Evaluation of a new monocortical screw for anterior cervical fusion and plating by a combined biomechanical and clinical study

The purpose of this combined study was to evaluate the stability and safety of a new monocortical screw-plate system for anterior cervical fusion and plating (ACFP) according to Caspar in comparison with classical bicortical fixation. In the biomechanical part of the study two groups, each comprising six fresh human cadaveric spines (C4–C7), matched for bone mineral density, additionally resulting in almost the same mean age, were used. Range of motion and neutral zone were analyzed in flexion-extension, rotation (left, right) and lateral bending (left, right) using pure moments of ± 2.5 Nm for each specimen in the intact state, after discectomy at C5/6 and after discectomy at C 5/6 followed by bone grafting plus plating (Caspar plates), with either monocortical or bicortical screws. For all three motion planes, no significant difference could be found between the new monocortical and the bicortical fixation techniques. The clinical part of the study was performed as a prospective study on 30 patients suffering from symptomatic degenerative cervical disc disease in one segment. At the latest follow-up, no hardware- or graft-related complications were seen in any of the patients. Following these findings monocortical screw fixation can be recommended for the majority of anterior cervical fusion and plating procedures in degenerative disease, making the procedure quicker, easier, and safer. Bicortical screw fixation still has specific indications for multilevel stabilization, poor bone quality (osteoporosis, rheumatoid disease – as bicortical oversized rescue screw), unstable spines (trauma, tumour) and in particular for the realignment of kyphotic deformities (restoration of the normal lordotic curve). Due to the design of the study the results apply only to surgical treatment of monosegmental degenerative disc disease at the time. Received: 28 November 1998 Revised: 19 March 1999 Accepted: 29 May 1999     

Treatment Strategies in Thoracolumbar Vertebral Fractures: Are there Indications for Biomaterials?

Abstract Treatment concepts in thoracolumbar vertebral fractures include conservative treatment, internal fixator, and vertebral body replacement with implants and autologous bone grafts. The role of biomaterials in these concepts is unclear. Specific properties of biodegradable osteosynthetics seem not to be suitable for an employment in spine surgery. Growth factors may get significant importance in future when the risk of ectopic bone formation in the neurogenic canal is abandoned, particularly in combination with artificial bone substitutes. Bioresorbable bone substitutes are widely in use in vertebro- and kyphoplasty at this time and seem to replace bone cements. In vertebral body replacement they are employed to enlarge the amount of autologous cancellous bone, but not as stand-alone implants. As in many other fields, the use of biomaterials in thoracolumbar spinal injuries will rapidly increase in future.     

Classification of thoracic and lumbar spine fractures: problems of reproducibility

Reproducibility of fracture classification systems in general has been a matter of controversy. The reproducibility of spinal fracture classifications has not been sufficiently studied. We studied the inter-observer and intra-observer reproducibility of the Magerl (AO) classification using radiograms, CTs and MRIs of 53 patients. We compared this classification with the older and simpler Denis classification. Five observers classified the fractures, first using the radiograms and CTs and, 6 weeks later, with radiograms and MRIs. Three of the observers repeated the readings after 3 months. Three observers also classified the fractures according to Denis. Agreement was measured using Cohen's kappa test. The type (A, B, C) classification of the AO system was fairly reproducible with CTs. With MRI this was only moderate. Group subclassification of the types yielded higher kappa values, corresponding to substantial agreement. The agreement was, in general, better with the Denis classification, but the variance was higher due to the difficulty of finding proper categories for some injury patterns. Although the AO classification allows proper registration of all kinds of injury, the reproducibility, especially at the type level, is problematic. Use of MRI and better definition of the distinctive properties of the three different types may enhance the reproducibility of the scheme.     

