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Purpose To evaluate the AOSpine Thoracolumbar Spine Injury Classification System and if it is reliable and reproducible when applied to the paediatric population globally. Methods A total of 12 paediatric orthopaedic surgeons were asked to review MRI and CT imaging of 25 paediatric patients with thoracolumbar spine traumatic injuries, in order to determine the classification of the lesions observed. The evaluators classified injuries into primary categories: A, B and C. Interobserver reliability was assessed for the initial reading by Fleiss's kappa coefficient (kF) along with 95% confidence intervals (CI). For A and B type injuries, sub-classification was conducted including A0-A4 and B1-B2 subtypes. Interobserver reliability across subclasses was assessed using Krippendorff's alpha (αk) along with bootstrapped 95% CIs. A second round of classification was performed one-month later. Intraobserver reproducibility was assessed for the primary classifications using Fleiss's kappa and sub-classification reproducibility was assessed by Krippendorff's alpha (αk) along with 95% CIs. Results In total, 25 cases were read for a total of 300 initial and 300 repeated evaluations. Adjusted interobserver reliability was almost perfect (kF = 0.74; 95% CI 0.71 to 0.78) across all observers. Sub-classification reliability was substantial (αk= 0.67; 95% CI 0.51 to 0.81), Adjusted intraobserver reproducibility was almost perfect (kF = 0.91; 95% CI 0.83 to 0.99) for both primary classifications and for sub-classifications (αk = 0.88; 95% CI 0.83 to 0.93). Conclusion The inter- and intraobserver reliability for the AOSpine Thoracolumbar Spine Injury Classification System was high amongst paediatric orthopaedic surgeons. The AOSpine Thoracolumbar Spine Injury Classification System is a promising option as a uniform fracture classification in children. Level of Evidence III

Neuromuskulare Skoliosen (NMS) sind Skoliosen, die auf einer Storung des neuromuskularen Systems beruhen. Diese fuhrt zu einer fruh einsetzenden Deformitat mit rascher Progredienz. Konservative Therapien haben hier einen geringen Stellenwert, Korsette konnen im Wachstumsalter eingesetzt werden. Die Ziele der meist dorsalen Wirbelsaulenoperationen sind die Korrektur der Deformitat und die Verhinderung der Progression. In diesem Artikel gehen wir auf die Besonderheiten bei der Versorgung von Kindern mit NMS ein und beleuchten auch neuere Therapieverfahren fur sehr junge Kinder. Typische Falle werden detailliert beschrieben.

Echinokokkosen beim Menschen sind selten, ein Knochenbefall ist mit weniger als 1 % sehr selten, ein primar spinaler Befall durch Echinokokken gilt als Raritat. Wir berichten uber den lumbalen und sakralen Befall durch Echinococcus multilocularis bei einem 56-jahrigen mannlichen Kaukasier mit sensiblen neurologischen Ausfallen und im Vordergrund stehenden tief lumbalen Ruckenschmerzen. Bei Verdacht auf Spondylodiszitis als Arbeitshypothese erfolgten computertomographiegesteuerte Biopsien, die ohne Ergebnis blieben, sodass eine chirurgische Probenentnahme erfolgte. Die Diagnose des spinalen Echinokokkenbefalls konnte gestellt werden. Es wurde ein radikales chirurgisches Debridement durchgefuhrt und eine antihelminthische Therapie begonnen. Im vorliegenden Beitrag beschreiben wir diesen ungewohnlichen Fall im Detail und geben eine kurze Ubersicht uber die aktuelle Literatur zu dieser Erkrankung.

Purpose The atlantoaxial joint represents the most mobile joint complex within the spine, secured by ligaments and capsules. Integrity of the atlantoaxial joint is crucial with respect to the mobility of the head and the upper spine. Atlantoaxial rotatory dislocation is the most common type of injury within this joint in children and is characterized by a typical position of the head (cock robin position). Nevertheless, this type of injury is frequently overlooked. The purpose of the current study was threefold. First, the characteristics of the patients with atlantoaxial dislocation were identified. Next, we checked if the time to treatment did influence the type of treatment. Finally, we checked if the age of the child at the time of treatment influenced the type of treatment. Methods Forty-four children, who were treated consecutively due to atlantoaxial dislocation at a single spine center between September 1993 and October 2018, are analyzed retrospectively regarding age, sex, symptoms, etiology, time to diagnosis, time to treatment, and outcome. Results Forty-four children (30 girls, mean age 8.9 years) were included in the study. The cock robin head position was found in all of them, but neurological deficits were not found in any of them. In 21 patients, dislocation was caused by previous infection (Grisel's syndrome), whereas in 19 patients, dislocation was due to minor trauma. In 4 cases, etiology remained unknown. Mean time to sufficient treatment was 178 days. Eighteen patients received closed reduction and immobilization after 57 days at mean. Open reduction followed by temporary fixation was done in 12 patients after a mean time gap of 188 days. Bony atlantoaxial fusion was necessary in 14 children, who were diagnosed after 319 days on average. Invasiveness of treatment was dependent on the time delay between development of dislocation and treatment; a significant difference was found between invasiveness of treatment and time to treatment (Kruskal–Wallis test, p Conclusion Young girls are predisposed to incur an atlantoaxial rotatory dislocation, which usually occurs due to minor trauma or infection. The cock robin position is characteristic, but neurological deficits are not common. There is a need for early and sufficient treatment because delayed treatment necessitates more invasive treatment, thus leading to a complete loss of function of the most mobile joint within the spine. Finally, older children are predisposed to more invasive treatment strategies.

