V. Bühren

Operative Behandlung von Verletzungen des thorakolumbalen Übergangs: Teil 2: Operation und röntgenologische Befunde

ZusammenfassungDie Autoren berichten über eine prospektive multizentrische Studie zur operativen Behandlung frischer Verletzungen des thorakolumbalen Übergangs (Th10 bis L2). Die Studie soll die derzeitigen Behandlungsmethoden und ihre Ergebnisse an einem großen Kollektiv repräsentativ analysieren und wird von der Arbeitsgemeinschaft “Wirbelsäule” der Deutschen Gesellschaft für Unfallchirurgie (DGU) erarbeitet. An 18 unfallchirurgischen Kliniken in Deutschland und Österreich wurden von September 1994 bis Dezember 1996 insgesamt 682 Patienten prospektiv erfasst. Die Nachuntersuchung der Patienten ist z. Z. noch nicht abgeschlossen. Im Teil 1 (Epidemiologie) wurden Studiendesign und epidemiologische Daten des Kollektivs dargestellt.Der vorliegende Teil 2 schildert die Details der Operationen sowie Messdaten der konventionellen Röntgenuntersuchungen und Computertomographien (CT); 448 (65,7%) Patienten wurden von dorsal, 197 (28,9%) kombiniert dorsoventral und 37 (5,4%) isoliert von ventral operiert; 72% der 448 von dorsal stabilisierten Patienten erhielten eine transpedikuläre Spongiosaplastik. Die kombinierten dorsoventralen Eingriffe wurden bei 75 (38,1%) Verletzten einzeitig und bei 122 (61,9%) zweizeitig durchgeführt. Die durchschnittliche Operationszeit war bei kombiniertem Eingriff mit 4:14 h signifikant länger als bei dorsalem (p<0,001) oder ventralem (p<0,05). Der durchschnittliche Blutverlust war bei dorsalem und ventralen Vorgehen vergleichbar hoch und signifikant geringer als bei kombinierter Operation (p<0,001 bzw <0,05). Die intraoperative Durchleuchtungszeit war mit 4:08 min bei dorsaler Behandlung am längsten und signifikant (p<0,005) länger als bei ventraler.Als dorsales Implantat wurde fast ausnahmslos ein Fixateur interne verwendet (8 verschiedene Modelle). Bei den ventralen Eingriffen kamen überwiegend winkelstabile Platten- oder Stabsysteme (n=22) und seltener winkelinstabile Platten (n=12) zum Einsatz. Der Spinalkanal wurde bei 82,6% der Patienten mit neurologischem Defizit und bei 70,8% derjenigen ohne Ausfallserscheinungen direkt mit Eröffnung des Spinalkanals oder indirekt mit Hilfe des Instrumentariums dekomprimiert. Eine intraoperative Myelographie wurde bei 22% der Patienten für notwendig gehalten.Wir fanden eine statistisch signifikante Korrelation zwischen dem Ausmaß der neurologischen Beeinträchtigung und der Einengung des Spinalkanals im präoperativen CT. Der im seitlichen Röntgenbild ermittelte Körperwinkel des betroffenen Wirbels und der sagittale Index betrugen im Gesamtkollektiv präoperativ im Mittel −17,0° und 0,63; postoperativ lagen die Werte bei −6,3° und 0,86. Eine signifikant (p<0,01) stärkere Verformung des Wirbelkörpers bestand präoperativ in der kombinierten gegenüber der dorsalen Gruppe. Der segmentale Kyphosewinkel GDW 1 wurde von prä- zu postoperativ durchschnittlich um 11,3° und der GDW 2 um 8,8° lordosiert. Die signifikant (p<0,005) größte Korrektur wurde bei den kombiniert Behandelten erzielt.Bei insgesamt 101 (14,8%) Patienten wurden intra- oder postoperative Komplikationen beobachtet, davon 41 (6,0%) revisionspflichtige. Die 3 Behandlungsgruppen wiesen unterschiedliche Komplikationsraten auf, der Unterschied war jedoch nicht signifikant (χ2-Test). Die Rate von Fehllagen transpedikulärer Schrauben betrug 139 von 2264 (6,1%) Schrauben; jede nicht optimal plazierte Schraube wurde dabei als Fehllage dokumentiert. Bei 7 (1,0%) Patienten wurde eine Schraubenfehllage als Komplikation gewertet und 4 (0,6%) von diesen wurden deswegen revidiert.Die Sammelstudie ermöglicht eine aktuelle Standortbestimmung für Verletzungshäufigkeiten und -muster sowie die verschiedenen, heute angewendeten Operationsmethoden. Mit der multizentrischen Studie konnten erstmals der operative Aufwand sowie Möglichkeiten und Risiken der verschiedenen Behandlungsformen dargestellt werden. Weiterführende Ergebnisse sind von den noch andauernden klinischen und radiologischen Nachuntersuchungen zu erwarten.SummaryThe authors report on a prospective multicenter study with regard to the operative treatment of acute fractures and dislocations of the thoracolumbar spine (T10–L2). The study should analyze the operative methods currently used and determine the results in a large representative collective. This investigation was realized by the working group “spine” of the German Trauma Society. Between September 1994 and December 1996, 682 patients treated in 18 different traumatology centers in Germany and Austria were included.Part 2 describes the details of the operative methods and measured data in standard radiographs and CT scans of the spine. Of the patients, 448 (65.7%) were treated with posterior, 197 (28.9%) with combined posterior-anterior, and 37 (5.4%) with anterior surgery alone. In 72% of the posterior operations, the instrumentation was combined with transpedicular bone grafting. The combined procedures were performed as one-stage operations in 38.1%. A significantly longer average operative time (4:14 h) was noted in combined cases compared to the posterior (P<0.001) or anterior (P<0.05) procedures. The average blood loss was comparable in both posterior and anterior groups. During combined surgery the blood loss was significantly higher (P<0.001; P<0.05). The longest intraoperative fluoroscopy time (average 4:08 min) was noticed in posterior surgery with a significant difference compared to the anterior group.In almost every case a “Fixateur interne” (eight different types of internal fixators) was used for posterior stabilization. For anterior instrumentation, fixed angle implants (plate or rod systems) were mainly preferred (n=22) compared to non-fixed angle plate systems (n=12).A decompression of the spinal canal (indirect by reduction or direct by surgical means) was performed in 70.8% of the neurologically intact patients (Frankel/ASIA E) and in 82.6% of those with neurologic deficit (Frankel/ASIA grade A–D). An intraoperative myelography was added in 22% of all patients.The authors found a significant correlation between the amount of canal compromise in preoperative CT scans and the neurologic deficit in Frankel/ASIA grades.The wedge angle and sagittal index measured on lateral radiographs improved from −17.0° and 0.63 (preoperative) to −6.3° and 0.86 (postoperative). A significantly (P<0.01) stronger deformity was noted preoperatively in the combined group compared to the posterior one. The segmental kyphosis angle improved by 11.3° (8.8° with inclusion of the two adjacent intervertebral disc spaces). A significantly better operative correction of the kyphotic deformity was found in the combined group.In 101 (14.8%) patients, intra- or postoperative complications were noticed, 41 (6.0%) required reoperation. There was no significant difference between the three treatment groups. Of the 2264 pedicle screws, 139 (6.1%) were found to be misplaced. This number included all screws, which were judged to be not placed in an optimal direction or location. In seven (1.0%) patients the false placement of screws was judged as a complication, four (0.6%) of them required revision.The multicenter study determines the actual incidence of thoracolumbar fractures and dislocations with associated injuries and describes the current standard of operative treatment. The efforts and prospects of different surgical methods could be demonstrated considering certain related risks. The follow-up of the population is still in progress and the late results remain for future publication.

