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A retrospective single center cohort study with prospective collected data from an institutional spine registry.To determine whether restoration of lordosis L5/S1 is possible with both anterior lumbar interbody fusion (ALIF) and transforaminal lumbar interbody fusion (TLIF) and to find out which technique is superior to recreate lordosis in L5/S1.Seventy-seven patients with ALIF and seventy-nine with TLIF L5/S1 were included. Operation time, estimated blood loss), and complications were evaluated. Segmental lordosis L5/S1 and L4/5, overall lordosis, and proximal lordosis (L1 to L4) were measured in X-rays before and after surgery. Oswesery disability index and EQ-5D were assessed before surgery, and 3 and 12 months after surgery.Mean operation time was 176.9 minutes for ALIF and 195.7 minutes for TLIF (p = 0.048). Estimated blood loss was 249.2 cc for ALIF and 362.9 cc for TLIF (p = 0.005). In terms of complications, only a difference in dural tears were found (TLIF 6, ALIF none; p = 0.014). Lordosis L5/S1 increased in the ALIF group (15.8 to 24.6°; p 0.001), whereas no difference was noted in the TLIF group (18.4 to 19.4°; p = 0.360). Clinical results showed significant improvement in the Oswesery disability index (ALIF: 43 to 21.9, TLIF: 45.2 to 23.0) and EQ-5D (ALIF: 0.494 to 0.732, TLIF: 0.393 to 0.764) after 12 months in both groups, without differences between the groups.ALIF and TLIF are comparable methods for performing fusion at L5/S1, with good clinical outcomes and comparable rates of complications. However, there is only a limited potential for recreating lordosis at L5/S1 with a TLIF.Eine retrospektive Single-Center-Kohortenstudie mit prospektiv erhobenen Daten eines institutionellen Wirbelsäulenregisters.Es wurde untersucht, ob eine Wiederherstellung der Lordose L5/S1 sowohl mit ALIF als auch mit TLIF möglich ist und welche Technik zur Wiederherstellung der Lordose bei L5/S1 überlegen ist.77 Patienten mit ALIF und 79 mit TLIF L5/S1 wurden eingeschlossen. Operationszeit (OT), geschätzter Blutverlust (EBL) und Komplikationen wurden ausgewertet. Die segmentale Lordose L5/S1 und L4/5, die Gesamtlordose (LL) und die proximale Lordose (L1 bis L4) wurden in Röntgenbildern vor und nach der Operation ermittelt. Oswesery disability index (ODI) und EQ 5D wurden vor der Operation, 3 und 12 Monate nach der Operation ausgewertet.Die mittlere OT betrug 176,9 min für ALIF und 195,7 min für TLIF (p = 0,048). Die EBL betrug 249,2cc für ALIF und 362,9 cc für TLIF (p = 0,005). In Bezug auf Komplikationen wurde nur ein Unterschied bei den Duraläsionen gefunden (TLIF 6, ALIF keine, p = 0,014). Die Lordose L5/S1 nahm in der ALIF-Gruppe postoperativ zu (15,8 bis 24,6°, p 0,001), während in der TLIF-Gruppe kein signifikanter Unterschied festgestellt wurde (18,4° bis 19,4°, p = 0,360). Die klinischen Ergebnisse zeigten eine signifikante Verbesserung des ODI (ALIF: 43 auf 21,9, TLIF: 45,2 auf 23,0) und des EQ 5D (ALIF: 0,494 auf 0,732, TLIF: 0,393 auf 0,764) nach 12 Monaten in beiden Gruppen, ohne Unterschiede zwischen den Gruppen.Sowohl ALIF als auch TLIF sind vergleichbare Methoden zur Durchführung einer Fusion an L5/S1, mit guten klinischen Ergebnissen und vergleichbaren Komplikationsraten. Allerdings besteht bei Durchführung eines TLIF nur ein begrenztes Potenzial zur Wiederherstellung der Lordose bei L5/S1.

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.

