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Purpose Questionnaire survey among the members of the German Spine Society (Deutsche Wirbelsaulen-Gesellschaft, DWG) to objectify oncological infrastructure and current standard of care in spinal tumor treatment in Germany. Methods All DWG-members were contacted via the society's e-mail and asked to respond in anonymized form to a related questionnaire. Questions were asked regarding surgical specialty, type of institution involved, numbers of spinal procedures, as well as questions on treatment for primary tumors, whether the respondent belonged to a tumor center, decision-making procedures for surgery, and the type of procedure. Results 84 centers providing surgical treatment for spinal tumors in their departments were identified. 52.6% were carrying out more than 500 spinal procedures per year. There was a significant association (P ≤ 0.05) between the numbers of spinal surgeries, the number of treated tumor patients per year, the organisation in a tumor center and the treatment of primary tumors. 76% are part of a local tumor center for interdisciplinary decision making (i.e.surgical treatment and adjuvant therapy). 74% of the institutions stated that conventional postoperative radiotherapy is standardly administered in the case of secondary lesions, with 24% of them referring patients to external services for radiotherapy. Conclusion In spite of often large numbers of spinal operations, the centers perform relatively small numbers of tumor operations, particularly for primary tumors. A nearly three-quarter majority of the departments are integrated into interdisciplinary tumor care. However, there is a marked number that do not belong to an interdisciplinary organisation. Further advances in multidisciplinarity and oncology training are a continuous issue to increase treatment quality in spinal tumor patients.

In patients with adult spinal deformity, it was previously shown that 16 of the non-management items of the SRS-instrument showed a better fit to the theoretical four-factor model (pain, function, self-image, mental health) than did all 20 items. Whether the same phenomenon is observed in data from younger ( 20y) patients, for whom the questionnaire was originally designed, is not currently known.Confirmatory factor analysis was used to evaluate the factor structure of the 20 non-management items of the SRS-instrument completed by 3618 young patients with spinal deformity (75.5% female; mean age, 15.0 ± 2.0 years) and of its equivalence across language versions (2713 English-speaking, 270 Spanish, 264 German, 223 Italian, and 148 French). The root mean square error of approximation (RMSEA) and comparative fit index (CFI) indicated model fit.Compared with the 20-item version, the 16-item solution significantly increased the fit (p 0.001) across all language versions, to achieve good model fit (CFI = 0.96, RMSEA = 0.06). For both 16-item and 20-item models, equivalence across languages was not reached, with some items showing weaker item-loading for some languages, in particular German and French.In patients with adolescent idiopathic scoliosis, the shorter 16-item version showed a better fit to the intended 4-factor structure of the SRS-instrument. The wording of some of the items, and/or their equivalence across language versions, may need to be addressed. Questionnaire completion can be a burden for patients; if a shorter, more structurally valid version is available, its use should be encouraged.

Background The recently developed Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0) was proven a valid and reliable instrument measuring health-related quality of life (HRQOL) for patients with spinal malignancies. A German version was not available. Objective A cross-cultural adaptation of the SOSGOQ2.0 to the German language and its multicenter evaluation. Methods In a multistep process, a cross-cultural adaptation of the SOSGOQ2.0 was conducted. Subsequently, a multicenter, prospective observational cohort study was initiated to assess the reliability and validity of the German adaptation. To assess external construct validity of the cross-cultural adapted questionnaire, a comparison to the established questionnaire QLQ-C30 from the European Organisation for Research and Treatment of Cancer was conducted. Mean-difference plots were used to measure the agreement between the questionnaires in total score and by domain (deviation from mean up to 10% allowed). Further reliability and validity tests were carried out. Change to baseline was analysed 3–16 weeks later after different interventions occurred. Clinically relevant thresholds in comparison to the EORTC QLQ-C30 questionnaire were evaluated by ROC curve analysis. Results We could enroll 113 patients from four different university hospitals (58 females, 55 males). Mean age was 64.11 years (sd 11.9). 80 patients had an ECOG performance status of 2 or higher at baseline. External construct validity in comparison to the EORTC QLQ-C30 questionnaire in total score and by domain was confirmed (range of deviation 4.4 to 9.0%). Good responsiveness for the domains Physical Functioning (P

BackgroundStaphylococcus aureus surgical-site infections (SSIs) are a major cause of poor health outcomes, including mortality, across surgical specialties. Despite current advances as a result of preventive interventions, the disease burden of S. aureus SSI remains high, and increasing antibiotic resistance continues to be a concern. Prophylactic S. aureus vaccines may represent an opportunity to prevent SSI.MethodsA review of SSI pathophysiology was undertaken in the context of evaluating new approaches to developing a prophylactic vaccine to prevent S. aureus SSI.ResultsA prophylactic vaccine ideally would provide protective immunity at the time of the surgical incision to prevent initiation and progression of infection. Although the pathogenicity of S. aureus is attributed to many virulence factors, previous attempts to develop S. aureus vaccines targeted only a single virulence mechanism. The field has now moved towards multiple-antigen vaccine strategies, and promising results have been observed in early-phase clinical studies that supported the recent initiation of an efficacy trial to prevent SSI.ConclusionThere is an unmet medical need for novel S. aureus SSI prevention measures. Advances in understanding of S. aureus SSI pathophysiology could lead to the development of effective and safe prophylactic multiple-antigen vaccines to prevent S. aureus SSI.

