We aimed to systematically review the literature to analyze the differences in posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusion (ALIF), and transforaminal lumbar interbody ...fusion (TLIF), focusing on the complications, risk factors, and fusion rate of each approach. Spinal fusion surgery is a well-established surgical procedure for a variety of indications, and different approaches developed. The various approaches and their advantages, as well as approach-related pathology and complications, are well investigated in spinal surgery. Focusing only on lumbosacral fusion, the comparative studies of different approaches remain fewer in numbers. We systematically reviewed the literature on the complications associated with lumbosacral interbody fusion. Only the PLIF, ALIF, or TLIF approaches and studies published within the last decade (2007-2017) were included. The exclusion criteria in this study were oblique lumbar interbody fusion, extreme lateral interbody fusion, more than one procedure per patient, and reported patient numbers less than 10. The outcome variables were indications, fusion rates, operation time, perioperative complications, and clinical outcome by means of Visual Analog Scale, Oswestry Disability Index, and Japanese Orthopaedic Association score. Five prospective, 17 retrospective, and two comparative studies that investigated the lumbosacral region were included. Mean fusion rates were 91,4%. ALIF showed a higher operation time, while PLIF resulted in greater blood loss. In all approaches, significant improvements in the clinical outcome were achieved, with ALIF showing slightly better results. Regarding complications, the ALIF technique showed the highest complication rates. Lumbosacral fusion surgery is a treatment to provide good results either through an approach for various indications as causes of lower back pain. For each surgical approach, advantages can be depicted. However, perioperative complications and risk factors are numerous and vary with ALIF, PLIF, and TLIF procedures, as well as with fusion rates.
Purpose
Vertebral osteomyelitis (VO) has a high mortality and leads to chronic pain and functional disability. Surgical treatment is often necessary. To date, little is known about the consequences ...of surgery on patient outcome. The aim of this study was to determine the quality of life (QoL) and mortality rates of surgically treated VO patients for a period of 2 years.
Methods
Patients with VO undergoing surgical treatment in a tertiary referral hospital from 2008 to 2015 were included prospectively. Data were collected before (
T
0) as well as 1 year (
T
1) and 2 years (
T
2) post-surgery. Within the European Spine Tango registry, prospective patient and QoL data were collected using validated outcome scores: Oswestry Disability Index, Short Form 36/EuroQol, Visual Analog Scale, and Core Outcome Measures Index.
Results
From 195 patients surgically treated for VO, QoL data were available from 136 patients at
T
0, 100 patients at
T
1, and 82 patients at
T
2, respectively. The 1- and 2-year mortality rates were 20% and 23%. Mainly all QoL outcome scores showed significant improvement at
T
1 and did not change significantly from
T
1 to
T
2.
Conclusion
Surgical treatment of VO patients leads to significantly improved QoL. Nevertheless, QoL levels were below those of the general population. Our results underscore that spine disability questionnaires measuring QoL are mandatory to demonstrate comprehensively the severity of this entity. Our study confirms a high mortality and points out the role of VO as a potentially life-threatening condition.
Spinal fusion is a well-established procedure in the treatment of degenerative spinal diseases. Previous research shows that the use of this operative treatment has been growing in recent decades in ...industrialized countries and has become one of the most cost-intensive surgical procedures. It seems that in some countries such as Germany-with its large, industrialized, European population-this increase is mainly driven by demographic changes with low fertility rates, increasing life expectancy, and an aging population. Based on current projections, however, Germany faces a population trend that many other countries are likely to follow within a few decades. An increasingly shrinking and aging working population may eventually put the healthcare system under enormous pressure, with greater demands for spinal fusions and associated higher costs. Thus, we aimed to provide reliable projections regarding the future demand for posterior spinal fusion procedures including age- and gender-related trends up to 2060, which will be necessary for future resource planning and possible improvements in actual treatment strategies.
(1) How is the use of posterior spinal fusions in Germany expected to change from 2019 through 2060, if currents trends continue? (2) How is the use of posterior spinal fusions in Germany expected to change depending on patients' age and gender during this time period?
