INTRODUCTION Due to spinal instability and compressive neurologic deficits surgical management is sometimes necessary in patients with metastatic spinal lesions. However, in some cases open surgery is not possible and minimally invasive procedures, like cryoablation, are needed. The aim of the current study was to investigate whether a miniature cryoprobe provides adequate tissue cooling in vertebrae and to evaluate the direct impact of cryosurgery on vertebral body stability. MATERIALS AND METHODS Twelve thoracic vertebral bodies were harvested from fresh cadavers. After documenting bone density cryoablation was performed in six vertebral bodies according to a standardized procedure. Afterwards temperature inside the vertebral body and maximum breaking force were measured in the control and experimental groups. RESULTS Required temperature of -50° was reached in all areas. There was a significant correlation between maximum breaking force and measured bone density (p= 0.001). Mean breaking force within the experimental group was 5047 N (SD = 2955 N) compared to 4458 N (SD = 2554 N) in the control group. There were no observable differences in maximum breaking force between both groups. CONCLUSION Miniature cryoprobe can deliver adequate tissue cooling to -50°C in vertebral bodies. The procedure does not seem to influence breaking force of the treated bones in-vitro. Therefore, using miniature probes cryosurgery may provide a valuable alternative to conventional surgical resection of neoplastic diseases as well as of benign locally aggressive bone tumors.

BACKGROUND:Adult central movement disorders, malpostures, and scolioses can have their cause in various neurological underlying diseases such as Morbus Parkinson, Pisa syndrome, or segmental dystonia. Important clinical characteristics are marked postural distortions such as camptocormia (bent spine) or laterocollis. In cases of these adult scolioses, surgical spine treatment puts high demands on the surgeon. Surgery in Parkinson's disease, for example, is associated with serious surgery-specific as well as general complications. The more rarely occurring Pisa syndrome is an entity primarily requiring medical therapy.PATIENTS AND METHODS:A series of ten case reports of patients with Morbus Parkinson and Pisa syndrome who underwent spinal surgery is presented and discussed. From these reports, treatment recommendations have been derived and complemented by references from the literature. An extensive MEDLINE search was performed for this purpose.RESULTS AND CONCLUSION:In patients suffering from Parkinson's disease, even minor surgical interventions can lead to instability of whole spine segments or even the entire spine. Implant loosening, adjacent segment instability, general perioperative complications, and progressive malposture due to disease progress can bring forth disastrous treatment courses. Spinal fixation should be performed long-segmented in combination with ventral stabilisation. Due to osteoporosis, pedicle screw cement augmentation is recommended in this collective. If the diagnosis of Pisa syndrome is established, an optimised preoperative preparation should be initiated in close cooperation with neurologists. In many cases medical therapy is sufficient and surgical interventions can be avoided.

BACKGROUND:Percutaneous cement augmentation systems have been proven to be an effective treatment for vertebral compression fractures in the last 10 years. A special form available since 2009 is the radiofrequency kyphoplasty (RF) in which the applied energy raises the viscosity of the cement. The aim of this study is to find out if a smaller cement amount in radiofrequency kyphoplasty can also restore vertebral body height in osteoporotic vertebral compression fractures.METHODS:The treatment was minimally invasive using the StabiliT® vertebral augmentation system by DFine. In a retrospective study from 2011 to January 2012, 35 patients underwent RF kyphoplasty for 49 fresh osteoporotic vertebral compression fractures. From the clinical side the parameters, demographics and pain relief using a visual analogue scale (VAS: 0 to 100 mm) were collected. For the radiological outcome the vertebral body height (anterior, mean and posterior vertebral body height with kyphosis angle) after surgery and after three months was measured and compared to the cement volume.RESULTS:All patients still had permanent pain on the fractured level after conservative treatment. The time from initial painful fracture to treatment was 3.0 weeks ± 1.3. Average visual analogue scale results decreased significantly from 71 ± 9.2 preoperatively to 35 ± 6.2 postoperatively (p < 0.001) and to 30 ± 5.7 (p < 0.001) after three months. With a mean cement volume in the thoracic spine of 2.9 ± 0.7 ml (1.8-4.1) and lumbar spine of 3.0 ± 0.7 ml (2.0-5.0) we had a significant vertebral body height restoration. Anterior and mean vertebral body heights significantly increased by an average of 2.3 and 3.1 mm, kyphosis angle significantly decreased with an average of 2.1° at three-month follow-up (p < 0.05). In two vertebrae (4.1 %) a minimal asymptomatic cement leakage occurred into the upper disc. In two patients (5.7 %) we had new fractures in the directly adjacent segment that were also successfully treated with radiofrequency kyphoplasty.CONCLUSION:With a mean cement volume of 3.0 ml radiofrequency kyphoplasty achieves rapid and short-term improvements of clinical symptoms with a significant restoration of vertebral body height. There was no correlation between restoration of vertebral body height and pain relief. With a cement leakage of 4.1 % RF kyphoplasty is a safe and effective minimally invasive percutaneous cement augmentation procedure. Our data confirm the higher safety described in literature for kyphoplasty in contrast to vertebroplasty.