Cement augmentation of pedicle screws biomechanically increases screw purchase in the bone. However, clinical complications may occur. The pros and cons of the technique are discussed from different clinical perspectives.

The radiographic fusion rates, graft behaviour and clinical outcome of 41 patient with simultaneous combined anterior lumbar interbody fusion and posterior arthrodesis with translaminar screws were reviewed independently. In all patients a femoral cortical allograft (FCA) ring filled with autologous iliac crest cancellous bone was used anteriorly to replace the disc and achieve interbody fusion. The follow-up averaged 30.6 months, with a minimum follow-up of 24 months. All patients had disabling low-back pain with different degrees of radiating leg pain and either discogenic pain (n = 24) or a postdiscectomy syndrome (n = 15) respectively postfusion syndrome (n = 2). The overall fusion rate was 95.2% (59 of 62 segments). Time to radiographic fusion averaged 8.7 months (range 2-34 months), and in 66.1% radiographic fusion occurred without significant subsidence. In 18.6% fusion with subsidence resulted from resorption of the FCA and in 15.3% the FCA had protruded into the vertebral body. The posterior intervertebral disc height (PIVDH) increased postoperatively by 2 mm on average. However, loss of PIVDH was the rule, and occurred within the first 12 postoperative months, resulting in a negligible final gain in height of 0.3 mm on average. The segmental lordosis was increased by 3 degrees; however, loss of lordosis during the first 6 postoperative months led to a final gain in lordosis of 1.3 degrees on average. Graft incorporation occurred in 16 of 62 segments (25.8%) and was observed at an average of 21.9 months postoperatively. Subjectively, 82.4% of the patients were satisfied or highly satisfied with the clinical result of the fusion operation. In conclusion, the described technique has proven to be highly effective in achieving a high fusion rate with a good patient outcome.

Diagnostic radiology and magnetic resonance imaging (MRI) are the most important imaging tools in the evaluation of benign bone tumors. Computed tomography (CT) is an additional tool for bony lesions, such as in cases of confirmation of the diagnosis of osteoid osteomas. For benign bony lesions three-stage skeletal scintigraphy is an optional additional diagnostic tool. The identification of benign or semimalignant bone tumors is not always clear; therefore percutaneous biopsy is necessary in most cases. In benign spinal tumors an intralesional curettage with reconstruction and stabilization is sufficient. In cases of semimalignant tumors, e.g. giant cell tumors localized in the spine, an en bloc resection is necessary because of the high recurrence rate.

Patients suffering from ankylosing spondylitis are prone to injuries of the cervical spine even with minor trauma. Although the fractures are markedly unstable, nonsurgical treatment using a halo-thoracic plaster or jacket is a common approach.We present three patients with cervicothoracic fractures of the ankylosed spine to describe problems and complications inherent in this type of treatment. In two, pin track infections and pin protrusion through the skull occurred, leading in one case to an intracerebral hemorrhage. In the third patient, the halo had to be removed after 8 months, just early enough to prevent the pins from cutting through.One patient required craniotomy. The second one could be resolved by local revision. In the third case, the fracture eventually united after using a stiff collar for 2 years.Halo treatment for cervical spine fracture in patients with ankylosing spondylitis is a challenging task for orthopedic surgeons and neurosurgeons.

Indications for surgical treatment of idiopathic scoliosis are progressive curves greater than 40-50 degrees. In most cases, fusion of only the primary (structural) curve(s) is sufficient due to the flexibility and spontaneous correction of the secondary curves. Therefore, it is crucial to identify both primary and secondary curves. According to the Lenke classification, all curves with a residual curve of more than 25 degrees on the bending films and those with a pathological kyphosis are regarded as structural and should be fused, whereas the nonstructural curves can be left unfused. However, according to reports in the literature and to the author's experience, clinical parameters such as shoulder level and rib or lumbar hump as well as radiometric criteria such as rotation are relevant as well. In summary, the Lenke classification is an important and helpful tool for analysing idiopathic curves and determining fusion length, even though each scoliosis case needs to be evaluated individually, especially taking clinical parameters into account.

In spinal fusion procedures, the local bone that is resected serves as the base bone graft for attaining biological fusion. The local bone is frequently not sufficient and requires supplementary grafting. Autologous bone transplantation is still regarded as the gold standard but might cause additional complications; also, autograft resources are limited. Alternatively, allografts and a wide variety of different bone substitutes are available.The bone substitutes currently used in scoliosis surgery are presented, and their clinical significance is elucidated by a review of the literature. Furthermore, our own experiences and clinical practice are compared with those in the literature and are critically discussed. The recently growing number of scientific publications reporting on bone substitutes reflects the immense interest and relevance of this issue. In scoliosis surgery, calcium phosphate ceramics together with bone marrow aspirate are increasingly applied.Although harvesting of autologous bone continues to be the accepted standard to extend the local autograft in scoliosis surgery, there is a clear trend toward the use of bone substitutes.

Posterior correction and fusion of scoliosis with multisegmental instrumentation systems was developed by Cotrel-Dubousset in the 1980s. Initially correction and instrumentation was performed using hooks only. Later pedicle screws were implemented first for the lumbar and then for the thoracic spine. Nowadays instrumentation based on pedicle screws only is well established for posterior scoliosis surgery. Biomechanical studies demonstrated higher pull-out forces for pedicle than for hook constructs.In clinical studies several authors reported better Cobb angle correction of the primary and the secondary curves and less loss of correction in pedicle screw versus hook instrumentations. Furthermore, pedicle screw instrumentation allows fewer segments to be fused, especially caudally, and thus saving mobile segments. In most of these publications there were no differences in operation time, blood loss and complication rates. In summary, there is better curve correction without an increased risk using multisegmental pedicle screw instrumentation in modern posterior scoliosis surgery.

