest cortex of all lumbar spinous processes. Because the interspinous space narrows posteriorly and the cortex is thicker anteriorly, it seems that the best anatomic position for a stand alone interspinous spacers is anterior.

Spondylodiszitis – eineinterdisziplinäre Herausforderung

HISTORY AND ADMISSION FINDINGSnA 21-year-old man presented with severe lumbar back pain and progressive paraparesis with clinical signs of spondylitis. Laboratory findings revealed elevated infectious parameters. Because of a positive Mantoux-Test he had been treated with quadruple tuberculostatic drugs for eight weeks without prior identification of the causative pathogen.nnnINVESTIGATIONSnMagnetic resonance imaging of the spine revealed a multisegmental spondylitis of the lumbar vertebrae (L3 - L5) with epidural empyema. Computed tomography (CT) of the abdomen confirmed large bilateral abscesses in the psoas muscles.nnnTREATMENT AND COURSEnThe findings supported the diagnosis of spondylitis. The antibiotic regimen was continued. CT-guided drainage was placed in both psoas muscles. Laminectoma of L3 - 5 and dorsal spondylodesis of L2 - S1 were performed immediately. Mycobacterium tuberculosis was cultured from the intraoperative biopsies and treated according to the drug sensitivity test. After further surgical debridment and corporectomy of L4 and L5 the infection was successfully treated. Ten weeks after admission the patient was transferred to a neurologic rehabilitation unit for mobilization.nnnCONCLUSIONnSpondylodiscitis treatment is complex and requires a multidisciplinary approach.

Functional midterm outcome in 131 consecutive cases of surgical clubfoot treatment

IntroductionSince introduction and widespread use of the Ponseti method in the last decade, the need for surgical treatment of clubfeet is nowadays limited to resistant cases. In the time before, surgery via dorsomedial release was a very common treatment option.MethodVery few long-term follow-up studies cover the outcome of surgical methods, which is particularly interesting, as clinical results rather worsen with time. In the present study, 98 children (131 clubfeet), who underwent surgical correction using the Imhauser method at the age of 4.5xa0months were included. Follow-up time was 8.2xa0years (0–11.8xa0years) at average.ResultsData could be retrieved from 46 patients (71 feet), only 5 patients (7 feet) were lost to follow-up. The rate of relapses was high, as 47 patients (53 feet) needed surgical revision for recurrence, while clinical scores showed a good result in the Laaveg and Ponseti Score and the Foot-Function-Index. Isokinetic testing and clinical data indicated a significant weakness of the treated foot, when compared to the healthy side in 12 patients with unilateral deformity. The presented study supports like others the issue that the clinical outcome of a surgical, posteromedial release in terms of relapses is disappointing. This fact is apparently not sufficiently reflected in the current clinical scores, which showed rather good results.ConclusionAs the question of evaluation methods for results of clubfoot treatment remains controversial, isokinetic testing is an easy to use alternative that provides detailed information about functional limitations and may help in reducing the need for repeated radiographic examinations.

Spondylodiszitis – eine interdisziplinäre Herausforderung

HISTORY AND ADMISSION FINDINGSnA 21-year-old man presented with severe lumbar back pain and progressive paraparesis with clinical signs of spondylitis. Laboratory findings revealed elevated infectious parameters. Because of a positive Mantoux-Test he had been treated with quadruple tuberculostatic drugs for eight weeks without prior identification of the causative pathogen.nnnINVESTIGATIONSnMagnetic resonance imaging of the spine revealed a multisegmental spondylitis of the lumbar vertebrae (L3 - L5) with epidural empyema. Computed tomography (CT) of the abdomen confirmed large bilateral abscesses in the psoas muscles.nnnTREATMENT AND COURSEnThe findings supported the diagnosis of spondylitis. The antibiotic regimen was continued. CT-guided drainage was placed in both psoas muscles. Laminectoma of L3 - 5 and dorsal spondylodesis of L2 - S1 were performed immediately. Mycobacterium tuberculosis was cultured from the intraoperative biopsies and treated according to the drug sensitivity test. After further surgical debridment and corporectomy of L4 and L5 the infection was successfully treated. Ten weeks after admission the patient was transferred to a neurologic rehabilitation unit for mobilization.nnnCONCLUSIONnSpondylodiscitis treatment is complex and requires a multidisciplinary approach.

The future of surgical orthopaedics of the knee.

Abstract Over the past two decades, orthopaedics has gone through major changes, principally in the surgical treatment options for articular defects of the knee. This paper explores the advantages and shortcomings of the current surgical treatment modalities for cartilaginous defects in the knee. Emphasis is placed on current techniques in knee arthroplasty, including a view on the future of orthopaedic knee surgery.