异体冷冻干燥骨在脊柱结核手术治疗中的应用

目的 对手术治疗脊柱结核患者进行回顾性研究，了解异体冷冻干燥骨在其治疗中的作用。方法 1999年1月～2004年8月对31例脊柱结核患者均采用同种异体冷冻干燥松质骨作为植骨材料，装入钛网或人工椎体中，在彻底清除病灶后，进行前路支撑植骨和内固定。结果 23例获1．5～5年随访，平均3．7年。21例术后6个月观察到骨融合现象；2例术后2个月停止正规抗结核治疗，局部结核复发，其中1例胸椎结核患者出现螺钉松动并部分退出；继续抗结核治疗后，2例患者均于术后12个月观察到骨融合现象；螺钉松动患者的内固定物位置无进一步变化，但胸椎后凸角度加大。结论 异体冷冻干燥骨可作为脊柱结核的植骨材料，为了使植骨达到良好的再生和重塑，应进行稳固的内固定，术后抗结核治疗十分重要。     

Do MRI findings correlate with mobility tests? An explorative analysis of the test validity with regard to structure

To find out whether segmental magnetic resonance imaging (MRI) findings such as intervertebral disc degeneration (DD) and facet joint osteoarthritis (FJO) are associated with motion deficiencies as seen in common mobility tests and observed range of motion (ROM). A total of 112 female subjects, nurses and office workers, with and without low back pain, were examined by clinical experts, and lumbar mobility was measured including modified Schober, fingertip-to-floor distance (FTFD) and ZEBRIS motion analysis. An MRI of the lumbar spine was made. Mobility findings were correlated with segmental morphologic changes as seen on MRI at the levels of L1-2 through L5-S1. Only a few statistically significant correlations between MRI findings and the results of the mobility tests could be found. Lateral bending was weakly and negatively correlated to DD and FJO but only on the level of L5-S1. The FTFD showed a weak positive correlation to endplate changes on the level of L4-5. When ROM is observed by clinical experts, there are several significant relationships between MRI findings and the observed motion. There is a highly significant segmental correlation between DD and disc form alteration as seen on MRI on the level of single motion segments. Pain history and current pain level did not moderate any association between MRI and mobility. There is no clear relationship between the structural changes represented by MRI and the measured mobility tests used in this study. Our findings suggest that close observation of spinal motion may provide at least equal information about the influence of spinal structures on motion than the commonly used measured mobility tests do.     

Rheumatoid arthritis patients are at increased risk for adverse events following lumbar discectomy

BACKGROUND CONTEXTLumbar discectomy is a common procedure for which patients with rheumatoid arthritis (RA) may be considered. RA is an autoinflammatory disease that may predispose patients to postoperative adverse outcomes.PURPOSETo assess the relative odds of adverse events after lumbar discectomy for those with versus without RA in a large, national, administrative dataset.STUDY DESIGN/SETTINGRetrospective cohort study using the 2010 to 2020 MSpine PearlDiver dataset.PATIENT SAMPLEAfter exclusion of patients under 18 years old, those with any trauma, neoplasm, or infection diagnosis within the month before lumbar discectomy, and any patients who had any alternative lumbar spinal surgery performed on the same day as lumbar discectomy, we identified 36,479 lumbar discectomy patients. 2,937 (8.1%) of these patients had a prior diagnosis of RA. After matching 4:1 by patient age, sex, and Elixhauser Comorbidity Index (ECI, a longitudinal measure of patient comorbidity burden generated via ICD-9 and 10 diagnosis codes), 8,485 lumbar discectomy patients without RA and 2,149 with RA were included.OUTCOME MEASURESIncidence of severe and minor adverse events in the 90-days following lumbar discectomy, predictive factors for adverse events within 90-days of lumbar discectomy, risk of adverse events within 90-days of lumbar discectomy stratified by patient medication regimen, 5-year survival to reoperation following lumbar discectomy.METHODSPatients undergoing lumbar discectomy were identified from the PearlDiver MSpine dataset. The subset of those with versus without RA were identified and matched 1:4 based on patient age, sex, and ECI scores. The incidence of 90-day adverse events in the two groups was determined and compared by univariate and multivariate analyses. Subgroup analysis was performed based on RA medications being taken.RESULTSMatched lumbar discectomy patients with RA (n=2,149) and without RA (n=8,485) were identified. Controlling for patient age, sex, and ECI, those with RA were at significantly higher odds of any (odds ratio [OR] 3.30), severe (OR 2.78), and minor (OR 3.30) adverse events (p<.0001 for all).Stratifying by medications being taken (and relative to those without RA), there was increasing odds of all adverse events (AAE) based on potency of medications (no biologic or disease modifying antirheumatic drugs [DMARDs] OR 2.33, DMARDs only OR 3.86, biologic±DMARDs OR 5.69 (p<.0001 for all). Despite this, no statistically significant difference in 5-year survival from subsequent lumbar surgery was found between those with versus without RA (p=.1000).CONCLUSIONSLumbar discectomy patients with RA were found to be at significantly higher risk for 90-day adverse events following lumbar discectomy, and this was incrementally greater for those on increasingly suppressive medications. Lumbar discectomy patients with RA bear specific consideration and perioperative monitoring when considered for lumbar discectomy.     