In primary tumors of the spine and, with limitations, solitary metastasis, the surgical approach should aim for curative treatment of the disease. Because the prognosis of malignant bone tumors is extremely limited, if an intralesional approach is performed, an extralesional en bloc resection is the treatment of choice. Therefore, it is mandatory to use an appropriate staging system. For the spine, the WBB staging system has been approved, which transfers the principles of the Enneking classification for treating primary malignant tumors of the limb to the spine. After en bloc spondylectomy, rigid and primary stable instrumented dorsoventral reconstruction must be performed - posteriorly with a dual-rod system using pedicle screws, and anteriorly in the ideal case by means of a vertebral body replacement cage. The possibility of extralesional (wide or marginal) resection of spinal tumors depends on tumor size and location. Extralesional resection and, if indicated, other neoadjuvant, adjuvant, or local therapeutic modalities have a strong positive influence on long-term survival rates. A good prognosis for primary tumors is associated with a good response to chemotherapy and extralesional resection. Solitary metastases have a much worse quod vitam prognosis. Therefore, local control of the disease in en bloc resections of solitary metastasis is a second relevant goal, although curative treatment is the primary aim.

In the surgical treatment of idiopathic scoliosis both anterior and posterior correction and instrumentation techniques are available. The aim of the present study was to analyse the results of a new anterior dual rod instrumentation.Prospective analysis of radiometric and clinical parameters of 93 patients operated on between 1996 and 2004 using the Münster Anterior Dual Rod System.The average curve correction was 65% (fusion length usually Cobb levels) with a preoperative Cobb angle of 59 degrees. Postoperative loss of correction amounted to 1.5 degrees (average follow-up of 36 months). Apical vertebral derotation averaged 45% in the thoracic and 53% in the lumbar spine with a subsequent correction of the rib hump of 66% and the lumbar hump of 81%. There were no revisions or neurological complications.Anterior dual rod instrumentation enables an effective and safe three-dimensional curve correction in single structural curves with only minimal loss of correction.

The idiopathic scoliosis is a three dimensional spinal deformity mostly occurring in female adolescents. Untreated it can progress and result in back pain, impaired lung capacity and psychosocial disorders due to the cosmetic appearance of the deformed trunk. The treatment depends on the severity of the curve and ranges from physiotherapy and observation, brace treatment to surgical treatment with partial correction and fusion of the primary curve. Patients with an idiopathic scoliosis should be encouraged to actively take part in sports activities. Positive influences on the general fitness including the lung function, on the trunk muscles and on the psyche can be expected. There are no scientific data indicating that any kind of sport activities alter the natural history of idiopathic scoliosis.

Lumbar interbody fusion used to be the most common surgical treatment for painful lumbar disc degeneration. With the technical development of total disc prostheses, replacement of the degenerated disc by a motion preserving implant has become a widely discussed alternative. The advantages of such replacement appear to include the prevention of adjacent segment disease as well as less perioperative morbidity. Three types of total disc prostheses are currently in common use. Although numerous studies have been made, a review of the literature reveals only two multicenter randomized studies comparing the outcome of disc prostheses with a control group of fusion patients. After 2 years, the available results show similar improvement after both types of surgery without significant differences. However, there is a trend towards faster recovery and improvement in disc arthroplasty patients. The long-term results of current and future randomized studies, including studies comparing results after disc arthroplasty, with results of standardized conservative therapies will determine the fate of lumbar disc prostheses.

The functional assessment of individuals with congenital defects of the spine requires a differentiated judgement. A lumbalisation or sacralisation of the lumbosacral junction does not seem to be associated with increased lower back pain. However, it remains unclear whether this is the case in individuals with a spina bifida occulta. Defects of segmentation or formation alter the biomechanical loading of the spine, especially in cases of a secondary spinal deformity the functional status can be substantially impaired. Spinal deformities include idiopathic scoliosis, Scheuermanns kyphosis and spondylolisthesis. Depending on the severity of the deformity, they can affect the functional status and may be associated with increased lower back pain.

The aim of this paper was to analyse the vertebral morphometry in idiopathic scoliosis with respect to pedicle screw instrumentation by means of computed tomography scans. The pedicle morphometry between T5 and L4 was analysed by computed tomography scans in 29 surgically treated patients with idiopathic right thoracic scoliosis. Measurements included chord length, endosteal transverse pedicle diameter and transverse pedicle angle. The endosteal transverse pedicle diameter was significantly smaller (P0.05) on the concavity in the apical region of the thoracic spine. The chord length was the shortest at the fifth thoracic vertebra with significantly larger dimensions on the concavity of the apical region in the thoracic spine (P0.05). The transverse pedicle angle varied between 6 degrees in the lower thoracic spine and 12 degrees at the upper thoracic and lower lumbar spine. The morphometry in scoliotic vertebrae is substantially different from those in normal spines with an asymmetrical intra-vertebral deformity. Pedicle screw instrumentation in the middle thoracic spine appears critical due to the small endosteal pedicle diameter, especially on the concave side.