Comprehensive nationwide data provided by the Federal Statistical Office, the official institution for documenting all data on operations and procedures performed in Germany, were used to quantify posterior spinal fusion rates as a function of calendar year, age, and gender. Because there is a lack of evidence regarding future trends in the use of posterior spinal fusions, an autoregressive integrated moving average model on historical procedure rates from 2005 to 2019 in relation to official population projections from 2020 to 2060 was chosen to forecast future absolute numbers and incidence rates of this procedure in Germany. Long-term forecasting is more prone to unexpected disruptions than forecasting over short-term periods; however, longer spans facilitate estimates of how trends may challenge future healthcare systems if those trends continue, and thus are useful for research and planning.
The incidence rate of posterior spinal fusion was projected to increase by approximately 83% (95% CI 28% to 139%) to 102% per 100,000 inhabitants (95% CI 71% to 133%) in 2060, with a 1.3-fold higher rate of women undergoing surgery in terms of absolute numbers. The highest increase identified by the model occurred in patients 75 years and older with 38,974 (95% CI 27,294 to 50,653) posterior spinal fusions in 2060, compared with 14,657 in 2019. This trend applied for both women and men, with a 246% (95% CI 138% to 355%) increase in the total number of posterior spinal fusions for women 75 years and older and a 296% (95% CI 222% to 370%) increase for men 75 years and older. At the same time, posterior spinal fusions in all age groups younger than 55 years were projected to follow a constant or even negative trend up to 2060.
Our findings suggest that increasing use of posterior spinal fusion, particularly in patients 75 years and older, will challenge healthcare systems worldwide if current trends persist. This study may serve as a model for many other industrialized countries facing similar demographic and procedure-specific developments in the future. This emphasizes the need to focus on frailty research as well as appropriate financial and human resource management. Effective perioperative medical management, multidisciplinary treatment, and interinstitutional protocols are warranted, especially in older patients as we attempt to manage these trends in the future.
Level III, economic and decision analysis.
Introduction
Idiopathic scoliosis, defined as a > 10° curvature of the spine in the frontal plane, is one of the most common spinal deformities. Age, initial curve magnitude and other parameters ...define whether a scoliotic deformity will progress or not. Still, their interactions and amounts of individual contribution are not fully elaborated and were the aim of this systematic review.
Methods
A systematic literature search was conducted in the common databases using MESH terms, searching for predictive factors of curve progression in adolescent idiopathic scoliosis (“adolescent idiopathic scoliosis” OR “ais” OR “idiopathic scoliosis”) AND (“predictive factors” OR “progression” OR “curve progression” OR “prediction” OR “prognosis”). The identified and analysed factors of each study were rated to design a top five scale of the most relevant factors.
Results
Twenty-eight investigations with 8255 patients were identified by literature search. Patient-specific risk factors for curve progression from initial curve were age (at diagnosis < 13 years), family history, bone mineral status (< 110 mg/cm
3
in quantitative CT) and height velocity (7–8 cm/year, peak 11.6 ± 1.4 years). Relevant radiological criteria indicating curve progression included skeletal maturity, marked by Risser stages (Risser < 1) or Sanders Maturity Scale (SMS < 5), the initial extent of the Cobb angle (> 25° progression) and curve location (thoracic single or double curve).
Discussion
This systematic review summarised the current state of knowledge as the basis for creation of patient-specific algorithms regarding a risk calculation for a progressive scoliotic deformity. Curve magnitude is the most relevant predictive factor, followed by status of skeletal maturity and curve location.
Introduction
Lumbar and lumbosacral spinal fusion is an established procedure for the treatment of degenerative spondylolisthesis. However, the impact of reduction in the affected segment and of ...improvement in the radiological sagittal parameters on the clinical outcome remains unclear. Purpose of the study is to analyze the correlation between the radiological sagittal parameters and clinical outcome after lumbar spinal fusion in low-grade degenerative spondylolisthesis.