In the operative treatment of idiopathic scoliosis, posterior correction and fusion in freehand technique is a proven procedure and is frequently performed. Malpositioned pedicle screws can result in serious neurovascular complications. Intraoperative fluoroscopy and neurophysiological measurements are performed to ensure the correct position of pedicle screws. Newer procedures with fluoroscopic- and computertomographic-assisted navigation are advertised as less dangerous and with a more accurate screw position.Is the freehand technique used in the surgical treatment of idiopathic scoliosis safer than other methods with regard to complications caused by screw malposition and intraoperative radiation exposure?Register data of 34 consecutive idiopathic scoliosis patients with two structural curves (Lenke 3 and 6) were collected prospectively in our scoliosis center and were retrospectively analyzed. The following parameters were evaluated: total radiation product, time of fluoroscopy, number of fused segments, time of operation, blood loss, screw-related complications and number of instrumented pedicle screws. All values were given as mean ± standard deviation and statistically analyzed. Finally, our data were compared on accuracy of screw placement and radiation exposure to data from literature with screw placement under navigation.Average age at the time of surgery was 23.6 ± 12 years. The average thoracic curve was 69.2 ± 14.2° preoperatively and 21.7 ± 12.8° postoperatively (correction 69.9%), the average lumbar curve was 64.3° ± 10.8° preoperatively and corrected to 15.6 ± 10.4° postoperatively (correction 76.2%). The total radiation product per patient was 145.7 ± 86.1 cGy*cm², the time of fluoroscopy 31.7 ± 23.5 s (11.5 segments), the time of operation 267.2 ± 64.1 min and the blood loss 700.4 ± 522.3 ml. A total of 803 pedicle screws were placed. No screw-associated complications were detected in the entire collective. The comparison of our data with freehand placement of pedicle screws to literature data showed a noticeable higher radiation exposure for the patient during fluoroscopic- and computertomographic-assisted navigation.The results showed that positioning of pedicle screws with freehand technique in patients with idiopathic scoliosis is accompanied with considerably lower intraoperative radiation exposure compared to fluoroscopic- or computertomographic-assisted navigation. An increased radiation exposure of these typically young patients is associated with an increased long-term risk for the occurrence of radiation-induced malignant diseases. With appropriate surgical experience, placement of pedicle screws in freehand technique is safe and effective and with similar accuracy than screws placed under navigation, but produces significantly less radiation exposure to the patients.In der operativen Therapie der idiopathischen Skoliose hat sich die dorsale Korrekturspondylodese mit Pedikelschrauben-Doppelstabsystem in Freihandtechnik bewährt und wird häufig durchgeführt. Durch Fehllage der Pedikelschrauben können schwerwiegende neurovaskuläre Komplikationen resultieren. Zur Überprüfung einer korrekten Schraubenlage werden intraoperative fluoroskopische Kontrollen sowie neurophysiologische Messungen durchgeführt. Neuere Verfahren mit fluoroskopischer oder computertomografisch gestützter Navigation werden als risikoärmer und mit genauerer Schraubenlage beworben.Ist die Freihandtechnik in der operativen Behandlung der idiopathischen Skoliose in Bezug auf die Komplikationen durch Schraubenfehllage und die intraoperative Strahlenexposition im Vergleich zu anderen Verfahren sicher?Prospektiv wurden Registerdaten von 34 konsekutiven Patienten erfasst und retrospektiv analysiert, die aufgrund einer doppelbogigen idiopathischen Skoliose (Lenke 3 und 6) in unserem Skoliosezentrum operiert wurden. Folgende Parameter wurden ausgewertet: Gesamtstrahlenprodukt, Durchleuchtungszeit, Anzahl fusionierter Segmente, Operationszeit, Blutverlust, schraubenassoziierte Komplikationen und Anzahl der gesetzten Pedikelschrauben. Alle Werte wurden als Mittelwert ± Standardabweichung angegeben und statistisch ausgewertet. Es erfolgte ein Vergleich unserer Daten zur Genauigkeit der Pedikelschraubenlage und der Strahlenbelastung mit den Daten der Literatur bei navigierten Verfahren.Das Alter zum Operationszeitpunkt betrug 23,6 ± 12 Jahre. Die durchschnittliche thorakale Krümmung betrug präoperativ 69,2 ± 14,2° und postoperativ 21,7 ± 12,8° (Korrektur 69,9%), die durchschnittliche lumbale Krümmung präoperativ 64,3 ± 10,8° und postoperativ 15,6 ± 10,4° nach Cobb (Korrektur 76,2%). Das Gesamtstrahlenprodukt pro Patient betrug 145,7 ± 86,1 cGy*cm², die Durchleuchtungszeit 31,7 ± 23,5 s (11,5 Segmente), die Operationszeit 267,2 ± 64,1 min und der Blutverlust 700,4 ± 522,3 ml. Insgesamt wurden 803 Pedikelschrauben gesetzt. Es traten im gesamten Kollektiv keine schraubenassoziierten Komplikationen auf. Der Vergleich unserer Daten in Freihandtechnik mit Literaturdaten zeigte eine für den Patienten deutlich höhere Strahlenexposition bei der fluoroskopisch gestützten und computertomografisch gestützten Technik.Anhand der Ergebnisse konnte gezeigt werden, dass die dorsale Instrumentation mit Pedikelschrauben-Doppelstabsystem in Freihandtechnik bei Patienten mit adoleszenter und adulter idiopathischer Skoliose mit einer erheblich geringeren intraoperativen Strahlenbelastung im Vergleich zu navigierten Verfahren einhergeht. Dabei ist die Art des navigierten Verfahrens unerheblich. Eine erhöhte Strahlenexposition der meist jungen Patienten ist verbunden mit einem erhöhten langfristigen Risiko für das Auftreten strahleninduzierter maligner Erkrankungen. Bei entsprechender chirurgischer Erfahrung können Pedikelschrauben in Freihandtechnik mit vergleichbarer Genauigkeit sicher und effektiv gesetzt werden, führen jedoch zu einer signifikant geringeren Strahlenbelastung für den Patienten.