To prospectively evaluate the results of brace treatment in idiopathic scoliosis and to define risk factors of treatment failure.Fifty-two patients with a Cobb angle of between 25 and 40 degrees were included in the study. Prior to initiation of brace treatment with the Chêneau-Toulouse-Muenster orthesis, skeletal age and flexibility of the curve (bending films) were evaluated. The average follow-up after weaning of the brace was 42 months (36-78 months).An average initial Cobb angle of 31 degrees was corrected to 18 degrees (43 %) under brace treatment with a flexibility to 6 degrees Cobb angle on bending films. Three years after weaning there was an overall increase of the Cobb angle to 37 degrees on average. The apical vertebral rotation was corrected from 16 degrees to 11 degrees (31 %) and increased to 20 degrees during follow-up. Thoracic kyphosis changed from 24 degrees to 18 degrees during treatment. At the latest follow-up kyphosis had returned to the pre-treatment angle again. Twenty-two patients had a curve progression during or after brace treatment of more than 5 degrees. In 14 patients surgical correction and fusion have been indicated. There was a positive correlation between flexibility and Cobb angle correction during brace treatment and a negative correlation between Cobb angle correction during brace treatment and curve progression (p0.05).Curve progression was prevented in 58 %. Prognostic risk factors are a young age at initiation of brace treatment, a thoracic curve, unsatisfactory curve correction in the brace and a male gender.

Radiometric curve analysis of instrumented primary and spontaneous secondary curve correction after anterior correction and fusion of idiopathic thoracic scoliosis.Sixty-four patients with idiopathic thoracic scoliosis were prospectively evaluated. All patients were operated either with the Zielke-VDS or with a primary stable double rod instrumentation with selective fusion of the thoracic curve from end-to end-vertebra. Follow-up averaged 29 months (24 - 52 months).The Cobb angle of the primary curve averaged 63.2 degrees preoperatively and was corrected to 21.4 degrees postoperatively with an average loss of correction of 5.3 degrees (58 % final curve correction). Apical thoracic vertebral rotation was corrected by 48 %. The secondary lumbar curve measured 38.2 degrees preoperatively (72 % correction on the bending films) and was spontaneously corrected by 57 % to 16.4 degrees without significant loss of correction in the final follow-up. Apical vertebral rotation averaged 11.3 degrees in the lumbar curve and was corrected spontaneously by 24 % to 8.6 degrees without significant loss of correction. Lumbar apex vertebra deviation showed no significant reduction. There was no case of lumbar curve decompensation in either frontal or sagittal plane. Implant related complications were observed in 7 patients (rod breakage), but no pseudarthrosis occurred. There were no neurological complications noted.Selective anterior correction and fusion in idiopathic thoracic scoliosis enables a satisfactory correction of both primary and lumbar secondary curves. The advantage of selective anterior correction and fusion of thoracic scoliosis is the short fusion length, better derotation and satisfactory correction of the secondary lumbar curve. The disadvantages of single threaded rod techniques in terms of lack of primary stability and a kyphogenic effect have been eliminated by the development of a primary stable, small size double rod instrumentation.

The expert evidence of operated patients with idiopathic scoliosis is determined by functional and pulmonary restriction. The degree of deformity and the extent of fusion is crucial for grading disability. In a retrospective study on the quality of life (SF-36) and low back pain (Roland-Morris Score) of 82 patients (22 - 40 years) with idiopathic scoliosis treated with Harrington instrumentation the grading was registered.An average of 16.7 years after the surgery, these data were correlated with the type and size of curve and to the extension of fusion.Compared to the age-matched healthy population, there was no significant difference in the physical SF-36 scale (P = 0.98). Surgically treated patients showed significantly lower scores than at baseline in the psychological SF-36 scale (P = 0.005). Sixty-five (79.3 %) of the eighty-two patients reported no or occasional back pain in the Roland Index. Five patients (6.1 %) complained of chronic back pain. 33 patients (40 %) were legally defined in their rate of disability as severely handicapped patients. The grading disability was associated with the physical SF-36 scale (P0.001) and the low back pain (P = 0.02). A significant correlation between the grading disability and the extent of fusion (P = 0.53) or the size of curve (p = 0.4) could not be proven.Despite good long-term outcomes, 40 % of operated treated patients with idiopathic scoliosis were legally defined as severely handicapped persons. The additional measurements of quality of life and low-back pain can improve legal assessment in orthopaedics.

Aim of this study was to compare the results of the surgical repair of full-thickness rotator cuff tears with and without resection of the lateral clavicle.102 patients were retrospectively observed by an independent observer for a mean follow-up of 21 months (12 - 42). 93 patients had medium to large sized tears (1 - 5 cm) and 9 had massive tears (5 cm). Additional resection of the lateral end of the clavicle was performed in 20 patients. The mean age of the 68 men and 34 woman was 57.3 years (28 - 80). For the evaluation the Constant score, the ASES score and the visual analogue scales for postoperative satisfaction, function, strength, pain and ADL were used.The subjective results were good to excellent in 79 patients (76 %), fair in 14 patients (13.7 %) and poor in 9 patients (8.9 %), too. After surgery the Constant score was 87 % of the contralateral side for all patients, 89 % for group I and 84 % for group II and the mean ASES score was 86 %, 87 % and 82 % of the contralateral side. Comparing the pre- and post-operative values on the visual analogue scale pain and disability in ADL were decreased highly significantly in all patients (p0.001).We conclude that in patients with a full-thickness rotator cuff tear the patient's satisfaction and function will improve after acromioplasty and rotator cuff repair. The results are not significantly influenced by an additional resection of the lateral clavicle.