Purpose The complement system is a crucial part of innate immunity. Recent work demonstrated an unexpected contribution to tissue homeostasis and degeneration. This study investigated for the first time, in human disc tissues, the deposition profile of the complement activation product terminal complement complex (TCC), an inflammatory trigger and inducer of cell lysis, and its inhibitor CD59, and their correlation with the degree of disc degeneration (DD). Methods Disc biopsies were collected from patients diagnosed with DD (n = 39, age 63 ± 12) and adolescent idiopathic scoliosis (AIS, n = 10, age 17 ± 4) and compared with discs from healthy Young (n = 11, age 7 ± 7) and Elder (n = 10, age 65 ± 15) donors. Immunohistochemical detection of TCC and CD59 in nucleus pulposus (NP), annulus fibrosus (AF) and endplate (EP) was correlated with age, Pfirrmann grade and Modic changes. Results Higher percentage of TCC+ cells was detected in the NP and EP of DD compared to Elder (P P P Conclusion TCC deposition positively correlated with the degree of disc degeneration. A functional relevance of TCC may exist in DD, representing a potential target for new therapeutics.

Magnetically controlled growing rods (MCGR) for the surgical treatment of early onset scoliosis (EOS) allow non-invasive outpatient based distractions during spinal growth. The purpose of this study is to present the results of a single center case series of 22 patients, evaluate the effect of MCGR treatment on the development of spino-pelvic parameters during growth, and report initial outcomes after end of treatment.Prospectively collected data of 22 EOS patients with MCGR treatment has been analyzed. The following radiological parameters were measured before index surgery, after index surgery, 1 year after index surgery, and at last follow-up: Cobb angle of the major curves, thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). Mean age at index surgery was 9.5 years (range: 4-14 years). Mean length of follow-up was 47.6 months (range: 25-121 months). Etiology of diagnosis was idiopathic in 14 patients, associated with neurofibromatosis in 2 patients, and neuromuscular or syndromic in 6 patients.Mean Cobb angle of the major curve was 57° preoperatively and 29° at last follow-up (p 0.0005). Mean TK was 20.1° preoperatively and 20° at last follow-up (p 0.05). Mean LL was 52.8° preoperatively and 53.2° at last follow-up (p 0.05). Mean PI was 43.2° preoperatively and 46.3° at last follow-up (p 0.05). Mean PT was 4.1° preoperatively and 5.8° at last follow-up (p 0.05). Mean SS was 39.2° preoperatively and 41.7° at last follow-up (p 0.05). 14 patients finished treatment: nine received final fusion and five received rod removal without fusion. Twelve complications occurred: one deep wound infection, six patients developed proximal junctional kyphosis (PJK), one rod fracture, two rods failed to distract, one deformity progressed after rod removal and required spinal fusion, and one patient developed autofusion of the spine prior to end of treatment.MCGR treatment is able to control deformity progression. Complication rate was 54.5%. Sagittal balance was not altered and treatment does not seem to have a negative impact on the development of spino-pelvic parameters during growth. Optimal end of treatment for the individual patient still has to be defined.

