Die atlantoaxiale Kyphose

Atlantoaxial kyphosis (AAK) is a rare sagittal deformity of the occiptoatlantoaxial junction. It is defined as a subgroup of anterior translatory atlantoaxial instability. AAK is a symptom of several ligamentours or bony disorders of the craniocervical junction; however, rheumatoid arthritis and trauma are the most common causes for AAK. AAK can be diagnosed on lateral radiographic views of the upper cervical spine if the angle between McGregor's line and the atlas plane is less than-15 degrees or the atlas-axis angle is greater 105 degrees. Treatment modalities for AAK depend on the ability to reduce the deformity. If closed reduction is achieved, posterior atlantoaxial fusion by sublaminar wiring according to Brooks or transarticular screw fixation according to Magerl are possible choices. Irreducible AAK can be treated with a combined transoral decompression, anterior plating according to Harms, and posterior wiring according to Brooks. This staged therapy for AAK was successful in our rheumatoid patient population with AAK.     

Die zervikale spondylotische Myelopathie

Background

The pathogenesis of cervical spondylotic myelopathy (CSM) is often multifactorial. Hence, the treatment of this disease requires a differentiated surgical approach in order to adequately address the underlying pathology.

Purpose

The aim of this review is to identify factors that influence the choice of treatment strategy and to summarize them in an algorithm that serves as a decision aid in choosing the optimal indication for surgical treatment. An attempt is made to define the threshold values for the indication of surgical treatment and to discuss the ideal timing for performing surgery.

Materials and methods

On the basis of the published data, the influencing factors on the prognosis of CSM, as well as surgical approaches are discussed.

Results

Circumferential spinal cord compression, a sharply defined myelopathy signal in the T2-weighted MRI sequence, and segmental instability at the level of the myelopathy signal mean an unfavorable prognosis for the worsening of CSM. The most important factors that influence the choice of the surgical access point are the sagittal profile of the cervical spine, the extent of myelopathy, the extent of stenosis, and the location of the myelopathy-inducing pathology. Previously existing neck pain and prior cervical surgery must also be considered.

Discussion

On the basis of the research carried out, we developed an algorithm that could serve as an aid in choosing the right treatment in the setting of cervical spondylotic myelopathy.

     

Die operative Behandlung der Kyphose

Zusammenfassung Es wird über 17 Patienten berichtet, bei denen eine Kyphose unterschiedlicher Genese operativ behandelt wurde. Die Korrektur selbst erfolgte nach diversen präoperativen Korrekturmaßnahmen vom vorderen und/oder dorsalen Zugang zur Wirbelsäule. Insgesamt konnte eine Korrektur der Kyphose von durchschnittlich 22,3 Grad, das sind 48 Prozent des Ausgangswertes, erreicht werden.

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The operative treatment of kyphose

Summary Report is given on 17 patients with operative treatment of their kyphoses of various etiology. The correction itself has been carried out following diverse preoperative methods of correction using an anterior and/or dorsal approach to the spine. Altogether an average correction of 22.3 degree, that is 48 per cent could be obtained.

     

Die zervikale interkorporelle Spondylodese mit der Titan-Verriegelungsplatte

Operationsprinzip Die Halswirbel-Verriegelungsplatte mit Hohlschrauben aus Titan ist ein System für die implantatgestützte vordere Spondylodese der Halswirbel-oder oberen Brustwirbels?ule. Die Schrauben werden winkelstabil in der H-f?rmigen Platte verriegelt. Sie sind mit einer Plasmabeschichtung versehen und gelocht, was das rasche oss?re An- und Einwachsen erm?glicht. Diese Konstruktionsmerkmale ergeben eine hohe prim?re und sekund?re Stabilit?t der Plattenosteosynthese. Deshalb mu? mit den Schrauben die dorsale Kortikalis der Wirbelk?rper nicht mitgefa?t werden. Dies erh?ht die intraoperative Sicherheit. Die prim?re Stabilit?t ist derjenigen konventioneller Platten wegen der Verriegelung des Schraubenkopfes in der Titanplatte überlegen und wird bei ventralen L?sionen nur durch eine zus?tzliche dorsale Stabilisation übertroffen.      

Biomechanik der Kyphose

Kyphosis is a dorsally convex curvature of the spine in the sagittal plane. A pathological kyphosis of the thoracic spine has a Cobb angle greater than 50 degrees. It occurs when the anterior and/or posterior load-transferring elements of the spine are overloaded or damaged. Wedge-shaped vertebral bodies may be found at one or several levels. A wedge-shaped vertebral body increases the curvature of the spine and moves the centre of gravity of the body parts above of the corresponding vertebral body in a ventral direction. This increases the flexion-bending moment acting on the spine. In the case of a wedge-shaped deformation of a vertebral body, the relative increase of the flexion moment is a function of the wedge angle and of the original position of the centre of gravity of the upper body.     