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.

Die fixierteGefugestorung ist begrifflich nicht klar definiert und im englischen Sprachraum so nicht bekannt. Daher einigten sich die Kontrahenten auf die Beleuchtung der stabilen (fixierte) degenerativen Spondylolisthesis mit Spinalstenose. Die Durchsicht der Literatur belegt bei Dekompression mit gleichzeitiger instrumentierter Fusion eine geringere Kreuzschmerzrate und -intensitat (VAS), eine hohere Lebenqualitat bei Betrachtung standardisierter Messinstrumente (ODI, EQ-5 D) und eine signifikant geringere Revisionsrate. Daruber sollten Patienten mit diesem Krankheitsbild, bei denen nur eine Dekompressions-OP geplant ist, aufgeklart werden.

Degenerative Lumbaskoliosen gehen nahezu ausnahmslos mit Ruckenschmerzen und in bis zu 70 % der Falle mit neurogenen Beinschmerzen einher. Das Auftreten einer segmentalen lateralen Olisthese ist dabei ein entscheidender Faktor fur die frontale und sagittale Progression der Deformitat. Operative Masnahmen sind mit einer sehr hohen Komplikationsrate assoziiert, sodass eine umfassende konservative Behandlung immer Ausgangspunkt therapeutischer Uberlegungen sein sollte. Erst bei gravierenden Beschwerden ist eine operative Intervention in Form von isolierten dekomprimierenden Eingriffen, kurzstreckigen Fusionen oder langstreckigen Korrekturspondylodesen indiziert. Neben der Beurteilung der klinischen Symptomatik ist eine gezielte bildgebende Diagnostik die Voraussetzung fur die Wahl des geeigneten Verfahrens. Die alleinige Dekompression ist nur bei stabilen Deformitaten und fuhrender neurologischer Symptomatik eine sinnvolle Therapieoption. Die kurzstreckige, bis zu 3 Segmente umfassende Fusion kann wiederum bei einer fokalen Pathologie im Anfangsstadium der Deformitat gerechtfertigt sein. Als weniger invasive Alternative bei fortgeschrittenen degenerativen Lumbalskoliosen eignet sich die limitierte Fusion nicht. Ausgepragte Deformitaten mit Zeichen der Progression erfordern fur eine anhaltende Beschwerdereduktion eine multisegmentale Korrektur und Spondylodese unter Berucksichtigung des frontalen und sagittalen Alignements. Voraussetzung fur die Durchfuhrung dieses komplexen Eingriffes ist ein standardisiertes perioperatives Management. Die Erfolg versprechende operative Therapie einer degenerativen Lumbalskoliose setzt stets differenzierte und individuelle Entscheidungen voraus.