Wirbelsaulenverletzungen im Kindesalter sind insgesamt sehr selten. Aktuelle einschlagige Studien mit grosen Fallzahlen, aus welchen sich evidenzbasierte Empfehlungen zu Diagnostik und Therapie von Wirbelsaulenverletzungen bei padiatrischen Patienten ableiten lassen, existieren nicht. Formulierung von Empfehlungen zu Diagnostik und Therapie von Verletzungen der Brust- und Lendenwirbelsaule im Kindesalter. Zunachst erfolgte eine Recherche von Primar-, aber auch Sekundarliteratur zum Themenkomplex Diagnostik und Therapie von Verletzungen der Wirbelsaule bei Kindern. Eine entsprechende interne Literaturdatenbank wurde angelegt und gepflegt. Im Zeitraum von April 2017 bis Dezember 2019 fanden sich die Mitglieder der Arbeitsgemeinschaft Wirbelsaulentrauma im Kindesalter der Sektion Wirbelsaule der Deutschen Gesellschaft fur Orthopadie und Unfallchirurgie zu einem Konsensusprozess zusammen. In 9 Arbeitstreffen wurden systematisch Empfehlungen zu Diagnostik und Therapie von Verletzungen der Wirbelsaule bei Kindern formuliert. Es konnten Empfehlungen zu Diagnostik und Therapie von Verletzungen der Brust- und Lendenwirbelsaule fur 3 Altersstufen (Altersstufe I: 0 bis 6 Jahre; Altersstufe II: 7 bis 9 Jahre; Altersstufe III: 10 bi s16 Jahre) formuliert werden. Die Prinzipien der Diagnostik und Therapie aus der Erwachsenenmedizin konnen nicht problemlos ubertragen werden. Wirbelsaulenverletzungen im Kindesalter sind selten und sollten der Behandlung in geeigneten Zentren zugefuhrt werden. Die MRT-Diagnostik sollte beim kardiopulmonal stabilen Kind mit Verdacht auf ein Monotrauma der Wirbelsaule als initiale Bildgebung indiziert werden. Die grundlegenden Therapieziele bei Verletzungen der Brust- und Lendenwirbelsaule im Kindesalter sind die Wiederherstellung der Stabilitat, der Schutz der neurogenen Strukturen und das Wiederherstellen der anatomisch korrekten Verhaltnisse. Bei der Indikationsstellung zur konservativen vs. operativen Therapie mussen das Korrektur- und Regenerationspotenzial der einzelnen Wirbelsaulenabschnitte in Abhangigkeit vom Patientenalter berucksichtigt werden. Die operative Stabilisierung soll v. a. uber minimalinvasive Techniken, im Sinne einer Instrumentierung ohne Spondylodese und fruhzeitiger Metallentfernung, erfolgen.

Generell stellen Wirbelsaulenverletzungen bei Kindern im Alter unter 16 Jahren eine seltene Verletzungsentitat dar. Fur Deutschland liegen keine belastbaren Daten bezuglich der Epidemiologie von Verletzungen der Wirbelsaule im Kindesalter vor. Gerade bei padiatrischen Patienten, bei denen sowohl die Anamnese, die klinische Untersuchung, aber auch die Durchfuhrung der bildgebenden Diagnostik haufig erschwert sind, mussen samtliche Hinweise auf eine Verletzung der Wirbelsaule mitberucksichtigt werden. Das Ziel der vorliegenden Studie war die Bereitstellung epidemiologischer Daten von padiatrischen Patienten mit Wirbelsaulenverletzungen in Deutschland, um diese zukunftig in die Entscheidungsfindung bei der Diagnostik und Therapie dieser Patienten einfliesen lassen zu konnen. Im Rahmen einer nationalen Multizenterstudie wurden retrospektiv Patientendaten innerhalb eines Zeitraums von 7 Jahren aus 6 Wirbelsaulenzentren erhoben. Neben den demografischen Daten wurden der Unfallmechanismus, die betroffene Wirbelsaulenregion und auch die Begleitverletzungen erhoben. Zudem erfolgte die Erfassung der bildgebenden Diagnostik sowie der jeweiligen Therapie. Es konnten 367 Kinder (weiblich: mannlich = 1:1,2) mit insgesamt 610 Verletzungen an der Wirbelsaule in die Studie eingeschlossen werden. Das mittlere Alter betrug 12 (±3,5) Jahre. Die haufigsten Unfallmechanismen in allen Altersgruppen waren ein Sturz aus unter 3 m Hohe sowie Verkehrsunfalle. Die bildgebende Diagnostik musste nur in Ausnahmefallen in Narkose durchgefuhrt werden. Wahrend jungere Kinder (0 bis 9 Jahre) eher Verletzungen im Bereich der Halswirbelsaule erlitten, zeigten sich Verletzungen der thorakolumbalen Wirbelsaule eher bei Kindern >10 Jahren. Die Kinder wiesen haufige Begleitverletzungen an Kopf und Extremitaten auf. Im Bereich der Wirbelsaule befanden sich weitere Verletzungen meist benachbart und nur selten in anderen Regionen. Rund 75 % der Kinder wurden konservativ behandelt. Die Ergebnisse unterscheiden sich von den Erkenntnissen aus der Erwachsenenmedizin und beschreiben spezielle Gegebenheiten fur padiatrische Patienten mit Wirbelsaulenverletzungen. Trotz gewisser Limitationen konnen sie so bei der Entscheidungsfindung uber die durchzufuhrende Diagnostik und Therapie dieser Patienten helfen.