Long-standing pain in a 25-year-old patient with a non-diagnosed cervical osteoblastoma: a case report

Benign osteoblastomas are infrequent tumors, representing less than 1% of all bone tumors. The spinal location accounts for 40–50% of all osteoblastomas from which only 20% are located in the cervical spine. The majority of the spinal osteoblastomas arise from the posterior elements: pedicles, laminas, transverse or spinous processes. We present a case report of a young male that due to the lack of specific symptoms was diagnosed of a cervical osteoblastoma 14 months after the first symptoms. The tumor was located in the right C7 pedicle. We then operated, resected the tumor and a posterior C6-T1 bilateral instrumentation was performed to stabilize the spine. Nowadays, this delay in diagnosis may be avoided by the routine use of MRI or CT for unspecific cervical symptoms. The treatment of this lesion is the complete surgical resection based on a correct preoperative planning with CT and MRI in order to define precisely the location, size and extension of the tumor. Currently, percutaneous or minimally invasive surgery is not commonly used in the treatment of this lesion.     

Long-level intramedullary spinal cord astrocytoma complicated with spine scoliosis: Report of two cases

Introduction and importanceLong-level intramedullary astrocytomas complicated with spine scoliosis are rare. Surgical treatment of such tumors becomes more complicated and challenging when spinal scoliosis is present. However, studies describing the treatment of long segmental intramedullary spinal cord astrocytomas complicated with severe spine scoliosis have been rarely reported.Case presentationTwo cases of long-level intramedullary astrocytomas complicated with severe spine scoliosis were surgically treated with one-stage operation of tumor resection and scoliosis correction in this report. Case 1: A 16-year-old boy presented to our hospital with a five-month progressive paresthesia, weakness of the left lower limb, and a long-time abnormal body appearance. MRI showed a T4-T12 intramedullary tumor combined with spinal scoliosis. Case 2: A 14-year-old boy presented at our service with a 6-year history of visible spine scoliosis and a 1-year progressive motor disability of bilateral lower limbs. Spine MRI indicated a long-level abnormal syringomyelia signal from C4 to L1 and there was irregular enhancement after intravenous contrast medium administration at C7-T2 and T9-T12 level.DiscussionWe performed a laminectomy over the whole length of the tumor and corrected the scoliosis with trans-pedicle screws. The patients exhibited a long-time tumor free with largely neurological function preservation. One-stage operation did not generate severe short- or long-term complications. The correction of the scoliosis prevented the progression of the spinal deformity and facilitated the recovery of normal life.ConclusionThis case report demonstrates that the one-stage resection of long-level intramedullary astrocytoma and correction of the complicated scoliosis might be a feasible option.     

Epidemiology of spine trauma in an Irish regional trauma unit: a 4-year study

Currently there is a lack of information on the full spectrum of spine trauma presenting to medical services in a defined geographic area. This study analyses the aetiology and demographics of a cohort of spine trauma in the West of Ireland. A regional trauma unit has been investigated for a 51-month period. Two hundred and eighty-five cases admitted with spine trauma were documented. The annual incidence of traumatic spinal injury was 19.54 cases/100,000 persons per year. Falls and low-energy trauma are shown to constitute a significant proportion of all cases (60.35%). Injury at greater than one level is frequently present. The highest peak of injury occurred in the 20-24-year-old age group (11.58%). A second peak occurred at 75-79 years of age (7.37%). The commonest cause of neurological injury was falls (n=9; 64.3%). This spine trauma register has provided valuable insights into the patterns of injury encountered in spine trauma patients in this region. It may act as a blueprint for a national spine trauma register and highlights the importance of patient education and injury prevention strategies.     

