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Eine bewahrte und haufig angewandte Operation bei Patienten (Pat) mit idiopathischer Skoliose (IS) ist die dorsale transpedikulare Korrekturspondylodese in Freihandtechnik. Neuere Verfahren mit fluoroskopisch- und CT-gestutzter Navigation sind mutmaslich risikoarmer und exakter. Ist die Freihandtechnik bei IS bezuglich der schraubenassoziierten Komplikationen und intraoperativen Strahlenbelastung sicher? Anhand prospektiv erfasster Daten (2017–2018) von 39 konsekutiven Pat (durchschn. Alter 18,7 J.) mit thorakal einbogiger IS (61,7° ±13,9) eines Skoliosezentrums wurden folgende Parameter (Mittelwert ± Standardabweichung) ausgewertet: Gesamtstrahlenprodukt, Durchleuchtungszeit, fusionierte Segmente, Operationszeit, Blutverlust und schraubenassoziierte Komplikation. Es erfolgte ein Literaturvergleich mit Daten zur intraoperativen Strahlenbelastung bei Navigationsverfahren. Das Gesamtstrahlenprodukt/Pat betrug 71,7 ± 44,0 cGy * cm2, die Durchleuchtungszeit 17,4 ± 8,6 s (7,8 Segmente), die Operationszeit 183,5 ± 54,2 min und der Blutverlust 379,5 ± 183 ml. Keine schraubenassoziierte Komplikation im gesamten Kollektiv. Die Korrektur der Hauptkrummung betrug 75,7 %. Der Vergleich der erhobenen Daten mit denen aus der Literatur zeigte eine fur den Pat 1,25- bis 12,5-fach hohere Strahlenexposition bei fluoroskopisch- gestutzter Navigation und 9,25- bis 12,3-fach hohere bei CT-gestutzten Verfahren. Freihandiges Setzen von Pedikelschrauben ist bei entsprechender Erfahrung mit vergleichbarer Genauigkeit und geringerer Strahlenbelastung fur den Pat verbunden als navigierende Verfahren. Hinsichtlich des geringen Alters der Pat sollte ein strahleninduziertes Langzeitrisiko fur maligne Erkrankungen berucksichtigt werden.

A proven and frequently used surgical procedure in patients with idiopathic scoliosis (IS) is posterior transpedicular corrective spondylodesis using the freehand technique. Novel procedures with fluoroscopically and computed tomography (CT)-assisted navigation are presumed to be less risky and more accurate.Is the freehand technique for IS safe with respect to screw-associated complications and intraoperative radiation exposure?Prospectively collected data (2017-2018) from 39 consecutive patients (average age 18.7 years) with thoracic single curvature IS (61.7° ± 13.9°) from a specialized scoliosis center were evaluated for the following parameters (mean ± standard deviation): total radiation product, fluoroscopy time, fused segments, operative time, blood loss and screw-associated complications. A comparison with data from the literature on intraoperative radiation exposure using navigation procedures was carried out.The total radiation product per patient was 71.7 ± 44.0 cGy*cmThe results of this study showed that with appropriate experience freehand positioning of pedicle screws is associated with comparable accuracy and less radiation exposure for patients than navigation procedures. With respect to the young age of patients, a radiation-induced long-term risk for malignant diseases should be taken into consideration.

Sehr geehrte Leserin, sehr geehrter Leser, der oben genannte Beitrag wurde mit einem fehlerhaften Titel publiziert. Bitte beachten Sie den korrekten Titel und Untertitel: Geringe intraoperative Strahlenbelastung fur Skoliosepatienten. Freihandige Instrumentation mit Vergleich zur Navigation Wir …

Hintergrund Die perioperative Gabe von Antikoagulanzien (AK) und Thrombozytenaggregationshemmern (TAH) in der Wirbelsaulenchirurgie (WSC) suggeriert eine erhohte Rate epiduraler Blutungen, Daten dazu fehlen. Oft sind die Substanzen zur Verhinderung thromboembolischer Komplikationen unverzichtbar. Eine ubergreifende Handlungsempfehlung zum Einsatz von AK und TAH fehlt.