Over the past two decades, orthopaedics has gone through major changes, principally in the surgical treatment options for articular defects of the knee. This paper explores the advantages and shortcomings of the current surgical treatment modalities for cartilaginous defects in the knee. Emphasis is placed on current techniques in knee arthroplasty, including a view on the future of orthopaedic knee surgery.

Background: Interspinous stand-alone implants are inserted without open decompression to treat symptomatic lumbar spinal stenosis (LSS). The insertion procedure is technically simple, low-risk, and quick. However, the question remains whether the resulting clinical outcomes compare with those of microsurgical decompression, the gold standard.Material and Methods: This prospective, comparative study included all patients (n = 36) with neurogenic intermittent claudication (NIC) secondary to LSS with symptoms improving in forward flexion treated operatively with either interspinous stand-alone spacer insertion (Aperius (R); Medtronic, Tolochenaz, Switzerland) (group1) or microsurgical bilateral operative decompression (group 2) between February 2007 and November 2008. Data (patient data, operative data, COMI, SF-36 PCS and MCS, ODI, and walking tolerance) were collected preoperatively as well as at 6 weeks, at 3, 6, and 9 months, and at one year follow-up (FU). All patients had complete FU over 1 year.Results: Compared to preoperative measurements, surgery led to improvements of all parameters in the entire collective as well as both individual groups. There were no statistically relevant differences between the 2 groups over the entire course of FU. However, improvements in the ODI and SF-36 MCS were not significant in group 1, in contrast to those of group 2. Also, although in group 1 the improvements in leg pain (VAS leg) were still significant (p < 0.05) at 6 months, this was no longer the case at 1 year FU. In group 1 at 1 year FU an increase in leg pain was observed, while in group 2 minimal improvements continued. Walking tolerance was significantly improved at all FU times compared to preoperatively, regardless of group (p < 0.01). At no time there was a significant difference between the groups. In group 1, admission and operative times were shorter and blood loss decreased. The complication rate was 0% in group 1 and 20% in group 2, however reoperation was required by 27.3% of group 1 patients and 0% of group 2.Conclusion: Implantation of an interspinous stand-alone spacer yields clinical success comparable to open decompression, at least within the first year of FU. The 1-year conversion rate of 27.3% is, however, decidedly too high.