Background Atlantoaxial fixation is technically challenging in younger children. The C1-C2 screw-rod fixation technique is established for adults but limited data about the clinical and radiographical outcome for the treatment of children with 5 years of age or younger is available. Methods All files of children who were consecutively treated for spinal disorders were reviewed. Inclusion criteria for further evaluation were: 0 to 5 years of age at initial procedure; detailed surgical report of a posterior C1-C2 fusion with mass lateral and pedicle screw-rod fixation as described by Harms; a minimum clinical and radiographical follow-up of 24 months. The postoperative and last follow-up computed tomography scan and radiographs were used to assess the positioning and stability of the C1-C2 screw-rod construct. Results Eleven patients (3 boys) with a mean age of 46 months (range: 8 to 66 mo) fulfilled inclusion criteria and were evaluated retrospectively. The mean clinical and radiographical follow-up was 79 months (range: 24 mo to 170 mo). The diagnosis was atlantoaxial rotatory dislocation (4 cases), C1-C2 instability with subluxation (3 cases), atlantoaxial dislocation and os odontoideum (1 case), type II odontoid fracture (1 case), traumatic odontoid epiphysiolysis (1 case), and traumatic rupture of the transverse ligament with C1 subluxation (1 case). Intraoperatively and postoperatively no new neurovascular or vascular complication occurred. C1 lateral mass screws were placed correctly in all cases. Twenty-two C2 pedicle screws were placed correctly (85.7%), and 3 screws showed penetration of the pedicle wall (14.3%). No implant revision, implant failure, and pseudarthrosis were noted. Loss of correction was noted in 1 patient with unilateral C1-C2 fixation and a repeated dorsal fusion procedures were performed. A repeat procedure for implant removal and segmental release was performed in 3 patients to increase the axial rotation of the head. Conclusions The C1-C2 screw-rod fixation is a safe technique that achieves solid fixation of the atlantoaxial complex in young children with various disorders. The technique preserves the joint and allows for segmental release via implant removal.

We present the case of a postoperative intracranial hypotension due to a misplaced intrathecal screw. Although typical symptoms such as orthostatic headache were present immediately after surgery, diagnosis was hidden until 20 years later, resulting in a disastrous clinical course.

Motion preserving surgery within the cervical spine may be performed by special implants, for example, c spine disc prosthesis or total disc replacement (cTDR), or by simple decompression of the cervical nerve roots. However, also fusion surgery may be performed with good results. Here, we summarize indications as well as contraindications for motion preserving techniques and indications for fusion surgery. cTDR is indicated in special cases of soft disc herniation, especially in younger individuals without signs of myelopathy. Posterior decompression may be used as an alternative, especially if anterior surgery is not possible. If degeneration is severe, in the presence of kyphosis, severe canal encroachment, instability, and in cases of myelopathy, cervical spine fusion seems to be the better way.

Das Harlekinsyndrom ist eine seltene Symptomkonstellation, gekennzeichnet durch einseitige Anhidrose und Blasse des Gesichts auf der betroffenen Seite, was insbesondere durch kontralaterale Rotung wahrend sportlicher Aktivitat erkennbar wird. Das Syndrom ist meistens idiopathisch, tritt aber auch nach thoraxchirurgischen Eingriffen auf, vor allem bei Oberlappenresektionen. Im Folgenden prasentieren wir zwei Falle eines Harlekinsyndroms nach zervikothorakaler Skoliosechirurgie.

ZusammenfassungIn diesem Artikel werden die Besonderheiten der konservativen und operativen Therapie bei der kindlichen Spondylodiszitis und der spezifischen, tuberkulösen Spondylitis besprochen. Beides sind seltene Erkrankungen, bei beiden gibt es sinnvolle konservative Therapieansätze und bei beiden stellen Deformitäten im weiteren Verlauf häufige und ernsthafte Komplikationen dar.

Dysphagia is a common complication following anterior cervical spine surgery and may occur in over 70% of patients. There is an emerging evidence that dysphagia also appears after posterior cervical spine surgery. Nevertheless, hardly any study is focusing on changes in swallowing physiology with regard to surgical approach. Aim of this study: To investigate changes in swallowing physiology following: 1. anterior cervical spine surgery, and 2. posterior cervical spine surgery. Methods: A standardized videofluoroscopic swallowing study (VFSS) was performed in 28 patients who underwent cervical spine surgery (anterior approach n = 19, Mage 56±14; posterior approach n = 9, Mage 58±17) one day before surgery and after surgery (mean 4 days). Data were analyzed retrospectively with the Modified Barium Swallow Impairment Profile (MBSImPTM©). Results: 1. In the anterior group, pharyngeal sum score was significantly higher after surgery (p < .001). Significant changes were found in 4 out of 8 analyzed pharyngeal components. 2. In the posterior group, pharyngeal sum score was significantly higher after surgery (p = .015). No significant changes were found in the oral or pharyngeal components. Conclusions: Whereas more changes in swallowing physiology occurred following anterior surgery, there were also overall changes in the posterior group. Understanding the swallowing pathophysiology associated with cervical spine surgery is indispensable to decrease the rate of secondary complications and improve quality of life for this patients.