Aspects of spinal deformity in familial dysautonomia (Riley-Day syndrome)

Familial dysautonomia (FD) is a rare autosomal recessive disease occurring in Jews of Ashkenazi descent, with only some 500 recognized cases. The causative gene was identified on chromosome 9. FD is of considerable orthopedic interest, because of the prevalence of skeletal deformity. About 90% of surviving dysautonomic children will develop a spinal curvature, commonly a scoliliotis. The scoliotic curve is usually kyphotic rather than lordotic, and appears during the first decade of life. Fifty-one of the 90 reported cases of familial dysautonomia in Israel involved patients who were seen at the scoliliotis clinic for assessment and treatment of their spinal deformities. Most of the patients presented with a scoliotic deformity associated in 37 cases with an increased thoracic kyphosis. In our series orthotic treatment and physiotherapy were found to be minimally successful at best. Surgical treatment of the spine was performed in 13 of 51 patients in this series. A retrospective review of these patients' charts and radiographs was carried out. Six years of follow-up are reported. The primary indication for surgery was progression of the spinal curve. Only posterior spinal fusions were performed. Anterior transthoracic procedures were avoided in spite of the significance of the kyphotic deformity, because of the frequency of pulmonary complications. Harrington distraction and compression instrumentation was used. Three-millimeter compression rods were used in a distraction mode in thin, young children. Harri-Luque segmental sublaminar wiring technique and Wisconsin spinous process segmental wiring was used in some. In all cases, the spine fusion was supplemented by bank bone only, to avoid the additional trauma of graft removal. We believe that surgical intervention is advantageous, if done early in the evolution of spinal deformity. Greater technical difficulties and a higher complication rate were encountered in this series relative to the problems usually seen after spinal deformity surgery in children; this is all the more important in a disease in which general anesthesia is an additional major complicating factor. It is hoped that the improved physical condition now seen after early gastrostomy and fundoplication will aid in reducing this high complication rate. Only a small degree (about 25%) of correction was achieved in the majority of patients. Some of this apparent rigidity derived from the inability to apply sufficient instrumental corrective force because of the friable osteoporotic bone. After surgery, there was a marked decrease in the frequency of pneumonia and an improvement in the degree of ataxia, for reasons not understood, which led to an obvious improvement in the quality of life.     

360-degree osteosynthesis via a posterolateral transpedicular approach in high-risk patients

Purpose

Patients requiring anterior–posterior thoracic spine stabilization and suffering from concomitant cardiopulmonary disease are at increased risk to develop procedure-related complications. In order to reduce cardiopulmonary complications, the efficacy of a posterolateral transpedicular approach for 360-degree fusion was investigated.

Methods

Fourteen consecutive patients presenting with spinal cord compression from osteoporotic, metastatic and tuberculotic fractures were treated. Spinal cord decompression was achieved by laminectomy, facetectomy and corpectomy with subsequent posterior instrumented fusion using a screw–rod system.

Results

The procedure was successfully performed in 14 high-risk patients. Preoperatively, all patients presented with thoracic and lower back pain and nine patients with a paraparesis (Frankel grade C). The implants were introduced monoportally or biportally. In all cases, neurological symptoms moderately improved.

Conclusion

The posterolateral transpedicular approach might be a safe, less-invasive and efficient alternative to anterior–posterior fusion. However, biomechanic efficacy and long-term outcome as compared to the transthoracic technique remains to be studied in a larger patient cohort.     