Die degenerative Spondylolisthese (DS) ist eine haufige Ursache chronisch rezidivierender Lumbalgien sowie radikularer Beinschmerzen. Bei einer Fusion sollten symptomatische degenerierte Nachbarsegmente („degenerative disc disease“, DDD) einbezogen werden. In dieser Arbeit wird die tansforaminale lumbale interkorporelle Fusion (TLIF) hinsichtlich ihrer Ergebnisse bei Patienten mit monosegmentaler degenerativer Spondylolisthese und einem degenerierten Anschlusssegment untersucht. Es handelte sich um 28 Patienten mit monosegmentaler DS und einem symptomatischen Anschlusssegment mit DDD (alle bisegmental dorsal instrumentiert und fusioniert, ventral 14 bisegmentale TLIF, 14 monosegmentale TLIF). Die Werte der visuellen Analogskala (VAS) Schmerz und des Oswestry Disability Index (ODI) wurden ermittelt, auserdem erfolgte eine radiometrische Auswertung pra- und 12 Monate postoperativ. Weiter wurde die vergleichende Subanalyse der bi- mit monosegmentaler interkorporeller Abstutzung vorgenommen. Die Schmerzreduktion war signifikant (VAS von 8,7 auf 3,1), der ODI verbesserte sich ebenfalls signifikant von 63 auf 28%. Radiologisch wurden die Segmenthohe und das Wirbelgleiten (Etagen mit TLIF und Spondylolisthese) signifikant verbessert. Die bisegmentale ventrale Abstutzung zeigte gegenuber der monosegmentalen Vorgehensweise eine signifikant bessere Relordosierung. Bei monosegmentaler DS mit symptomatischem Anschlusssegment stellt die Versorgung der Spondylolisthese mittels TLIF ein sicheres und effektives Verfahren dar. In der klinischen Ergebnislage zeigt sich fur das degenerierte Nachbarsegment kein Unterschied zwischen der zusatzlichen interkorporellen Abstutzung und der alleinigen dorsalen Fusion. Allerdings ergeben sich durch eine zusatzliche ventrale Abstutzung Vorteile fur die Relordosierung des Segments, sodass mogliche langfristige Effekte zugunsten der bisegmentalen TLIF diesbezuglich untersucht werden sollten.

Adult scoliosis is defined as a spinal deformity with a Cobb angle of more than 10 degrees in the coronal plain in a skeletally mature patient. Patients predominantly suffer from back pain symptoms, often accompanied by signs of spinal stenosis (central as well as lateral). Asymmetric degeneration leads to asymmetric load and therefore to a progression of the degeneration and deformity as either scoliosis (0.5-1 degree per year), kyphosis, or both. The diagnostic evaluation includes static and dynamic imaging, magnetic resonance imaging, and myelo-computed tomography, as well as invasive diagnostic procedures such as discograms, facet blocks, and epidural and root blocks. The treatment, either conservative or surgical, is then tailored to the patient's specific symptomatology. Surgical management is usually complex and must take into account an array of specific problems, including the patient's age and general medical condition, the length of the fusion, the condition of the adjacent segments, the condition of the lumbosacral junction, osteoporosis, and any previous scoliosis surgery. The main goal of corrective surgery is a balancing of the coronal and sagittal planes.This review focuses on the special indications for vertebral body cement augmentation in patients with osteoporosis and the problem of adjacent level degeneration and its surgical management.