ZusammenfassungThorakolumbale Wirbelsäulenverletzungen sind bei Kindern deutlicher seltener als bei Erwachsenen. Entsprechend sind Informationen zu diesem Themenkomplex spärlich. In diesem Artikel sollen vier Aspekte zu thorakolumbalen Frakturen der kindlichen Wirbelsäule näher beleuchtet werden:1. die Epidemiologie von kindlichen thorakolumbalen Verletzungen2. Besonderheiten bei pädiatrischen thorakolumbalen Verletzungen3. spezielle Aspekte der Diagnostik4. Therapie der kindlichen thorakolumbalen Verletzungen

Die zervikale spondylogene Myelopathie ist eine Erkrankung, bei der intensiv uber das ideale Timing zur Operation diskutiert wird. Vor allem ist noch nicht mit ausreichend hoher Evidenz belegt, wie bei leichten zervikalen Myelopathie ideal vor zu gehen ist: fruh operieren oder initial abwarten und damit spat operieren? Hier gilt es insbesondere abzuwagen: den Spontanverlauf der Erkrankung, Risiken des Einzelnen, die Komplikationen des zu wahlenden Verfahrens unter Berucksichtigung von radiologische und elektrophysiologischen Befunden. In diesem Artikel soll erortert werden, welche Patienten spat operiert werden konnen oder sollten. Nach dem derzeitigen Stand der Literatur erscheint es akzeptabel, Patienten mit geringradiger Stenose und normalem MEP Befund initial konservativ zu behandeln und somit spater zu operieren. Auch Patienten mit konstanten, leichteren Verlaufen und ohne erhohtes Sturzrisiko sind am ehesten geeignete Kandidaten fur eine spate Operation. Bei alteren Patienten mit hoherem operativem Risikoprofil kann ebenfalls abgewartet werden, sofern es die klinische Symptomatik zulasst. Funf Fallbeispiele illustrieren die Uberlegungen. Today, there is still a debate about the ideal timing of surgical intervention if cervical spondylotic myelopathy is diagnosed. This is even more pronounced in patients presenting with only mild symptoms: is it beneficial to operate as early as possible or is late surgery better especially with respect to complications that may occur and affect the patients quality of life. Within this article, we try to illuminate, which patients could be candidates for late surgery. Today, it seems to be acceptable, to operate late on patients harboring a mild grade stenosis combined with mild clinical symptoms and normal latencies as measured by MEP. Moreover, elderly people as well as individuals with low risk of trauma in sports and daily activity may be candidates for late surgery. Five case clinical case reports are added to illuminate special aspects.

Study Design Case report. Background and Study Aims For stabilizing surgery of the atlantoaxial region, a precise evaluation of the course of the vertebral artery (VA) is essential to avoid vessel injury and life threatening complications. In patients with aberrant VA course, an appropriate way for fusion needs to be found. This article presents a case of an unusual VA course and illuminates the importance of surgical planning with computed tomography angiography identifying VA variations at the atlantoaxial region. Case Report A 71-year-old woman with atlantoaxial arthrosis had a VA variation (persistent first intersegmental artery). She underwent C1–C2 posterior fixation according to Harms/Goel using the typical entry points, requiring VA dissection in caudal direction. The postoperative clinical as well as radiographic result was excellent. Angiography 6 months postoperatively showed the VAs below the C1 screws with normal blood flow. Conclusions Placement of C1 screws in a patient with a persistent first intersegmental VA is possible. Careful VA dissection is the key step for safe screw placement, screw anchoring, and clinical success.

Object Surgical treatment of atlantoaxial injuries may be performed by a variety of surgical procedures, with each of these having its own specific advantages and disadvantages. To preserve the range of motion within the atlantoaxial joint after surgical treatment, posterior atlantoaxial screw fixation according to the method of Goel and Harms could be beneficial. This technique is not considered to fix the joint permanently if the screws are removed. However, this must not necessarily be true, especially if one notices that cervical joints have a tendency for rapid fusion after surgery. The objective of this study was to analyze left-right axial rotation following implant removal, with the following research questions addressed: 1) is there a relevant rotational left-right mobility in C1–2; 2) is there a difference in mobility depending on sex; 3) is there a correlation of mobility to age; 4) is there a correlation of mobility to the “implant-in-body time”; and 5) is neck pain improved by this method of surgical treatment? Methods This is a retrospective study in 10 patients who had received atlantoaxial fixation according to the Harms method following atlantoaxial injury. These patients had undergone implant removal after a mean time of 128 days, followed by functional atlantoaxial CT in left-right rotation. Statistical analysis was performed using the SPSS software package; significance was assumed for p < 0.05. Results The following findings are reported. 1) Left-right axial rotation within the atlantoaxial joint was measured to be 17° (mean value) following implant removal. 2) There was no significant difference between men (20°) and women (14.8°) (p = 0.595). 3) Left-right axial rotation negatively correlated to the age of the patient (r = −0.646, p = 0.043). 4) “Implant-in-body time” did not influence left-right axial rotation (r = 0.04, p = 0.907) if the implants are removed within 90–180 days after surgery. 5) Neck pain as assessed by the patients themselves on the visual analog scale was 7.9 ± 1.1 preoperatively and 3.6 ± 1.2 (mean ± SD) after implant removal (p = 0.002). Conclusions The authors conclude that removal of the implants 3–6 months after posterior atlantoaxial fixation according to the method of Goel and Harms is beneficial for obtaining some axial rotation within the atlantoaxial joint. The range of motion preserved depends on the age of the patient.