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 …

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.

Ventrale dreidimensionale Korrektur einer skoliotischen Deformitat sowohl in der koronaren als auch in der sagittalen Ebene mit Schaffung eines physiologischen Wirbelsaulenprofils bei moglichst kurzer Fusionsstrecke. Skoliotische Deformitat mit thorakaler, lumbaler oder thorakolumbaler Hauptkrummung zwischen 40° und 90° (Cobb) im Bereich von Th4 bis L4. Die Indikation zur selektiven anterioren Korrektur der idiopathischen Skoliose muss anhand der Lokalisation der Deformitat unter Berucksichtigung der Flexibilitat (der Haupt- und Nebenkrummung) und des sagittalen Profils (Lordose, Kyphose) erfolgen. Nach der Lenke-Klassifikation eignen sich fur ein solches Operationsverfahren vor allem der Typ 1 („main thoracic“) und der Typ 5 („thoracolumbar/lumbar“). Osteoporose. Infektion. Metallallergie (Titan Ti 6Al-4V). Fehlende Flexibilitat der Nebenkrummung. Strukturelle Kyphose im Bereich der Hauptkrummung. Pathologische Kyphose kranial oder kaudal der geplanten Instrumentation. Zugangsweg und Praparation des Instrumentationsbereichs entsprechend der Thorakotomie und Thorakophrenolumbotomie mit Darstellung der ventralen Wirbelsaule. Vollstandige Diskektomie im Fusionsbereich und Fixation der Bugelplatten seitlich an den Wirbelkorpern mit zwei divergierend eingebrachten Schrauben, die bikortikal verankert werden. Korrektur der Deformitat uber verschiedene Manover wie Cantilever-Forces, Stabrotation und segmentale Kompression. Erzielen der Primarstabilitat durch Einbringen eines rigiden und teilflexiblen Stabs (Doppelstabsystem). Schichtweiser Wundverschluss der Thorakotomie unter Einlage einer Bulau-Drainage. Korsettfreie Nachbehandlung. Physiotherapie. Atemtherapie. Nahezu immer Erreichen der knochernen Spondylodese. Exzellente und nachhaltige frontale Korrektur von 60–70%. Sehr gute spontane Korrektur der kranialen und auch der lumbalen Nebenkrummung von ca. 40% sowie Herstellung eines physiologischen Profils. Fusionsstrecke und Korrekturwinkel vergleichbar mit modernen dorsalen transpedikularen Doppelstabsystemen.

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.

INTRODUCTION AND AIM OF THE STUDY The advantages of the VDS according to Zielke with excellent three dimensional correction and shorter fusion levels in comparison to posterior instrumentation techniques are well known. A disadvantage is the postoperatively necessary long immobilisation in a body cast due to lack of primary stability. Aim of the presented double-rod-VDS is to optimize the system by augmentation and allow a postoperative plaster cast- and brace-free treatment. METHOD AND MATERIAL Following thoracolumbar phrenotomy and ligation of the segmental vessels Kaneda-clamps are inserted. First VDS-screws are implanted into the posterior holes of these clamps. Using a M-4 compression rod, correction is obtained by centripetal compressive forces to the nuts. Next VDS-screws for the M-5 treated rod are inserted into the anterior holes of the Kaneda clamps. The rod is implanted in a slightly compressive manner and augments the system. Within a prospective study 12 patients with idiopathic and neuromuscular scoliosis underwent this surgical procedure. Three patients with thoracolumbar scoliosis have been followed for 12 months postoperatively and are presented as case reports. All patients were treated brace-free postoperatively, only using a semi-elastic vest for 4 months. RESULTS Remarkable intra- and postoperative complications have not been noted. Curve correction ranged from 75 to 86%. Implant related complications and loss of correction have not been noted so far. The sagittal plane was within physiological limits postoperatively. Scanning stereography demonstrated excellent three dimensional correction. CONCLUSION The results of the Double-rod-VDS allow the statement, that the advantages of the VDS according to Zielke are optimized by augmentation of the system with the possibility of plaster cast and brace-free postoperative treatment. Larger operation numbers and a longer follow-up period are needed for further assessment.