The perioperative use of anticoagulants (AC) and platelet aggregation inhibitors (PAI) in the field of spinal surgery suggests an increased rate of epidural bleeding. However, evidence is lacking and these medications are most often indispensable in the prevention of thromboembolic complications. Comprehensive recommendations for the correct use of AC and PAI are lacking.The aim of this study was an analysis of the current situation with regards to the use of AC and PAI in spinal surgery and development of new recommendations.Two independent surveys on the perioperative use of AC and PAI were obtained from centers for spinal surgery in Germany. The study obtained information on the perioperative use of AC and PAI, risk assessment of thromboembolic and hemorrhagic events as well as on the type and extent of the substance groups used.Almost the entire patient collective (98%) received perioperative low molecular weight heparin. In 64% the medical prophylaxis was started before surgery and in 36% after surgery. The period of prophylaxis was determined arbitrarily. Approximately 40% of interviewees employed paravertebral infiltration and 19% injected into the epidural space in patients on PAI medication. Open spinal canal surgery was performed in 30% of PAI medicated patients and closed spinal canal surgery was executed in 40%. The risk assessment of PAI differed significantly between aspirin and receptor blocker medication as well as dual administration of PAI.The use of AC and PAI in spinal surgery in Germany is very heterogeneous and large deviations from the guidelines frequently occurred. Therefore, there is a strong need for further studies to accurately assess the perioperative use of AC and PAI and to formulate precise recommendations.

Degenerative spondylolisthesis (DS) is a common cause of lumbal and lumbosacral pain as well as radicular pain. Retention and fusion is a good treatment option. Some patients have a symptomatic adjacent degenerative disc disease (DDD) in addition to DS. In these cases the adjacent segments should be fused as well. There are different techniques of fusion available, such as posterior with instrumentation or additional anterior support. This study evaluated results of transforaminal lumbar interbody fusion (TLIF) in patients with monosegmental DS and adjacent DDD.A total of 28 patients with monosegmental DS and adjacent DDD were included into the study (all patients with bisegmental posterior instrumentation and fusion, 14 patients 1 level TLIF, 14 patients 2 level TLIF). Before surgery and 12 months after surgery the following measurements were made: pain (visual analog scale VAS), Oswestry disability index (ODI) and plain radiographs with radiometric analysis. In a sub-analysis patients with 1 and 2 level TLIF were compared.Pain reduction (average VAS from 8.7-3.1) and ODI (63% to 28%) showed significant improvements. Radiometric analysis showed a significant disc height reconstruction and a significant reduction of spondylolisthesis (TLIF level with spondylolisthesis). Bisegmental anterior support showed a significantly better relordosation compared to monosegmental anterior support. The complication rate was 21.4% including hemorrhages, dura leakage, wound infection and adjacent segment degeneration. There were no fatal complications.The TLIF procedure is a safe and effective treatment for monosegmental DS with adjacent symptomatic DDD. Clinical results (pain, function) show no difference between both kinds of fusion (dorsal fusion and instrumentation versus dorsal fusion with instrumentation and TLIF) for the adjacent DDD. However, additional anterior support is more effective for relordosation of the segment. This could have impact on the mid-term and long-term outcome or in cases of adjacent segment fusion.

Adult scoliosis is defined as a spinal deformity with a Cobb angle of more than 10 degrees in the coronal plain in a skeletally mature patient. Patients predominantly suffer from back pain symptoms, often accompanied by signs of spinal stenosis (central as well as lateral). Asymmetric degeneration leads to asymmetric load and therefore to a progression of the degeneration and deformity as either scoliosis (0.5-1 degree per year), kyphosis, or both. The diagnostic evaluation includes static and dynamic imaging, magnetic resonance imaging, and myelo-computed tomography, as well as invasive diagnostic procedures such as discograms, facet blocks, and epidural and root blocks. The treatment, either conservative or surgical, is then tailored to the patient's specific symptomatology. Surgical management is usually complex and must take into account an array of specific problems, including the patient's age and general medical condition, the length of the fusion, the condition of the adjacent segments, the condition of the lumbosacral junction, osteoporosis, and any previous scoliosis surgery. The main goal of corrective surgery is a balancing of the coronal and sagittal planes.This review focuses on the special indications for vertebral body cement augmentation in patients with osteoporosis and the problem of adjacent level degeneration and its surgical management.