The posterior extension osteotomy leads to a lengthening of the anterior column, which is associated with neurological complications and the risk of injuring retroperitoneal structures. Especially in high-grade syndesmophytosis the results are dissatisfactory. In this study we report on the results of an alternative procedure named the transpedicular subtraction osteotomy.After resection of the posterior elements of the vertebra at the level of the osteotomy, a wedge of the vertebral body including the pedicles with posterior basis is resected followed by an instrumented closing wedge, which leads to relordosation. 12 patients were treated with this method and reexamined with a minimum follow-up of 2 years (2 - 6 years). The level of osteotomy ranged from T12 to L3.The mean segmental correction averaged 30.1 degrees (25 - 36 degrees ). The overall relordosation averaged 35.9 degrees and was related to additional correction in the adjacent segments. With this dissatisfactory a sufficient correction of spinal balance and visual axis was obtained. All patients were satisfied with the result of the operation and would undergo surgery again from a retrospective point of view.With the transpedicular subtraction osteotomy fixed kyphotic deformities of the spine in patients with ankylosing spondylitis can be corrected produce safely. The level of osteotomy is discussed and should depend upon the apex of kyphosis.

Radiographic analysis of long-term results following CDI.Retrospective analysis of radiographs of 43 patients with idiopathic right thoracic scoliosis with an average follow-up of 82 months. Extensive radiographic analysis with special regard to curve correction in the frontal and sagittal planes.The average Cobb-angle of the preoperative primary curve was 61.6 degrees (min.: 40 degrees, max.: 84 degrees ), the correction postoperatively was 51.1 % representing 29.9 degrees. Due to the loss of correction of 7.1 degrees, the overall outcome was 39.9 % by the time of follow-up. More than 90 % of the loss of correction occurred within the first 2 years. The lumbar secondary curve correction was 47.2 % (preop.: 37.5 degrees; postop.: 19.8 degrees ). Average fusion length was 11 segments, fusion usually ended two vertebrae below the end vertebra. Translation of the apex was corrected by 38.8 % (preop.: 4.9 cm; postop.: 3.0 cm), tilt of the last instrumented vertebra by 44.2 % (preop.: 18.2 degrees; postop.: 10.16 degrees ). The amount of derotation was negligible (preop.: 24.1 degrees; postop.: 22.6 degrees ). The readjustment of a preoperative pathologic sagittal profile, meaning a thoracic hypokyphosis, was successful in 12 out of 15 cases. Blood loss, duration of operation and complications were documented.CD-Instrumentation in scoliosis surgery offers a long-lasting suffcient correction of the fronal and a good correction of the sagittal plane. Stability of correction is achieved 2 years after operation.

A low-dose radiotherapy with 5 Gy on the lumbar spine in patients with chronic low back pain was investigated.31 patients with non-radicular low back pain since three years at the age of at least 50 years (64.3 years on average) were treated. A psychosomatic etiology of pain was excluded. 5 Gy or 0.5 Gy (placebo dose) were applied in five fractions to the lumbar spine including the facet joints. The pain was evaluated by means of the Oswestry-Disability-Score before, six weeks after therapy, and every three months during the follow-up (22.4 months on average). Drug therapy, physiotherapy, and physical treatment were continued.According to the randomised distribution, 18 patients were treated with 5 Gy and 13 patients with 0.5 Gy. The Friedman-Test did not reveal any significant difference (p0.05) of the Oswestry-Disability-Index before and after therapy for both single questions and the sum of questions in both groups.No significant decrease of the Disability Index after radiotherapy on the lumbar spine with 5 Gy could be demonstrated in the verum and placebo group. The authors do not recommend radiotherapy in cases of chronic low back pain. Individual successes have to be attributed to conservative treatment or placebo effects.

While the biomechanical properties of pedicle screws have proven to be superior in the lumbar spine, little is known concerning pullout strength of pedicle screws in comparison to hooks in the thoracic spine. In vitro biomechanical pullout testing was performed to evaluate the axial pullout strength of pedicle screws versus pedicle and laminar hooks in the thoracic spine with regard to surgical correction techniques in scoliosis. Nine human cadaveric thoracic spines were harvested and disarticulated. To simulate a typical posterior segmental scoliosis instrumentation, standard pedicle hooks were used between T4 and T8 and supralaminar hooks between T9 and T12 and tested against pedicle screws. The pedicle screws were loaded strictly longitudinal to their axis; the hooks were loaded perpendicular to the intended rod direction. In total, 90 pullout tests were performed. Average pullout strength of the pedicle screws was significantly higher than in the hook group (T4-T8: 531 N versus 321 N, T9-T12: 807 N versus 600 N, p0.05). Both screw diameter and the bone mineral density (BMD) had significant influence on the pullout strength in the screw group. For scoliosis correction, pedicle screws might be beneficial, especially for rigid thoracic curves, since they are significantly more resistant to axial pullout than both pedicle and laminar hooks.