INTRODUCTION AND AIM OF THE STUDY Harrington-Instrumentation (HI) was the golden standard of scoliosis surgery for more than two decades and is still frequently used. The effects of instrumentation on rib hump reduction in long term follow-up is not well documented. 104 patients with idiopathic thoracic scoliosis were studied with a minimum follow-up of five years (min. 5 y., max. 8 years). METHODS The rib-cage deformity was determined as rib hump index (RHi) by measuring the rib hump to the depression. The long term effect of HI was investigated using full standing AP radiographs. Measuring cobb angle (CA), translation (TA) and rotation of apical vetebra (RA) were obtained for every patient preoperatively, postoperatively and at follow-up. Patient were analysed in 3 different groups. Single curve thoracic scoliosis (n = 54) (King III and IV), double curve thoracic/lumbar scoliosis (n = 35) (King I and II) and double curve thoracic scoliosis (n = 15) (King V). RESULTS With an average preoperative measurement of 62.7 degrees and a postoperative measurement angle of 32.9 degrees the correction of CA achieved is 47.5% (23-73%). The mean thoracic translation improved by 50% (0-100%). Rotation of the scoliosis was not reduced significant. In follow up studies no loss of correction in frontal plane deformity was obtained. The mean RHi in all groups was seen to improve by 25-30% (min. 0%, max. 60%), depending on form of scoliosis. In group of patients King II/III scoliosis (n = 52) the mean RHi increased measurably to 11.5% (min. 0%, max. 50%) correction at long term follow up. In group of patients King I/II scoliosis average RHi was increased from 31% (5-100%) to 21% correction. The mean RHi correction in the group of patients King V scoliosis correction rate of 26% (0-50%) was unchanged at long term follow up. CONCLUSION HI leads to a permanent and stable improvement of the frontal plane including apical vertebral translation. HI does not have derotational capabilities. The effect of the rib-cage deformity was less impressive with loss of correction at follow up.

AIM OF THE STUDY We prospectively studied 9 patients with deformities of the thoracic spine who underwent thoracoscopic surgery to critically evaluate the benefits and limitations of thoracoscopy. METHODS 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. RESULTS 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. CONCLUSIONS 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.

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.

Aim of the study To evaluate the midterm radiographic behaviour of femorocortical allograftrings (FCA) in lumbosacral fusions in patients with disabling low back pain. Methods 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. Results 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%). Conclusion The described technique has proven to be highly effective in achieving a high fusion rate with a stable midterm graft behaviour.

UNLABELLED Several studies demonstrated the necessity of rehydration of lyophilized bone allografts prior to implantation. The purpose of the presented study was to evaluate the influence of different rehydration periods on the stability of human cortical lyophilized and gamma-irradiated allografts, the capability of lyophilized bone for rehydration, as well as the effects of lipid extraction on rehydration. Breaking strength of lyophilized irradiated cortical bone after different rehydration periods (0.5, 1, 2, 4, 8 hours) showed no significant difference. Weight reduction after lyophilization of human femoral heads was between 7.6% and 41%. Further weight reduction occurred after lipid extraction (38.7%). Total weight loss was 56.9%. There was a significant influence of intraosseous lipid content on the rehydration capability. After lyophilization alone the rehydration weight after 8 hours was only 18.1%, whereas after lipid extraction the weight increase was 43% after 0.5 hours, 36.4% after 1 hour, 57.6% after 2 hours, 60% after 4 hours, and 92.7% after 8 hours. CLINICAL RELEVANCE Based on the presented data rehydration time of 0.5 hours seems to have no disadvantage compared to longer time periods concerning breaking strength. Therefore a longer intraoperative time period seems not to be necessary. This is of advantage for a possible secondary contamination while the allograft is rehydrated. Rehydration after lipid extraction is more effective than rehydration after lyophilization alone. However, the question whether lipid extraction alter bone stability has to be proved in further studies.