For more than 2 decades ventral derotation spondylodesis (Zielke VDS) as a major improvement over Dwyer instrumentation (DI) was the gold standard of instrumented curve correction and stabilization from the anterior approach. As the first available system it enables a true three-dimensional curve correction. A disadvantage is the low internal stabilization capability with a need for long-term external stabilization by means of cast and brace treatment postoperatively. Meanwhile with the development of modern single and dual solid rod systems these disadvantages can be avoided completely. Video-assisted (thoracoscopic) anterior scoliosis surgery accounts for less than 2% of anteriorly treated scoliosis cases, mainly due to a long operating time and significant learning curve.From the posterior approach the Cotrel-Dubousset instrumentation (CDI) as a polysegmentally attached posterior hook threaded dual rod system used to be state of the art for a long time, since it eliminated the disadvantages of Harrington instrumentation (HI) in terms of only one-dimensional correction and low stabilization capabilities. However even with CDI effective derotation was impossible. In posterior scoliosis surgery there is a strong trend away from hook systems towards transpedicular segmentally fixed dual rod systems not only in the lumbar spine but also in the thoracic area. Advantages of these newer techniques are shorter fusion, improved correction, and less loss of correction over time.Advantages of modern anterior instrumentation systems in comparison to posterior transpedicular instrumented dual rod systems are less blood loss, better derotation, slightly shorter fusion levels, and a better influence on sagittal plane control or improvement especially for hypokyphotic thoracic scoliosis cases. Our data also document a superior spontaneous correction of the lumbar curve after selective anterior instrumented correction (Lenke 1B+C), although other studies could not find significant differences. In our experience the neurological risk of anterior instrumented correction is also lower than that of posterior scoliosis surgery, although the morbidity and mortality data of the Scoliosis Research Society could not prove that anymore in recent years. A negative effect of anterior transthoracic scoliosis surgery in comparison to posterior surgery is a more negative effect on lung function, which improves slower after surgery and does not quite reach the levels of posterior surgery at follow-up. But new data on posterior segmental transpedicular correction and fusion also prove a lordosating effect with negative effect on lung function.

In the German health system the payment of a hospital stay is standardised. The common basis is the G-DRG System (German diagnosis-related groups) in which every stay is paid by a lump sum. Scoliosis correction in our times means pedicle screw-based multilevel double rod instrumentation or anterior plate-rod instrumentation with primary stability. The outcome of those methods has improved the results of correction and decreased the complication rate but also means high costs due to the implants. Scoliosis correction is covered by DRG I06. Due to constant efforts a general improvement took place in the assessment of DRG I06. That is the reason why the losses incurred in DRG I06C could be lowered to 38% and in I06D to 22% in 2008. For an appropriate assessment further improvements are required.

Functional diagnostics of the dorsal root are especially effective via nociceptive fibers on account of less intersegmental overlap compared to large-diameter fibers of the mechanoreceptive afferents. Laser-evoked potentials (LEP) are induced by short, painful heat stimuli. The aim of this work was to describe changes of the LEP in cases of dorsal root damage. The recorded LEP changes will be discussed with regard to their prognostic value as well as pathophysiologic aspects of dorsal root damage. Dorsal root function was tested in 21 patients suffering from clinically proven radiculopathy in one of the segments L4 to S1. Mechanosensibility and thermosensibility were clinically investigated. LEP were induced by slightly painful stimuli (80 on the affected and 80 on the contralateral unaffected dermatome). The LEP were evaluated by amplitude of the averaged electroencephalogram (EEG). In addition, a subjective pain rating was recorded after each stimulus. Investigation of dorsal root function by LEP in patients with radiculopathy yields two typical changes of the amplitude. On the one hand, there were significant reductions of amplitude, and on the other hand, a complete loss of LEP was found. LEP changes allow a graduation of patients who show no obvious differences in their clinical appearance. Which mechanisms are responsible as concerns deafferentiation and neuropathy of the dorsal root fibers are discussed. With regard to the LEP changes, a prognostic relevance in patients with dorsal root affections is likely. This question will be addressed in a prospective study soon.