Repositionsmöglichkeiten mittels perkutaner dorsaler Instrumentierung

BACKGROUND The purpose of this investigation was to evaluate the options of percutaneous systems for reducing relevant posttraumatic kyphosis in spinal burst fractures. Clinical advantages of percutaneous techniques are evident from the literature and a disadvantage can be a lack of repositioning options in reducing the fracture kyphosis. Better results seem to be possible with new techniques and especially monoaxial percutaneous screws. PATIENTS AND METHODS A total of 70 patients with burst fractures (AO type Magerl A3.1-A3.3) of the thoracolumbar spine were treated with a special percutaneous reduction technique in the Trauma Clinic in Murnau (BGU) Germany between July 2009 and March 2011. Posttraumatic, intraoperative and postoperative kyphosis was measured in computed tomography (CT) scans in monosegmental and bisegmental angles. Two different percutaneous fixation systems were compared for reduction. Statistical analyses were carried out with Students t-test. RESULTS We found a highly significant difference between preoperative and postoperative kyphosis angles but no differences in reduction between the two percutaneous systems. In 39 cases additional reconstruction of the anterior column was necessary because of a ventral defect. In comparison to the MCS 2 study of the German Society of Trauma Surgery (DGU) we found no differences in postoperative kyphosis angles (3°). CONCLUSION A significant reduction of posttraumatic kyphosis of thoracolumbar burst fractures is possible with percutaneous techniques. Prerequisites are percutaneous monoaxial screws and tools and a special percutaneous technique as described.