Timing of intervention for spinal injury in patients with polytrauma

ObjectiveThe optimal timing of surgical intervention of spinal fractures in patients with polytrauma is still controversial. In the setting of trauma to multiple organ systems, an inappropriately timed definitive spine surgery can lead to increased incidence of pulmonary complications, hemodynamic instability and potentially death, while delayed surgical stabilisation has its attendant problems of prolonged recumbency including deep vein thrombosis, organ-sp ecific infection and pressure sores.MethodsA narrative review focussed at the epidemiology, demographics and principles of surgery for spinal trauma in poly-traumatised patients was performed. Pubmed search (1995–2020) based on the keywords – polytrauma OR multiple trauma AND spine fracture AND timing, present in “All the fields” of the search tab, was performed. Among 48 articles retrieved, 23 articles specific to the management of spinal fracture in polytrauma patients were reviewed.ResultsSpine trauma is noted in up to 30% of polytrauma patients. Unstable spinal fractures with or without spinal cord injury in polytrauma require surgical intervention and are treated based on the following principles - stabilizing the injured spine during resuscitation, acute management of life-and limb-threatening organ injuries, “damage control” internal stabilisation of unstable spinal injuries during the early acute phase and, definitive surgery at an appropriate window of opportunity. Early spine fracture fixation, especially in the setting of chest injury, reduces morbidity of pulmonary complications and duration of hospital stay.ConclusionRecognition and stabilisation of spinal fractures during resuscitation of polytrauma is important. Early posterior spinal fixation of unstable fractures, described as damage control spine surgery, is preferred while a delayed definitive 360° decompression is performed once the systemic milieu is optimal, if mandated for biomechanical and neurological indications.     

Our experience and early results with a complementary implant for the correction of major thoracic curves

Purpose

In our article, we would like to introduce a new auxiliary implant called the CAB hook, for use in posterior approach scoliosis surgery.

Methods

Since 2007, we operated 42 patients with the CAB hook with an average preoperative Cobb angle of 59.3° (28°–92°). In three cases, the posterior approach was preceded by ventral release and Halo traction. In four cases, besides the CAB hooks, SCS hooks and pedicular screws, in three cases both CAB and SCS hooks, in nine cases CAB hooks with SCS pedicular screws, and in 23 cases, only CAB were used. The average follow-up time was 21.6 month (2–51).

Results

All the patients are satisfied with the results. No reoperation was needed due to the loss of correction, pain, implant failure, or infection. The average postoperative Cobb angle decreased to 24.7° (4°–60°). Based on this we calculated the Cincinnati Correction Index (CCI), which was 1.53 (0.7–4.8), which means that our correction exceeded the flexibility of the spine based on the lateral bending X-ray by 53 %.

Conclusion

As with all new surgical techniques and implants after the short learning curve, we were able to improve the degree of correction and decrease the time of surgery. One of the advantages of the CAB hook is that besides a few implant-specific instruments, no special instrumentation is required for insertion, and image intensifier need not be used.     

Lumbar spinal stenosis: comparison of surgical practice variation and clinical outcome in three national spine registries

Background Context

Decompression surgery for lumbar spinal stenosis (LSS) is the most common spinal procedure in the elderly. To avoid persisting low back pain, adding arthrodesis has been recommended, especially if there is a coexisting degenerative spondylolisthesis. However, this strategy remains controversial, resulting in practice-based variation.

Osteoblastoma of the vertebral body of the third lumbar vertebra

The case of a 22-year-old woman presenting with progressive low back pain as a result of a recurrent osteoblastoma of the body of L3, is reported. Total spondylectomy together with anterior and posterior fusion was carried out in a two-stage procedure. We highlight the rarity of the site of occurrence of osteoblastoma, the difficulty in diagnosis and the fact that a radical treatment needs to be performed. Received: 17 July 1996 Revised: 20 January 1997 Accepted: 1 February 1997     

Myeloscopy

Summary Clinical experience with myeloscopy is presented and discussed. The examinations were undertaken on 86 patients without deleterious side effects. The cauda equina could be seen as well as accompanying blòod vessels.The authors are indebted to Mr. John Ek for his editorial assistance     

SSE Spine Tango – content, workflow, set-up

The Spine Tango registry is now accessible via the SSE webpage under www.eurospine.org – Spine Tango. Links to the Swiss/International, German and Austrian modules are provided as well as information about the philosophy, methodology and content. Following the links, the users are taken to the respective national modules for registration or log-in and data entry. The Swiss/International module, also accessible under www.spinetango.com, is used by all Swiss and international users, who do not have a separate national module. The physician administered forms for surgery, staged surgery and follow-up can be downloaded as PDFs.The officially recommended Spine Tango patient forms are also available. All forms were implemented in an online version and as scannable optical mark reader forms which can be ordered from the corresponding author.