In order to evaluate the outcome of the operative treatment of neuromuscular scoliosis 45 patients were studied prospectively.27 Patients were operated by posterior correction and fusion using the Münster Posterior Doublerod-System (MPDS) (GI). 18 Patients were treated with one-stage ventro-dorsal procedure in combination of VDS with MPDS (GII). For all patients, medical and radiographic records were available, with a minimum follow-up of 2 years. Postoperative management, bloodloss and complications will be discussed.In group I the main curve (76.3 degrees), by an average flexibility of 36.1%, were corrected by 53.5% and 52.3% at follow up. The mean pelvic obliquity (7.7 degrees) averaged 53.8%. The mean major scoliosis of group II (107.1 degrees), by an average flexibility of 25%, gets improved by 61%. At most recent follow-up, the mean correction was 61.5%. The mean pelvic obliquity (23.1 degrees) averaged 73.2% and 70.6% respectively. The mean bloodloss in group I was 1840 ml and in group II 2180 ml.The data in the current study support the benefit of the operative treatment of patients with severe neuromuscular scoliosis. The quality of life gets improved by stability in seating and standing by correction of pelvic obliquity and trunk instability.

So far only radiometric and clinical methods have been available for the evaluation of results after anterior scoliosis surgery. Rasterstereography has proved to be a reliable method for three-dimensional surface measurement of conservatively treated idiopathic scoliosis patients. Therefore, patients treated operatively with anterior instrumentation were examined using rasterstereography to determine the three-dimensional correction of the spinal deformity. The aim was to measure back shape deformity, in particular derotation, and thus cosmetic improvements.31 patients with idiopathic thoracic, thoracolumbar and lumbar scoliosis (Cobb angle 57.2 degrees) were examined with raster stereography preoperatively, postoperatively and after follow-up (25.2 months) in a standardized standing posture. Standing radiographs were compared with raster stereography.The mean Cobb angle was reduced from 57.2 degrees to 17.2 degrees, the rasterstereographic maximal surface rotation from 16.5 degrees to 10.8 degrees, and the vertebral rotation according to Perdriolle from 29.2 degrees to 16.7 degrees. During follow-up the Cobb angle increased to 20.8 degrees, and surface rotation to 11.3 degrees. Vertebral rotation remained constant. Lordosis and kyphosis angles changed only slightly.Rasterstereography is a suitable tool for analyzing the three-dimensional correction of spinal deformities after anterior scoliosis surgery. In particular, the cosmetic improvement is clearly demonstrated. The measurement of surface rotation allows objective quantification of the obtained derotation.

Halm-Zielke Instrumentation (HZI) was developed to eliminate the disadvantage of ventral derotation spondylodesis (VDS)-Zielke in terms of lack of primary stability and in order to simplify sagittal plane control. Within a prospective clinical trial started in 1993, we have studied whether HZI fulfills these demands. HZI is an anterior double-rod system with a two screw per vertebral body fixation. The longitudinal components consist of a threaded VDS rod and a solid rod, which are attached to a hinge-conducted lid plate. Twenty-nine consecutive patients with idiopathic scoliosis and curves ranging from 36 degrees to 92 degrees were treated with HZI. The follow-up period ranged from 1 to 4 years. Correction of the frontal plane within the instrumented levels averaged 71.6% and 70.5% postoperatively and at follow-up, respectively. Derotation averaged 53.7% and mean correction of the tilt of the lowest instrumented vertebra was 69.5% at final follow-up. Thoracolumbar kyphosis was present in eight patients and was always completely corrected from +18.8 degrees to 3.3 degrees on average. One implant-related complication involved a screw breakage 18 months postoperatively without adverse effects. There was no case of pseudoarthrosis. All patients were mobilized without any additional external immobilization in terms of a brace or cast, and were allowed to go swimming for physiotherapeutical purposes immediately after wound healing. This study proves that HZI is a primary stable implant to perform VDS. Implant-related disadvantages typical of VDS are eliminated. Thereby, the period of rehabilitation is shortened by many months due to avoidance of cast and brace treatment.

Halm-Zielke Instrumentation (HZI) was developed to eliminate the disadvantage of VDS-Zielke in terms of lack of primary stability and in order to simplify sagittal plane control. Since 1993 we study within a prospective clinical trial, whether HZI fulfills these demands.HZI is an anterior double-rod system with a two screw per vertebral body fixation. The longitudinal components consist of a threaded VDS-rod and a solid rod, which are attached to a hinge-conducted lid plate. 25 consecutive patients with idiopathic scoliosis and curves ranging from 36 degrees to 92 degrees were treated with HZI. The follow-up period ranges from 2 to 4 years.Correction of the frontal plane within the instrumented levels averaged 71.4% and 70.4% postoperatively and at follow-up, respectively. Derotation averaged 51.7% and mean correction of the tilt of the lowest instrumented vertebra was 69.5% at final follow-up. Thoracolumbar kyphosis was present in 7 patients and always completely corrected. One implant related complication, a screw breakage 12 months postoperatively without adverse effects was noted. There was no case of pseudarthrosis. All patients were mobilized without any additional external immobilization in terms of a brace or cast and were allowed to go swimming for physio-therapeutical purposes immediately after wound healing.This study proves that HZI is a primary stable implant to perform the Ventral Derotation Spondylodesis. The VDS-typical implant related disadvantages are eliminated. With this the period of rehabilitation is shortened by many months due to avoidance of cast and brace treatment.