Study design Case report on resection of a hemivertebra at the craniocervical junction. Objective To describe technique and result of a hemivertebra resection within the craniocervical junction (axis). Summary of background data To our knowledge, this is the first report on a transoral and posterior hemivertebra resection at C2. Methods A 42-year-old patient presented with coronal imbalance due to a hemivertebra at C2. Correction was performed by a combined anterior (transoral) and posterior approach with hemivertebra resection and compression instrumentation. Results The postoperative course was uneventful. The radiographs showed a complete correction of the deformity with a perfect clinical result. Conclusion Hemivertebra resection at the craniocervical junction can be performed safely with good clinical and radiographical outcome. Level of evidence 4.

A case of late dislocation of a disc spacer L5/S1 with perforation of the sigmoid colon and transanal passage 4 years after implantation is reported. The objective is to describe an uncommon complication of anterior endoscopic spondylodesis L5/S1. To our knowledge, this is the first report on this rare complication. A 39-year-old patient suffering from a spondylolisthesis L5/S1 (Meyerding grade 2) with bilateral lysis L5 was operated with posterior instrumentation L5/S1 and anterior endoscopic insertion of two disc spacers. 4 years after surgery the patient noticed one of the spacers in the toilet. Radiographic examination of the colon with contrast dye revealed a perforation at the distal sigmoid colon. At the lumbosacral junction there was a bony defect at the site of the absent spacer and an anterior dislocation of the second spacer. A partial resection of the colon at the perforation site with end-to-end anastomosis was performed. The second spacer was removed, and the defect was packed with autologous cancellous bone and local antibiotics. The further course was uneventful. 2 weeks postoperatively the patient was discharged without signs of infection. The radiographic examination after 6 months showed healing of the bone graft with bony fusion L5/S1. In case of incomplete or absent bony fusion the dislocation of intradiscal spacers may arise even years after the primary surgery. In consequence periodical radiographic examinations of spinal instrumentations are recommended until complete bony fusion occurred. Unclear abdominal symptoms following anterior spine surgery require immediate examination.

Study design Retrospective study of posterior hemivertebra resection and osteotomies with transpedicular instrumentation in very young children. Objective Assessment of early intervention in congenital scoliosis with almost complete correction of the main deformity. Summary of background data There is a trend to early correction of congenital deformities, however, there is a lack of long-term follow-up. Methods Forty-one children aged 1 to 6 years with congenital scoliosis were operated on by hemivertebra resection by a posterior only approach with transpedicular instrumentation. Mean age at time of surgery was 3 years 5 months. They were retrospectively studied with a mean follow-up of 6 years 2 months. Results In group 1 (patients without bar formation), the average Cobb angle of the main curve was 36 degrees before surgery and 7 degrees after surgery. Compensatory cranial curve improved spontaneously from 15 degrees to 3 degrees, compensatory caudal curve from 17 degrees to 4 degrees. The angle of kyphosis was 22 degrees before surgery and 8 degrees after surgery. In group 2 (patients with bar formation) the main curve improved from 69 degrees to 23 degrees, cranial curve from 27 degrees to 11 degrees, caudal curve from 34 degrees to 14 degrees, and kyphosis from 24 degrees to 9 degrees. Conclusion Posterior hemivertebra resection, in case of bar formation with osteotomy of the bar, allows for excellent correction in both the frontal and sagittal planes, with a short segment of fusion. Early surgery in young children prevents the development of severe local deformities and secondary structural curves, thus allowing for normal growth in the unaffected parts of the spine.

Study design Retrospective study with clinical and radiologic evaluation of hemivertebra resection in children with congenital cervical scoliosis. Objective Assessment of hemivertebra resection in the treatment of congenital cervical scoliosis. Summary of background data To our knowledge, this is the first report on hemivertebra resection in the midcervical spine. Methods Three patients with torticollis due to a cervical hemivertebra were operated on by hemivertebra resection and fusion of the adjacent vertebrae. Resection was performed by a posterior-anterior (-posterior) approach. Mean age at time of surgery was 9 years 3 months. They were retrospectively studied with a mean follow-up of 4.8 years. Results Mean segmental Cobb angle at the hemivertebra was 29 degrees before surgery, 5 degrees after surgery, and 6 degrees at latest follow-up. Head tilt improved from 17 degrees before surgery to 1 degrees after surgery, and 3 degrees at latest follow-up. Bony fusion was achieved in all cases. There was weakness of the left deltoid muscle in 1 case due to C5 root compression by a facet screw, which resolved completely after revision with change of the screw. Conclusions Resection of a cervical hemivertebra may be an option in the treatment of congenital cervical scoliosis. A good correction of the local deformity and a complete correction of head tilt are achieved. By early operation in young children, the development of severe secondary deformities in the upper thoracic spine can be avoided.