Kraniale inkomplette Berstungsfraktur im thorakolumbalen Übergang

INTRODUCTION Ventral thoracoscopic spondylodesis of the thoracolumbar spine is an elegant treatment strategy. MATERIAL AND METHODS In the years 2002 and 2003 a total of 16 patients with incomplete cranial burst fractures were treated by ventral thoracoscopic monosegmental spondylodesis and were included in this study prospectively. The data acquisition was done preoperatively, postoperatively and after 3, 6, 12 and 18 months. After 6 years a follow-up examination was performed in 13 of these patients (5 men and 8 women, average age 36.3 years, follow-up rate 81%) and 8 patients were treated ventrally only whereas 5 patients were treated dorsoventrally. RESULTS The operative reduction of the kyphotic malalignment was superior in the dorsoventrally treated patients. The persistent gain of monosegmental correction after 6 years seemed to be higher in the patient group treated dorsoventrally. The average physical component summary (PSC) scores were comparable to a control group of the same age and revision surgery was performed in two patients both related to the iliac crest bone graft. CONCLUSIONS The ventral and dorsoventral therapy strategies showed good and very good functional outcomes, respectively. The dorsoventral treatment concept secured a persistent gain of monosegmental correction which seemed to be superior compared to a ventral only therapy strategy.

Wirbelsäulenverletzung im Sport

BACKGROUND The management of patients with sport-related injuries of the spine is a challenging issue with regard to the ability to resume former sport activities. The current study analyses the rate of resumption of sports participation after conservative and operative treatment. METHODS In a 2-year period, 96 patients with sport-related injuries of the thoracic and lumbar spine were included in this prospective study. Conservative (19%) or operative treatment (81%) was performed depending on the extent, severity and instability of the trauma. The reduction, the loss of reduction over time and the VAS and Odom scores were assessed. A questionnaire was included to estimate the rate of resumption of sports participation. RESULTS Of the patients 91% resumed sports participation and 9% had to abandon all sport activities mostly due to neurological deficits. Minor loss of correction was found in patients with 360 degrees short segment fusions and major loss was found after conservative treatment. CONCLUSION The current management of injuries of the spine effectuates a high rate of resumption of sports activity following conservative or operative treatment.

Increased intrathecal pressure after traumatic spinal cord injury: an illustrative case presentation and a review of the literature

PurposeEarly surgical management after traumatic spinal cord injury (SCI) is nowadays recommended. Since posttraumatic ischemia is an important sequel after SCI, maintenance of an adequate mean arterial pressure (MAP) within the first week remains crucial in order to warrant sufficient spinal cord perfusion. However, the contribution of raised intraparenchymal and consecutively increased intrathecal pressure has not been implemented in treatment strategies.MethodsCase report and review of the literature.ResultsHere we report a case of a 54-year old man who experienced a thoracic spinal cord injury after a fall. CT-examination revealed complex fractures of the thoracic spine. The patient underwent prompt surgical intervention. Intraoperatively, fractured parts of the ascending Th5 facet joint were displaced into the spinal cord itself. Upon removal, excessive protruding of medullary tissue was observed over several minutes. This demonstrates the clinical relevance of increased intrathecal pressure in some patients.ConclusionMonitoring and counteracting raised intrathecal pressure should guide clinical decision-making in the future in order to ensure optimal spinal cord perfusion pressure for every affected individual.

Auch Kliniken des Verletzungsartenverfahrens berücksichtigen

4 B. Fortmeier, Helios Hanseklinikum Stralsund 4 G. Balser, Kreiskrankenhaus Weilburg 4 A. Kaminski, Klinikum Mettmann 4 M. Krause, Klinikum Mutterhaus der Borromäerinnen Trier 4 L. Reinhold, Wirngrund-Klinik Ellwangen 4 M. Sarkar, Krankenhaus Leonberg 4 L. Krüerke, Main-Kinzig-Kliniken Gelnhausen 4 K. Kolb, Kreiskliniken Reutlingen 4 G. Schiffer, Vinzenz-Pallotti Hospital Bergisch Gladbach 4 D. Müller, Städtisches Klinikum Lüneburg 4 M. Raum, Helios Klinikum Siegburg 4 K. Klöpping, Helios Klinikum Schleswig 4 T. Haug, St. Franziskus-Hospital Ahlen 4 L. Özokyay, Marien-Hospital Wesel 4 C. Klostermann, Klinikum Lippe