Materials and methods
In a monocentric prospective, clinical study, patients with low-grade degenerative spondylolisthesis of a single lumbar segment have been included. All patients received a lumbar spinal fusion according to the pathology of the treated segment. Patients attended clinical and radiological follow-up examination 1 and 2 years postoperatively. Clinical outcome was assessed using the Core Outcome Measurement Index (COMI), the Oswestry Disability Index (ODI) and the EuroQol 5D. The sagittal spinopelvic radiological parameters, sagittal rotation and anterior displacement of the affected segment and lumbar lordosis were assessed. The correlation between the sagittal radiological parameters and clinical outcome was analyzed using Spearman-Rho bi-serial test.
Results
Sixty-two patients (35 female and 27 male) with an average age of 59.3 years were included in the study. All patients completed the follow-up examinations. Significant improvement in COMI, ODI and EuroQol 5D scores was shown in all follow-up examinations. Significant reduction in the anterior displacement was measured postoperatively, which was preserved during the follow-up. However, no correlation could be demonstrated between reduction in anterior displacement and improvement in clinical outcome. Nonetheless, correlation between correction of sagittal rotation and clinical outcome was shown.
Conclusions
Reduction in anterior displacement of the affected segment in the surgical treatment of low-grade degenerative spondylolisthesis does not have an impact on the clinical outcome.
Purpose
The incidence of bone and joint infections is increasing while their treatment remains a challenge. Although guidelines and recommendations exist, evidence is often lacking and treatment ...complicated by complex clinical presentations and therapeutic options. Interdisciplinary boards shown to improve management of other diseases, seem potentially helpful. We describe the establishment of an osteomyelitis board to show the existing demand for such a platform.
Methods
All patients discussed in the board for bone and joint infections between October 2014 and September 2020 were included in this retrospective study. Data were extracted from patient records and analyzed descriptively.
Results
A total of 851 requests related to 563 patients were discussed in the board during the study period. After a run-in period of 3 years, a stable number of cases (> 170/year) were discussed, submitted by nearly all hospital departments (22 of 25). Recommendations were mainly related to antibiotic treatment (43%) and to diagnostics (24%). Periprosthetic joint infections were the most frequent entity (33%), followed by native vertebral osteomyelitis and other osteomyelitis. In 3% of requests, suspected infection could be excluded, in 7% further diagnostics were recommended to confirm or rule out infection.
Conclusions
A multidisciplinary board for bone and joint infections was successfully established, potentially serving as a template for further boards. Recommendations were mainly related to antibiotic treatment and further diagnostics, highlighting the need for interdisciplinary discussion to individualize and optimize treatment plans based on guidelines. Further research in needed to evaluate impact on morbidity, mortality and costs.
Purpose
Chronic low back pain (CLBP) is one of the most important pain disorders with increasing social and economic implications. Given that CLBP is a multidimensional process associated with ...comorbidities such as anxiety and depression, treatment of chronic low back pain is still a challenge. Advancement of in vivo brain imaging technologies has revealed increasing insights into the etiology and pathogenesis of chronic pain; however, the exact mechanisms of chronification of LBP remain still unclear. The purpose of the present study was to analyse the neurostructural alterations in CLBP and to evaluate the role of comorbidities and their neurostructural underpinnings.
Methods
In the present study we investigated a well-characterized group of 14 patients with CLBP and 14 healthy controls applying structural MRI and psychometric measures. Using an improved algorithm for brain normalization (DARTEL) we performed a voxel-based morphometry (VBM) approach. Correlation analyses were performed to evaluate the role of anxiety and depression in neurostructural alterations observed in CLBP.
Results
The psychometric measures revealed significantly higher scores on depression and anxiety in the patient population. VBM analysis showed significant decreases in grey matter density in areas associated with pain processing and modulation, i.e. the dorsolateral prefrontal cortex, the thalamus and the middle cingulate cortex. With respect to anxiety and depression scores, we did not observe any correlations to the structural data.
Conclusions
In the present study we found compelling evidence for alterations of grey matter architecture in CLBP in brain regions playing a major role in pain modulation and control. Our results fit the hypothesis of a “brain signature” in chronic pain conditions. The results of the psychometric assessment underline the importance of an interdisciplinary therapeutic approach including orthopedic, neurological and psychological evaluation and treatment.