Fruhzeitige Korrektur kongenitaler Skoliosen mit kurzstreckiger transpedikularer Instrumentation vor der Ausbildung rigider sekundarer Gegenkrummungen. Durch Halbwirbel bedingte kongenitale Skoliose bei Kindern und Jugendlichen. Rigide langstreckige Skoliosen, nicht korrigierbare Sekundarkrummungen. Dorsaler Zugang zur Wirbelsaule. Pedikelschrauben werden in die dem Halbwirbel benachbarten Wirbel eingebracht. Die dorsalen Anteile des Halbwirbels werden reseziert; anschliesend werden unter Schutz des Duralsacks sowie der Nervenwurzeln der Halbwirbelkorper und die angrenzenden Bandscheiben entfernt. Die entstehende Lucke wird durch Kompression uber die transpedikulare Instrumentation geschlossen und so die Fehlstellung korrigiert. Von Juni 1991 bis Juli 2002 wurden 42 Halbwirbel bei 38 Patienten reseziert (22 Madchen, 16 Jungen, Durchschnittsalter 6 Jahre 1 Monat [1 Jahr 3 Monate bis 16 Jahre 7 Monate]). Die durchschnittliche Nachuntersuchungszeit betrug 43 Monate (7–129 Monate). Der Skoliosewinkel (Cobb) der Hauptkrummung betrug praoperativ durchschnittlich 43,5° (9–80°). Postoperativ korrigierte er sich auf 13,4° (–4° bis 45°) und betrug bei der letzten Nachuntersuchung 14,0° (–2° bis 59°). Die Kyphose im Bereich des Halbwirbels wurde von durchschnittlich 23,1° auf 9,7° und 9,0° korrigiert.

STUDY DESIGN Retrospective study of patients with anterior release and posterior correction instrumentation in a 2-stage procedure for rigid thoracic scoliosis. OBJECTIVE To examine the effect of the anterior release and shortening alone as well as its role in the overall correction. SUMMARY OF BACKGROUND DATA With segmental transpedicular instrumentation the need for an additional anterior mobilization became rare. However, its effect on sagittal profile was not sufficiently acknowledged. METHODS Twenty-two patients with rigid thoracic scoliosis (Lenke 1A, n = 3; 2A, n = 6; 2B, n = 2; 2C, n = 1; 4B, n = 1; 4C, n = 9 patients) were operated in a 2-stage procedure with anterior release followed by posterior correction. The anterior release included convex resection of the rib heads and shortening of the anterior column by resection of the discs and the convex anterolateral endplates in a mean of 8 (4-11) segments.After 14 days (6-27), the posterior instrumentation and correction was done. RESULTS The preoperative thoracic scoliosis measured a mean of 80°, upper thoracic 42°, and lumbar 49°. The thoracic curve corrected in bending 20° (25%), upper thoracic 10° (24%), and lumbar 26° (53%). The mean thoracic kyphosis (T5-T12) was 11°, lumbar lordosis was -41°.After the anterior release and shortening, thoracic scoliosis improved to 50°, thoracic kyphosis increased to 32°.After the posterior surgery the following values were noted: thoracic scoliosis 10°, upper thoracic 9°, lumbar 8°, thoracic kyphosis 25°, and lumbar lordosis -41°. The results were maintained at follow-up. CONCLUSION Anterior shortening results in a spontaneous correction of the thoracic scoliosis and hypokyphosis. In this series, the Cobb angle reduced 38% from a mean of 80° to a mean of 50°. Thoracic kyphosis increased from 11° to 32°. This correction was achieved without any corrective force or instrumentation. The second-stage posterior correction is facilitated and nearly complete correction is achieved with a residual curve on average of 10° with a physiological sagittal profile. LEVEL OF EVIDENCE 4.

Study design An innovative function preserving technique for the treatment of odontoid nonunion via ventral cancellous bone augmentation of the dens is described. A retrospective clinical study of 17 patients, thus treated by this technique is reported. Objectives Assessment of a new method, which preserves the rotational mobility of the C1/C2 joint. Summary of background data Nonunion after odontoid fractures are usually treated by posterior fusion of C1/C2. Although there are reports of good clinical results, restriction of rotational mobility is inevitable. Methods Seventeen patients with dens pseudarthrosis or delayed healing were operated on between the year 1991 and 2005. A hole was drilled in the dens and packed with autologous bone graft. Temporary Instrumentation C1/C2 (anteriorly or posteriorly) was performed for 3 to 4 months. Patients were evaluated clinically and radiographically, rotation computed tomography or magnetic resonance imaging studies were conducted. Results Fifteen patients were available for follow-up. Nine patients demonstrated healing of the pseudarthrosis with preservation of C1/C2 joint mobility (confirmed by rotation-computed tomgraphy or rotation -magnetic resonance imaging in 7 cases, average segmental rotation 37.3 degrees). Four patients showed persistent pseudarthrosis (2 were fused by posterior C1/C2 fixation) and 2 patients demonstrated spontaneous C1-C2 fusion. Conclusions Ventral cancellous bone augmentation of the dens and temporary instrumentation C1/C2 is a function-preserving option in the treatment of dens pseudarthrosis.