Vertebroplasty (VP) and kyphoplasty (KP) are minimally invasive vertebral augmentation procedures for the treatment of fresh vertebral compression fractures (VCFs) associated with osteoporosis, trauma, malignant conditions, hemangiomas, and osteonecrosis. During these procedures, bone cement (e.g., polymethylmethacrylate) is percutaneously injected into the vertebral body. Systematic reviews of both procedures have shown significantly improved back pain and quality of life compared to conservative therapy. Direct comparison between VP and KP is not possible because of the lack of prospective randomized data comparing the two procedures. Both appear to improve patient functional status in most studies, although it is difficult to pool the available data because of differing measurement scales. With increasing popularity of both techniques, particularly over the past ten years, a rising number of publications have detailed potential complications secondary to cement extravasation, from compression of neural elements to venous embolism. Overall complication rates for both procedures are low. Systematic reviews have found significantly higher rates of cement leakage after VP (40%) versus KP (8%), with 3% of VP leaks being symptomatic. The evidence for increased risk of adjacent level fracture after these procedures compared to conservative treatment is inconclusive. When performed by a well-trained practitioner in appropriately selected patients, vertebroplasty and kyphoplasty are both safe and effective treatments for fresh vertebral compression fractures. Results from ongoing randomized controlled trials will provide further detailed information about both procedures in the future.

HISTORY AND ADMISSION FINDINGS:A 21-year-old man presented with severe lumbar back pain and progressive paraparesis with clinical signs of spondylitis. Laboratory findings revealed elevated infectious parameters. Because of a positive Mantoux-Test he had been treated with quadruple tuberculostatic drugs for eight weeks without prior identification of the causative pathogen.INVESTIGATIONS:Magnetic resonance imaging of the spine revealed a multisegmental spondylitis of the lumbar vertebrae (L3 - L5) with epidural empyema. Computed tomography (CT) of the abdomen confirmed large bilateral abscesses in the psoas muscles.TREATMENT AND COURSE:The findings supported the diagnosis of spondylitis. The antibiotic regimen was continued. CT-guided drainage was placed in both psoas muscles. Laminectoma of L3 - 5 and dorsal spondylodesis of L2 - S1 were performed immediately. Mycobacterium tuberculosis was cultured from the intraoperative biopsies and treated according to the drug sensitivity test. After further surgical debridment and corporectomy of L4 and L5 the infection was successfully treated. Ten weeks after admission the patient was transferred to a neurologic rehabilitation unit for mobilization.CONCLUSION:Spondylodiscitis treatment is complex and requires a multidisciplinary approach.

Das Indikationsspektrum für Fusionsoperationen an der Lendenwirbelsäule umfasst Instabilitäten degenerativer (Spondylolisthesen) und traumatischer Art (Frakturen) sowie fehlgeschlagene Bandscheibenoperationen mit der Notwendigkeit zur Versteifung. Instrumentierte Spondylodesen mit Cage oder Beckenkammspan-Interposition erreichen dabei höhere Fusionsraten als nicht instrumentierte Spondylodesen, allerdings bei möglicherweise höherer Komplikationsrate [37]. Die bekanntesten Komplikationen sind Pseudarthrosenbildung, Cage-Dislokationen, Anschlussinstabilitäten, Implantatversagen oder ‐malpositionierung sowie persistierende Beschwerden nach erfolgreicher Fusion mit knöchernem Durchbau des fusionierten Segments. Es besteht also häufig eine Diskrepanz zwischen einer erfolgreichen instrumentierten Spondylodese mit radiologisch fassbaren, erhöhten Fusionsraten und dem klinischen Outcome. Daher ist vor der endgültigen operativen Segmentversteifung v. a. eine sorgfältige Indikationsstellung wichtig. Wenn eine Operation geplant ist, sollte ein optimales Profil angestrebt werden, d. h. eine kombinierte Reposition und Lordosierung der betroffenen LWS-Abschnitte.