Die zervikale lympho-venöse Anastomose beim Pfortaderhochdruck der Leberzirrhose

Zusammenfassung Bei 28 Patienten mit portaler Hypertension bei Leberzirrhose wurde der Ductus thoracicus im Angulus venosus freigelegt. Von diesen wurde in 3 F?llen wegen massiver ?sophagusvarizenblutung und in 9 F?llen wegen therapieresistentem Aszites der Ductus thoracicus mit der V. jugularis interna entweder Seit-zu-Seit (8mal) oder End-zu-Seit (4mal) anastomosiert. Die dabei durchgeführten Druckmessungen zeigten, da? keine mechanische Behinderung eines erh?hten Lymphflusses im Angulus veno-lymphaticus vorliegt, da? zwischen V. jugularis interna und Ductus thoracicus praktisch kein Druckgradient besteht und da? die zus?tzlich angelegte lymphoven?se Anastomose keine Drucksenkung im Pfortadergebiet bewirkt. Diese Befunde werden durch das schlechte Ergebnis der ausgeführten Anastomosen best?tigt, so da? ihre weitere klinische Anwendung nicht mehr vertretbar ist.

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Summary At 28 cirrhotic patients with portal hypertension the thoracic duct was prepared at its veno-lymphatic junction. In 3 cases with massive esophageal varical hemorrhage and in 9 cases with intractable ascites the terminal duct has been connected to the jugular vein 8-times by side-to-side and 4-times by an end-to-side anastomosis. Measuring the intraductal pressure we found out that there was no obstructive impediance to the raised lymphatic flow in the vena-lymphatic angle existing, that there was no gradient between the pressure in the duct and internal jugular vein, and further that an additional lympho-venous anastomosis could not decrease partal pressure. Our poor results of that procedure confirmed those findings beforementioned. Therefore we cannot recommend clinical use of that method further on.

     

Posttraumatische thorakolumbale Kyphose

The surgeon’s treatment strategies and the patient’s behavior are crucial regarding the development of posttraumatic kyphosis. Prophylaxis through optimal primary treatment of spinal fractures is essential. After failure of conservative treatment, indications for surgical correction are based on pain and dysfunction due to sagittal imbalance. Spinal alignment is extremely important for surgical treatment. Posttraumatic kyphosis is a complex disease that necessitates individualized planning of the approach and the surgical procedure. In addition to 180° and 360° approaches, osteotomies are often useful. If osteotomies are necessary, segment subtraction osteotomy is the method of choice. Because of the condition’s infrequency and complexity, posttraumatic kyphosis should be treated only in specialized centers.     

Die angeborene Kyphose und der angeborene Gibbus,ihre anatomischen Grundlagen und ihre formale Genese

Ohne Zusammenfassung     

Zur Differentialdiagnose der juvenilen Kyphose

Zusammenfassung An Hand von drei Beispielen wird die Differentialdiagnose juvenile Kyphose-Spondylitis tbc erörtert, wobei vor allem auf die charakteristischen röntgenologischen Veränderungen der verschiedenen Formen der juvenilen Kyphose eingegangen wird.Mit 3 Textabbildungen (5 Einzelbilder)     

Anforderungen an zervikale Bandscheibenprothesen

Ohne Zusammenfassung     

Spontane zervikale Ösophagusruptur

Ohne Zusammenfassung     

Korrektur der lumbosakralen Kyphose bei hochgradiger Spondylolisthese und Spondyloptose

Spondyloptoses, but also high-grade spondylolistheses, usually only develop at the lumbosacral junction and are nearly always classed among dysplastic spondylolistheses. Kyphosis of the lumbosacral junction leads to compensation mechanisms with increased lumbar lordosis and straightening of the pelvic tilt with involvement of the hip and knee joints. Reconstructing a physiological sagittal profile by more or less complete repositioning with permanent fusion of only the lumbosacral motion segment is thus of primary importance in the surgical management of high-grade spondylolisthesis and spondyloptosis. This aim led to the following treatment modality: Dorsal repositioning following sacral dome resection with subsequent intersomatic fusion with the posterior lumbar interbody fusion (PLIF) technique. This procedure was performed in 11 patients between January 1995 and January 1998 for six grade IV spondylolistheses and five spondyloptoses. Four patients had undergone previous surgery. Measurements of the slip angle (Boxall), sagittal translation (Taillard), sacral inclination (Boxall), and sagittal rotation (Wiltse and Winter) were done in the follow-up and to check the postoperative results. Denis' pain scale was used to classify pre- and postoperative complaints as well as those of the last examination. Only one inadequate repositioning occurred in a previously operated patient who required instrumentation from L4 to S1 after a pedicle screw had been torn out at L5. In another previously operated patient, the dura was damaged intraoperatively and managed accordingly. Postoperatively, this patient developed a unilateral nerve root syndrome, which did not improve in the further course. Another patient developed decompensation of the adjacent cranial motion segment in the follow-up period. In ten cases complete or nearly complete reposition was achieved. Firm bone consolidation was seen in all patients. Complaints were markedly reduced in all patients compared to the preoperative status.     

Mikrochirurgische, ventrale zervikale Diskektomie ohne Spondylodese

Operationsziel  

Beseitigung von radikul?ren Schmerzen und Funktionsst?rungen durch mikrochirurgische, ventrale Freilegung und Ausr?umung einer zervikalen Diskushernie ohne gleichzeitige Fusion des Bewegungssegmentes.     

Ultraschallgestützte kontinuierliche zervikale Sympathikusblockade mit Niedrigvolumina zur Therapie bei anhaltender ventrikulärer Tachykardie

Die Anaesthesiologie - Neben der Therapie bei komplexem regionalen Schmerzsyndrom (CRPS) ist die Ganglion-stellatum-Blockade eine Behandlungsoption bei refraktären intermittierenden...