Introduction and aim of the study The primary assumption for successful internal fixation of the spine is a stable screws fixation. Aim of this experimental examination was to point out the influences on axial pull-out strength of screws and to suggest improvements for its increase. Methods Eight specifically manufactured screw-prototypes were tested in standardized pull-out tests in comparison by pairs. An isotropic, synthetic hard-foam was used as test material. It resembled to the spongiose bone and reduced the deviation of the results. To show the transferability of the results on bone there were made pull-out tests out off calf vertebra. Results A significant increase of axial pull-out strength can be achieved by a wide external diameter, a big insertion depth, a flat angel of tooth profile and a small thread pitch. This examination could not prove a significant advantageous influence on axial pull-out strength by fast pull-out, asymmetrical "Butress-thread" or proportion of core- and external diameter difference. Conclusions Referring to the aim of this examination a wide outside-diameter can be recommended. Likewise the depth of insertion should be as deep as the anatomic conditions permit. The influence of these two factors are considerable. In contrast to other author's statements the maximum axial stability increases significantly by a small thread pitch and a flat angel of tooth profile.

In der operativen Therapie der idiopathischen Skoliose stehen sowohl dorsale als auch ventrale Korrektur- und Stabilisierungstechniken zur Verfugung. Ziel der vorliegenden Arbeit war die Analyse der Ergebnisse der ventralen Derotationsspondylodese unter Verwendung eines neueren Doppelstabsystems. Es erfolgt eine prospektive Analyse radiometrischer und klinischer Parameter von 93 Patienten, die zwischen 1996 und 2004 mit dem Munsteraner Anterioren Doppelstabsystem operativ behandelt worden sind. Bei einer kurzen Fusionstrecke von in der Regel End-zu-End-Wirbel gelang eine durchschnittliche Krummungskorrektur von 65% bei einem Ausgangswinkel von 59°. Der postoperative Korrekturverlust nach durchschnittlich 36 Monaten war mit 1,5° minimal. Die Derotation betrug thorakal 45% und lumbal 53%, wodurch sich der Rippenbuckel um 66% und der Lendenwulst um 81% korrigieren lies. Revisionsbedurftige oder neurologische Komplikationen traten nicht auf. Die ventrale Korrektur und Instrumentationsspondylodese in Doppelstabtechnik ermoglicht eine sehr gute und sichere dreidimensionale Krummungskorrektur strukturell einbogiger Skoliosen.

Mit der Harrington-Instrumentation (HI) begann die standardisierte instrumentierenden Skoliosechirurgie. Mit der HI konnten zufriedenstellende, dauerhafte Korrekturen der Seitausbiegung von etwa 50 % erzielt werden, jedoch ohne nennenswerte Derotation. Die Distraktion der Konkavitat fuhrt zur biomechanisch ungunstigen Abflachung des physiologischen Profils. Dieses vermeiden die multisegmental angreifenden Implantatsysteme, als deren erste Prototypen die Luque- (SSI) und die Cotrel-Dubousset-Instrumentation (CDI) anzusehen sind. Ideale Indikationen sind idiopathische strukturell doppelbogige und einbogige, flexible Skoliosen. Jedoch kann auch mit den modernen dorsalen hakengetragenen Doppelstabsystemen die Fehlrotation nur ungenugend korrigiert werden. Die segmentale Derotation ist unzweifelhaft an die Entkoppelung der zu instrumentierenden Segmente durch Bandscheibenausraumung gebunden. Eine entscheidende aktuelle Weiterentwicklung, basierend auf den Erfahrungen der Langzeitergebnisse der HI und CDI, ist die Nutzung von Pedikelschrauben, mit denen eine bessere Korrektur der frontalen Ebene bei haufig kurzerer Fusionsstrecke erzielt werden kann. Als „golden standard“ der Formkorrektur und Stabilisierung von Skoliosen uber den vorderen Zugangsweg ist die ventrale Derotationsspondylodese (VDS) nach Zielke als masgebliche Weiterentwicklung der Dwyer-Instrumentation (DI) anzusehen. Die VDS ist das erste Implantatsystem, mit dem eine wirkliche dreidimensionale, segmentale Formkorrektur erzielt werden kann. Die dauerhafte Korrektur von frontaler Seitausbiegung und Derotation im eigenen Krankengut betragt etwa 70 bzw. 50 %. Ideale Indikationen sind einbogige lumbale, thorakolumbale und thorakale Skoliosen. Der in den 80 er Jahren oft beobachtete kyphogene Effekt, der im Lumbal- und Thorakolumbalbereich unerwunscht ist, konnte in den letzten Jahren durch das bessere Verstandnis des Einflusses der Derotation auf die Relordosierung und durch die Auffutterung der interkorporellen Raume mit tragfahigen kortikospongiosen Spanen oder Titancages von uns ausnahmslos vermieden werden. Nachteilig sind die geringen internen Stabilisierungseigenschaften des Implantats mit dem Risiko des Stabbruches und der Pseudarthrose, die eine langmonatige Ruhigstellung im Rumpfgips oder Korsett notwendig machen. Durch die Weiterentwicklung zur primarstabilen Halm-Zielke-Instrumentation sowie durch Entwicklung anderer primarstabiler ventraler Systeme konnen diese Nachteile mittlerweile vollstandig eliminiert werden.