Kraniale inkomplette Berstungsfraktur im thorakolumbalen Übergang@@@Incomplete cranial burst fracture in the thoracolumbar junction: 6-Jahres-Ergebnisse nach thorakoskopischer monosegmentaler Spondylodese@@@Results 6 years after thoracoscopic monosegmental spondylodesis

INTRODUCTION Ventral thoracoscopic spondylodesis of the thoracolumbar spine is an elegant treatment strategy. MATERIAL AND METHODS In the years 2002 and 2003 a total of 16 patients with incomplete cranial burst fractures were treated by ventral thoracoscopic monosegmental spondylodesis and were included in this study prospectively. The data acquisition was done preoperatively, postoperatively and after 3, 6, 12 and 18 months. After 6 years a follow-up examination was performed in 13 of these patients (5 men and 8 women, average age 36.3 years, follow-up rate 81%) and 8 patients were treated ventrally only whereas 5 patients were treated dorsoventrally. RESULTS The operative reduction of the kyphotic malalignment was superior in the dorsoventrally treated patients. The persistent gain of monosegmental correction after 6 years seemed to be higher in the patient group treated dorsoventrally. The average physical component summary (PSC) scores were comparable to a control group of the same age and revision surgery was performed in two patients both related to the iliac crest bone graft. CONCLUSIONS The ventral and dorsoventral therapy strategies showed good and very good functional outcomes, respectively. The dorsoventral treatment concept secured a persistent gain of monosegmental correction which seemed to be superior compared to a ventral only therapy strategy.

Repositionsmöglichkeiten mittels perkutaner dorsaler InstrumentierungRepositioning options with percutaneous dorsal stabilization

BACKGROUND The purpose of this investigation was to evaluate the options of percutaneous systems for reducing relevant posttraumatic kyphosis in spinal burst fractures. Clinical advantages of percutaneous techniques are evident from the literature and a disadvantage can be a lack of repositioning options in reducing the fracture kyphosis. Better results seem to be possible with new techniques and especially monoaxial percutaneous screws. PATIENTS AND METHODS A total of 70 patients with burst fractures (AO type Magerl A3.1-A3.3) of the thoracolumbar spine were treated with a special percutaneous reduction technique in the Trauma Clinic in Murnau (BGU) Germany between July 2009 and March 2011. Posttraumatic, intraoperative and postoperative kyphosis was measured in computed tomography (CT) scans in monosegmental and bisegmental angles. Two different percutaneous fixation systems were compared for reduction. Statistical analyses were carried out with Students t-test. RESULTS We found a highly significant difference between preoperative and postoperative kyphosis angles but no differences in reduction between the two percutaneous systems. In 39 cases additional reconstruction of the anterior column was necessary because of a ventral defect. In comparison to the MCS 2 study of the German Society of Trauma Surgery (DGU) we found no differences in postoperative kyphosis angles (3°). CONCLUSION A significant reduction of posttraumatic kyphosis of thoracolumbar burst fractures is possible with percutaneous techniques. Prerequisites are percutaneous monoaxial screws and tools and a special percutaneous technique as described.

Wirbelsäulenverletzung im Sport@@@Spinal column injuries in sport: Versorgungsstrategie und klinische Ergebnisse@@@Treatment strategies and clinical results

BACKGROUND The management of patients with sport-related injuries of the spine is a challenging issue with regard to the ability to resume former sport activities. The current study analyses the rate of resumption of sports participation after conservative and operative treatment. METHODS In a 2-year period, 96 patients with sport-related injuries of the thoracic and lumbar spine were included in this prospective study. Conservative (19%) or operative treatment (81%) was performed depending on the extent, severity and instability of the trauma. The reduction, the loss of reduction over time and the VAS and Odom scores were assessed. A questionnaire was included to estimate the rate of resumption of sports participation. RESULTS Of the patients 91% resumed sports participation and 9% had to abandon all sport activities mostly due to neurological deficits. Minor loss of correction was found in patients with 360 degrees short segment fusions and major loss was found after conservative treatment. CONCLUSION The current management of injuries of the spine effectuates a high rate of resumption of sports activity following conservative or operative treatment.