We prospectively studied 9 patients with deformities of the thoracic spine who underwent thoracoscopic surgery to critically evaluate the benefits and limitations of thoracoscopy.Seven patients with deformities of the thoracic spine (5 scoliosis, 2 kyphosis) underwent a thoracoscopic release and posterior correction and fusion in a single stage. In one case of a crankshaft-phenomenon a thoracoscopic epiphyseodesis und in another case of a posttraumatic kyphosis a thoracoscopic instrumentation and fusion were performed. The average age was 21 years, the follow-up was 18 months with a minimum of 12 months. The perioperative data including complications were collected and a radiographic analysis concerning curve correction was carried out.The scoliotic curves measured preoperatively 84 degrees on average with a Cobb angle of 62 degrees on the traction films and were corrected by 57% to averagely 36 degrees at follow-up. In the two cases of Scheuermann kyphosis a preoperative kyphosis of 94 degrees respectively 82 degrees was corrected to 52 degrees respectively 58 degrees. Between 4 and 5 discs were excised with an average operative time of 160 min and a blood loss of 380 ml. A conversion to open thoracotomy was not necessary in any case. There were no intraoperative neurovascular complications.Thoracoscopic procedures in deformities of the thoracic spine are technically demanding; however, it is a minimally invasive procedure with a reduced approach-related morbidity compared to open thoracotomy. The indications for a thoracoscopic release are rigid kyphosis and scoliosis with rigid curves between 80 and 90 degrees Cobb angle in which an anterior correction and instrumentation alone is not considered.

In order to evaluate the results of posterior correction and fusion using the Münster Posterior Doublerod-System (MPDS) 48 patients with idiopathic scoliosis were studied prospectively.All patients underwent clinical examination and radiological analysis of the frontal and sagittal plane preoperatively, postoperatively and at follow-up (2-4 years). Pedicle screws were used at the lumbar and thoracolumbar spine exclusively.The preoperative average Cobb angle was 61.4 degrees with an average flexibility of 36.8% to 38.8 degrees. The average postoperative Cobb angle was 24.8 degrees (59.6%) with an average loss of correction of 2.6 degrees Cobb angle (3.6%). Due to the use of thoracolumbar and lumbar pedicle screws instrumented fusion could be stopped at the lower endvertebra in 71%. Patients in whom only pedicle screws had been used improved correction of frontal plane could be shown compared to combined instrumentations with hooks and screws.The posterior instrumentation guarantees primary stability with good results of correction and allows brace free treatment postoperatively. The postoperative correction compared to the results at follow-up proves the stability of the instrumentation largely. The results of mainly pedicle screw based instrumentations verify that an improved correction can be achieved. In most cases fusion levels end at the lower end vertebra and therefore are shorter compared to instrumentation's based on hooks only.

While scoliosis and kyphosis are the most common spinal deformities in patients with myelomeningocele, single lordotic deformitics are rare. There are only few reports about the operative treatment of a primary thoracic lordosis of -135 degrees Cobb angle. By means of a dorso-ventral-dorsal procedure correction and stabilisation of the lordotic deformity was performed. A correction of -26 degrees Cobb angle was achieved without loss of correction during follow up of 18 months. The case report shows that in individual cases even severe lordotic deformities can be treated with surgery successfully. An anterior-posterior procedure should be considered. The case is discussed with the rare national and international literature.

To evaluate the midterm radiographic behaviour of femorocortical allograftrings (FCA) in lumbosacral fusions in patients with disabling low back pain.The radiographs of 41 patients with a minimum follow-up of 2 years were analysed by an independent orthopedic radiologist. The fusion rate was determined on lateral tomograms routinely obtained at 3 months intervals. On lateral radiographs the posterior intervertebral disc height as well as the segmental lordosis were measured. Changes of the allografting such as mottling, resorption and incorporation were registered.The fusion rate was 95.2%. Time to radiographic fusion averaged 8.7 months (2-34 months) and in 66.1% radiographic fusion occurred without significant subsidence. In 18.6% fusion with subsidence resulted from resorption of the FCA and in 15.3% the FCA had protruded into the vertebral body. The posterior intervertebral disc height increased postoperatively by 1.9 millimeters on average. However, postoperative height loss was the rule and occurred within the first 12 postoperative months, resulting in a negligible final gain in height of 0.3 millimeters on average. The final gain in segmental lordosis was 1.3 degrees on average. Complete graft incorporation occurred in 16 of 62 segments (25.8%).The described technique has proven to be highly effective in achieving a high fusion rate with a stable midterm graft behaviour.

Video rasterstereography is a method for back surface measurement comprising automatic back surface reconstruction and shape analysis. Aim of this prospective study was to determine the accuracy of this method in comparison to the conventional frontal and lateral standing radiographs.95 patients with idiopathic scoliosis or scoliotic postural abnormalities and 18 patients with thoracic hyperkyphosis and Scheuermann's disease were investigated. The Cobb angles, the sagittal profile and apical vertebral rotation as well as pelvic obliquity and trunk decompensation were measured. The analysis was carried out by two independent observers.The root mean square (r.m.s.) deviation of the Cobb angle in the cases of idiopathic scoliosis ranged between 7 degrees and 8 degrees. In video rasterstereography there were no false negative results and two false positive results concerning differentiation between structural scoliosis and scoliotic postural abnormality. The r.m.s. deviation of apical vertebral rotation averaged 7.9 degrees and for pelvic obliquity respectively trunk imbalance 0.65 cm respectively 1.07 cm. The thoracic hyperkyphosis in Scheuermann's disease showed a r.m.s. deviation of 5.6 degrees.Video rasterstereography is a reliable method in the three-dimensional evaluation of spinal deformities and constitutes a valuable additional tool to the clinical examination and can reduce the number of radiographs.