Summary Retroperitoneal paraganglioma is a rare tumor, especially occurring in childhood and adolescence, with a marked tendency to become biologically malignant. It has not been possible to predict the clinical outcome of paraganglioma patients by conventional histology, hence malignancy can only be demonstrated by the occurrence of metastatic lesions. Currently, only limited information on the genetics of this tumor is available. We report on a 16-year-old girl with a large retroperitoneal paraganglioma and an osseous metastasis to the first lumbar vertebra. In addition to morphological and immunohistochemical examinations, a molecular cytogenetic analysis was performed. Comparative genomic hybridization (CGH) revealed imbalanced chromosomal aberrations with a loss of chromosome 1p and a gain of 1q, indicating isochromosome 1q. A loss of chromosome 3 as well as low-level gains of chromosomes 4, 5, 6q, 11q and 13q were detected. A PCR-based microsatellite analysis of 1p confirmed the loss of heterozygosity, including NB 1 and NB2 putative tumor- suppressor gene regions. Telomerase activity, which is found in the majority of malignant tumors, could not be detected. The case presented here is the first more comprehensive molecular genetic analysis of a sporadic malignant paraganglioma.

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.

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 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.

Unter Wirbelsaulendeformitaten versteht man Formanomalien der Wirbelsaule. Hierbei handelt es sich um krankhafte Abweichungen des Achsenorgans in der Frontal- und Sagittalebene. Mogliche Formen sind kyphotische Fehlstellungen (krankhafte Rundruckenbildung), lordotische Fehlstellungen (krankhafte Hohlschwingungen der Wirbelsaule) und Skoliosen. Diese drei Formen konnen fur sich allein entstehen oder kombiniert auftreten. Die wichtigsten Erkrankungen sind nachfolgend aufgelistet

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.

The age of standardized instrumented scoliosis correction and stabilization began with Harrington instrumentation (HI). With HI, satisfactory long-term correction of the frontal plane averaged approximately 50%, but without notable derotational capabilities. The distraction of the concavity leads to reduction of the sagittal contour of the spine (flat back), which is biomechanically disadvantageous. The newer multisegmentally attached implant systems avoid this disadvantage. The first prototypes of these systems were Luque- (SSI) Cotrel-Dubousset instrumentation. Ideal indications for posterior instrumented curve correction are structural idiopathic double major curves and flexible single curves. However, even with these newer doublerod systems derotation is low, because derotation is, without any doubt, related to anterior release and thus decoupling of the segments by means of disc resection. The optimum method of correction and stabilization of scoliosis using the anterior approach is the ventral derotation spondylodesis (VDS), according to Zielke, who considers it to be a major improvement over Dwyer instrumentation. VDS is the first implant system with which true three-dimensional, segmental curve correction was made possible. Long term correction of the frontal plane and derotation averages approximately 70% and 50%, respectively. Ideal indications are single lumbar, thoracolumbar and thoracic curves. In our experience, the so-called kyphogenic effect of VDS due to anterior convex compression, can be counteracted by derotation and preserving disc space height with weight bearing bone grafts or cages. The low internal stabilizing capabilities with the risk of rod fracture and pseudarthrosis are unfavorable. They make long term cast or brace treatment necessary postoperatively. Meanwhile, the disadvantage of the low internal stabilizing capabilities of VDS has been overcome with the development of the primary stable Halm-Zielke instrumentation and other primary stable anterior fixation systems.