Purpose
Anterior surgical approaches to the thoracic spine are common procedures for the treatment of many diseases of the thoracic spine. Purpose of this anatomic study is to investigate the course ...of the segmental vessels of the thoracic spine for the anterior and lateral transthoracic approach from the right side.
Methods
26 formalin-fixed human cadavers (20 femaless/6 male) with an average age of 84.9 ± 8.3 (range 67–97) were included. The segmental arteries and veins of the right thoracic cavity coursing between the third and twelfth thoracic vertebral body have been investigated. To define the localization of the vessels in accordance with the associated vertebral bodies, the distance between the endplates and vessels was measured in the ventral, middle and dorsal parts.
Results
The results of the study reveal that not only one, but also two segmental arteries and veins may course over the right hemi-vertebral body, especially in the upper and middle thoracic spine. Furthermore, in the middle and lower thoracic spine (T7–T12) the vessels course over the middle and lower third of the craniocaudal extent of the vertebral body. On the contrary, in the upper thoracic spine (T3–T6), the vessels may course over the entire extent of the vertebral body.
Conclusion
Due to these common anatomic variations and variability of the course of the segmental vessels, spinal surgeons should remain careful in the identification of the segmental vessels in order to minimize risk of vascular injury in case of right-sided anterior and lateral approach to the thoracic spine.
Purpose
E-scooters are a new type of urban transportation utilized in Germany since June 2019, primarily in larger cities in the context of sharing offers. Such electrically operated standing ...scooters can be driven at a maximum speed of 20 km/h. A helmet is not mandatory. The aim of this prospective study is to document the injury patterns over the period of 1 year and compare our findings with already available data.
Methods
Over a period of 1 year (July 2019–July 2020), data on E-scooter-related accidents treated at a level 1 trauma center of a major German city were prospectively documented. Injury patterns were analyzed, and epidemiological data evaluated.
Results
Fifty-nine (35 female, 24 male) accidents were included in the observation period. Mean age of accident victims was 30.03 years (± 9.32). Alcohol influence at the time of accident was detected in 9 cases (15.25%). Many of the accident victims suffered multiple injuries. Most of the injuries were upper (50.84%) and lower extremity (47.45%) as well as craniofacial injuries (62.71%). A helmet was not worn in any of the cases.
Conclusion
In the year following their introduction, E-scooter-related accidents have led to an additional burden on the emergency capacities of the involved University Hospital, especially in the summer months of 2019. Protective equipment is de facto not worn. Injuries to the extremities, head, and face were most common. None of the accident victims died. This coincides with results from other major cities in national and international comparison. A more intensive education about injury consequences of unprotected E-scooter use and the discussion of a possible obligation to wear a helmet and further protection equipment for the extremities should take place.
Objective
For surgical treatment of instable upper cervical injuries, the Harms technique using lateral mass screws provides rigid fixation and favourable clinical outcomes. The use of the posterior ...arch of C1 as a “pedicle” allows for screw anchorage, giving improved biomechanical stability. Therefore, the aim of this study was to introduce a bilateral safe zone for C1 pedicle screws, regarding screw angulation and pedicle height.
Material and methods
We retrospectively reviewed the CT scans of 500 patients. Three-dimensional reformats were generated for detailed measurements. Centre screw entry point (EP), length of lateral mass as screw trajectory, lateral mass width (LMW), length of screw trajectory (ST), maximal divergence (DI) and maximal convergence (CON) from EP without perforation, and pedicle height (PH) of the posterior arch were measured.
Results
The 500 cases consisted of 335 males and 165 females, with a mean age of 49.5 years. Measurements did not demonstrate significant side-related differences. The mean screw entry point was 22.8 mm from the midline-axis (left 22.6 mm; right 23.0 mm). From this point, a safe zone between 11.6° of divergence and 19.6° of convergence was detected. Measurements of female patients were generally smaller, with significant differences from male patients (
p
< 0.05). 158 subjects (31.6%) had a PH < 4 mm.
Discussion
C1 pedicle screws were feasible in the majority of patients. Proposing a safe zone for screw angulation may provide safety and avoid screw perforation. However, detailed knowledge of the individual C1 anatomy and the preoperative measurement is essential in the operative planning.
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