Thirty-one patients with spinal tumors underwent reconstructive surgery with our spinal instrumentation system (MPDS and MADS), with or without our new vertebral tumor prosthesis. The characteristics of the spinal tumors were analysed statistically and the treatment outcome was evaluated. There were 4 benign tumors, 6 malignant tumors, and 21 metastatic tumors. The malignant tumors involved the sacrum more frequently than the benign tumors (p = 0.0098). Metastatic tumors involved the thoracic spine more frequently than benign or malignant tumors (p = 0.0161). The average number of affected vertebrae was 1.2 in the benign tumors, 1.8 in the malignant tumors, and 2.4 in the metastatic tumors. The metastatic tumors had a tendency to involve the anterior or middle part of the spine more frequently than the benign or malignant tumors (statistically not significant). After surgery, neurological improvement was noted in 8 patients, nochange in 19 patients, and impairment due to resection of the nerve roots in sacral tumors in 4 patients.

We report on 48 patients with a mean postoperative follow-up of 7.7 years. 9 patients underwent simple anterior derotation spondylodesis (VDS), 31 patients were additionally fused with posterior Harrington spondylodesis. In 7 of 8 patients the Dwyer compression spondylodesis (DCS) was completed with the Harrington instrumentation. 2 of 3 scoliosis were idiopathic, the residual cases were mainly neuromuscular. The primary curve (preoperative mean: 69.9 degrees) was initially corrected by 62.8% and sustained a loss of correction of 7.6 degrees resp. 10.9% during long-term follow-up. The long-term loss of correction was maximal after DCS showing 10.4 degrees (14.4%), on the average, and minimal after combined VDS and Harrington spondylodesis showing 6.9 degrees (9.3%). After simple VDS the long-term progression of the curve was 7.0 degrees (12.9%). In this group the initial correction was above-average high showing 76.4%. The main loss of correction occurred during the first 2 years after surgery. The long-term correction stability did not show significant differences between simple VDS and combined antero-posterior instrumentation. After anterior instrumentation of the primary curve the secondary cranial nerve spontaneously straightened up by 30%, on the average, and remained stable in the long-term. The anterior instrumentation of the spine lead to a mean loss of lordosis of 13.6 degrees which in the long-term additionally increased by 6.4 degrees due to the anterior epiphyseodesis effect. In 17 patients (42.5%) 24 fractures of the 3 mm-threaded VDS-compression rod occurred. In case of single rod fractures no higher loss of correction or differences in incidence of pain were observed in comparison to intact implants.

Especially in idiopathic thoracolumbar scoliosis the approach and sort of instrumentation have controversially been discussed over the past years. Since 1986 32 patients with adolescent thoracolumbar scoliosis underwent operative treatment, 20 patients were treated with Cotrel-Dubousset Instrumentation (CDI), 10 patients underwent Ventral Derotation Spondylodesis (VDS). In 2 cases a combined two-stage VDS and CDI were performed. The follow-up was 38 months in the CDI-group and 19 months in the VDS-group. Length of the curve and the fusion were identical in the VDS-group. In the CDI-group, however, length of the fusion exceeded curve length by 4 segments on average. With CDI the fusion was carried down to L4 in most cases, in some cases to L5. Curve correction of the primary curve averaged 70% with VDS (preoperative mean 84 degrees) and 64% with CDI (preoperative mean 65 degrees). We observed a spontaneous correction of the secondary curve of 38% after VDS. With CDI the correction of the secondary curve averaged 42%, however, in secondary curves measuring more than 50 degrees primary and secondary curve were fused. A preoperatively physiological sagittal plane in the CDI-group remained unchanged after operative treatment. With VDS an average kyphosis of the thoracolumbar junction of +22 degrees was corrected to +7 degrees. We conclude that in the operative treatment of severe thoracolumbar scoliosis VDS offers significant advantages compared to CDI and should therefore be preferred. In moderate scoliotic deformities, where the number of caudally unfused segments is equal in both systems, CDI is justified.

The advantages of VDS according to Zielke with excellent 3-dimensional correction and shorter fusion levels in comparison to posterior instrumentation techniques are well known. A disadvantage is the necessity of long postoperative immobilization in a body cast or brace due to lack of primary stability. The aim of the VDS double-rod instrumentation is augmentation of the system with the possibility of postoperative treatment without plaster cast or braces. Following thoracolumbophrenotomy and ligation of the segmental vessels double-hole vertebra clamps are inserted. First VDS screws are placed in the posterior holes of these plates. With a 4-mm threaded compression rod correction is obtained by centripetal compressive forces on the nuts. Next VDS screws for the 5-mm threaded rod are inserted into the anterior holes of the vertebral clamps. The rod is implanted in a slightly compressive manner and augments the system. In a prospective study 8 patients, 4 with idiopathic and 4 with neuromuscular scoliotic deformities, underwent this surgical procedure and now have a follow-up of 2 years. Curves ranged from 45 degrees to 131 degrees Cobb angle. All patients were treated without plaster casts or braces postoperatively, but with only a semielastic vest for 4 to 6 months. Unusual intra- and postoperative complications have not been noted. Correction of the primary curve averaged 69.4% at follow-up. Tilt of the caudal end vertebra was corrected 75% to an average of 6.3 degrees. Spontaneous partial correction of the upper secondary curve was noted in all cases. Rod fracture of the 5-mm rod without fracture of the 4-mm rod at this level was seen in 1 patient without loss of correction. Solid fusion was achieved at every level in all patients. The sagittal plane was not adversely affected by the instrumentation. However, larger patient numbers and a longer follow-up are necessary.