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.

Harrington-Instrumentation (HI) was the golden standard of scoliosis surgery for more than two decades and is still frequently used. The effects of instrumentation on rib hump reduction in long term follow-up is not well documented. 104 patients with idiopathic thoracic scoliosis were studied with a minimum follow-up of five years (min. 5 y., max. 8 years).The rib-cage deformity was determined as rib hump index (RHi) by measuring the rib hump to the depression. The long term effect of HI was investigated using full standing AP radiographs. Measuring cobb angle (CA), translation (TA) and rotation of apical vetebra (RA) were obtained for every patient preoperatively, postoperatively and at follow-up. Patient were analysed in 3 different groups. Single curve thoracic scoliosis (n = 54) (King III and IV), double curve thoracic/lumbar scoliosis (n = 35) (King I and II) and double curve thoracic scoliosis (n = 15) (King V).With an average preoperative measurement of 62.7 degrees and a postoperative measurement angle of 32.9 degrees the correction of CA achieved is 47.5% (23-73%). The mean thoracic translation improved by 50% (0-100%). Rotation of the scoliosis was not reduced significant. In follow up studies no loss of correction in frontal plane deformity was obtained. The mean RHi in all groups was seen to improve by 25-30% (min. 0%, max. 60%), depending on form of scoliosis. In group of patients King II/III scoliosis (n = 52) the mean RHi increased measurably to 11.5% (min. 0%, max. 50%) correction at long term follow up. In group of patients King I/II scoliosis average RHi was increased from 31% (5-100%) to 21% correction. The mean RHi correction in the group of patients King V scoliosis correction rate of 26% (0-50%) was unchanged at long term follow up.HI leads to a permanent and stable improvement of the frontal plane including apical vertebral translation. HI does not have derotational capabilities. The effect of the rib-cage deformity was less impressive with loss of correction at follow up.

Thirteen patients with aneurysmal bone cyst of the spine (excluding sacral lesions) were retrospectively reviewed. Treatment for aneurysmal bone cysts remains controversial, but surgical resection, irradiation, and embolization are common treatment modalities for those involving the spine. Of 102 patients with aneurysmal bone cysts, 15 had a lesion of the spine, including 2 sacral cases. Of the 13 patients with a lesion of the thoracic or lumbar spine, 9 underwent resection of the lesion, 2 curettage and cementation, and 2 only currettage. Eleven patients underwent segmental arthrodesis with instrumentation after treatment of the primary or recurrent lesion, while 2 patients underwent segmental arthrodesis using autogeneic bone. Nine patients did not develop a local recurrence after resection of the lesion. However, the 2 patients who underwent curettage alone developed local recurrences. None of 4 patients developed recurrences after curettage and cementation. After recurrence, 1 patient underwent additional resection with irradiation, and 1 patient underwent resection alone. At the final follow-up, all lesions were under control. In one patient, lumbar kyphosis developed after segmental arthrodesis with instrumentation, and arthrodesis was performed again. Radical resection of aneurysmal bone cysts of the spine with instrumentation is the optimal method of acquiring a high degree of local control and preventing spinal deformity.

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.

The series of this article compares 148 patients with chronic tendinitis (group I) and 28 patients with significant partial-thickness tears (group II) of the rotator cuff managed with arthroscopic debridement and acromioplasty.All patients were evaluated by an independent observer with a mean follow-up of 26.5 (12-51) respectively 23.4 (12-50) months using the Constant-score, the ASES-score and a visual analog scale. The mean age in group I was 48.5 (25.4-71) and in group II 56.1 (33.2-80.6) years.In group I 127 patients (86%) and in group II 17 patients (62%) were satisfied at latest follow-up (p0.05). Concerning the exclusively subjective ASES-score with a maximum of 100 points group I had an average of 78.8 and group II of 61.6 points (p = 0.0019). According to the criteria of Constant group I scored with a mean of 81 points for the operated shoulder and 91.6 points for the non-operated side and group II with either 65.2 points and 89.9 points (p = 0.0036).Recognizing these results a thorough activity-related preoperative discussion with the patient about the treatment options for significant partial-thickness cuff ruptures should be performed.