Introduction: Painful fractures of the spine pose a serious clinical problem which gains in importance with the increasing ageing of our population. When conservative treatment of these fractures fails, with vertebroplasty and kyphoplasty we have two percutaneous minimally invasive stabilising procedures at our disposal.Patients and Methods: We performed a prospective study of 90 patients with fresh osteoporotic vertebral fractures who had been treated with vertebroplasty or kyphoplasty in our clinic between January 1, 2005, and December 31, 2007. Clinical analysis included Oswestry score and VAS index; the vertebral body height restoration (mean vertebral body height, kyphosis angle, anterior/posterior edge) was evaluated radiologically; furthermore, all occurring complications were recorded. The follow-up time was 1 year, 80 patients could be examined at follow-up; 8 patients had died of a tumour disease, lost to follow-up were 2.2%.Results: Both procedures succeeded in significantly (p < 0.001) increasing quality of life (Oswestry score) and reducing pain (VAS). Following vertebroplasty there were two cases of cement leakage into the spinal canal with consecutive paraparesis which disappeared completely after the cement had been surgically removed. Altogether, 11 adjacent level fractures were observed, 4 in the vertebroplasty and 7 in the kyphoplasty group.Conclusion: This study compares vertebroplasty and kyphoplasty with regard to their effectiveness, safety, and restoration of vertebral body height, and complications. There were no differences between the groups with regard to quality of life and pain improvement, but the rate of serious complications was higher after vertebroplasty. Mean vertebral body height restoration at 1 year follow-up was significantly higher (p < 0.05) in the kyphoplasty group. It remains to be seen in future long-term studies whether or not restoration of vertebral body height has an effect on the clinical result.

The clinical case of a 34-year-old patient is presented who was diagnosed with Ewing sarcoma in the right pedicle of the L5 vertebral body on the basis of persisting dorsolumbar pain. Staging examinations including CT scan of the thorax and abdomen as well as bone scintigraphy were inconspicuous. The patient underwent 6 cycles of neoadjuvant chemotherapy (VIDE, similar to Euro Ewing 99). Presurgically, embolisation of the L4 and L5 vertebral bodies was performed on both sides. The tumour was removed via a dorsal approach with corporectomy of L5 and resection of the right nerve root of L5. The defect was bridged by a titanium cage filled with bone cement; a dorsal L4-S1 instrumentation was performed. Early postoperative X-rays showed a screw dislocation in S1, making a revision intervention and screw replacement necessary. For additional fixation, S2 was instrumented. Histopathology classified the tissue samples as containing no active tumour cells. Surgery was followed by additional chemotherapy. The patient has remained free of recurrence until now. The aim of this case report is to call attention to the unusual site of the Ewing sarcoma as well as to discuss therapy options, especially dorsal corporectomy, and the prognosis together with a review of the most current literature.

Minimalinvasive Eingriffe an der Wirbelsäule zur Behandlung akuter oder chronischer Rückenschmerzen erfreuen sich seit Jahren einer großen Beliebtheit. Im 1. Teil unserer Fortbildung wurden die semiinvasiven Verfahren vorgestellt, insbesondere Injektionen und perkutane Verfahren. Weiterhin wurden Bandscheibenoperationen ohne Implantate beschrieben und erläutert, darunter intra- und extradiskale Interventionen. In unserem 2. Teil wollen wir nun näher eingehen auf Bandscheibenoperationen mit Implantaten, auf Interventionen bei Spinalkanalstenose, auf Fusionen und perkutane Versorgungen bei Wirbelkörperfrakturen. Ziel dieser Fortbildung soll es sein, einen Überblick über die derzeit in der Literatur beschriebenen und in der Praxis durchgeführten minimalinvasiven Operationstechniken an der Wirbelsäule zu geben. Entscheidungshilfen zur Indikationsstellung minimalinvasiver Maßnahmen an der Wirbelsäule werden dargestellt.

We present the clinical case of a fifty-year-old man who presented two times with a foot elevator paresis and an erysipel first on the right and after two months on the left side. Afterwards, we carried out a thorough case history with the help of clinical, radiological and magnetic resonance imaging. Even so the clinical pathology of the foot elevator paresis could not be manifested. A compartment syndrome could be discounted. In the context of the second stay during a neurology examination on both legs electromyography was performed and the nerve speed was tested. A peripheral peroneus paresis of unknown level and of unknown aetiology was demonstrated. The erysipel regressed rapidly under intravenous ampicillin antibiotics while the peroneus paresis was unchanged. The patent was released with a peroneus splint on both sides. With this case report we would like to point out the causes of peripheral peroneus paresis with regard to an additional erysipel. This case report is discussed regarding the possible aetiopathology and the current literature.