We present a case of an unusual course of the vertebral artery (VA) with intra-foraminal entrance at C4. A patient with traumatic fracture of C3 and C4 with dislocation C3/C4, spinal cord compression and ensuing quadriplegia presented with unilateral entrance of the VA at C4 detected on preoperative magnetic resonance imaging (MRI). The patient was surgically decompressed and stabilized by an anterior-posterior approach without intra-operative complications. Apart from anatomical findings no clinical case of entrance of the VA at C4 had been described in recent clinical literature. A physiologic high entrance of the VA is very rare but must be diagnosed preoperatively to avoid potential life threatening complications.

Study design A retrospective clinical and radiologic evaluation of patients with vertebral osteomyelitis treated via radical debridement and stabilization using titanium mesh cages. Objective To assess the efficacy of titanium mesh cages in the treatment of active vertebral osteomyelitis. Summary of background data Although titanium mesh cages have proven to be superior in trauma and tumor reconstructions, there are few reports regarding the use of titanium mesh cages in the presence of active pyogenic or tuberculotic vertebral osteomyelitis. Methods A total of 88 cases with vertebral osteomyelitis were operated on between January 2000 and December 2002. There were 2 craniocervical, 13 cervical, 19 thoracic, 11 thoracolumbar, and 43 lumbar infections. The titanium mesh cages replaced 1 disc in 34 cases, 1 vertebral body in 28 cases, 2 vertebral bodies in 23 cases, and 3 vertebral bodies in 3 cases. Results All patients showed a solid bony fusion without any recurrence of infection at latest follow-up. Changes in pain score, Frankel's classification, and blood parameters demonstrated a significant clinical improvement in all patients. The sagittal profile was restored. Conclusions The use of titanium mesh cages in the treatment of vertebral osteomyelitis effectively reconstructs the anterior column, while adding stability and restoring the sagittal profile. There is no increase in the rate of recurrence or persistence of infection related to the implantation of titanium mesh cages.

STUDY DESIGN A retrospective review of the clinical and radiographic outcomes of reduction by temporary instrumentation of L4 and monosegmental fusion of L5/S1 in patients with high-grade developmental spondylolisthesis. OBJECTIVE To assess the efficacy of this technique in the reduction of local deformity and correction of overall sagittal profile. SUMMARY OF BACKGROUND DATA In situ fusions as well as partial reduction with fusion L4-S1 via various approaches have been described previously. To date and to our knowledge, there have been no reports describing complete reduction and monosegmental fusion for high-grade developmental spondylolisthesis. METHODS A total of 27 consecutive patients with severe developmental spondylolisthesis of L5/S1 were treated with operative reduction via temporary instrumentation of L4 and monosegmental fusion of L5/S1. The clinical and radiographic outcomes were retrospectively reviewed for each case at a minimum of 2 years (mean follow-up of 45 months; range 24-80). Mean age at surgery was 16.7 years (range 9-29). RESULTS At most recent follow-up, 23 patients were pain free. There were 4 patients who had moderate pain. All radiographic parameters improved. Mean slippage improved from 74.0% before surgery to 11.0% after surgery and 10.0% at latest follow-up. Slip angle improved from 36.6 degrees before surgery to 8.1 degrees after surgery and 7.6 degrees at latest follow-up. Sacral inclination improved from 34.6 degrees before surgery to 43.4 degrees after surgery and 47.2 degrees at latest follow-up. The overall sagittal profile improved dramatically. There was 1 superficial infection, 6 patients had L5 root symptoms (5 of these resolved, 1 patient had a persistent sensory deficit). Four patients had decompensation at L4/5 (2 reoperations). CONCLUSIONS Reduction of L5/S1 with temporary instrumentation of L4 and monosegmental fusion of L5/S1 is an effective technique for the treatment of high-grade developmental spondylolisthesis. A complete reduction of local deformity and excellent correction of overall sagittal profile can be achieved. Fusion of the primarily healthy segment L4/5 can be avoided.

In spite of the great advances in medicine, there is no effective conservative or operative method that can succeed in halting the ankylosing process in the spine of ankylosing spondylitis (AS) patients. Moreover, there is no known effective joint replacement in the field of the spine that can restore part of the lost spinal movements in those patients. The main role of surgery is in restoring a balanced spine by recreating an acceptable sagittal contour.

Study design: Two cases of intraoperative, iatrogenic cervical spine fractures in patients with ankylosing spondylitis are reported. Objective: To describe the uncommon complication of iatrogenic cervical spine fractures occurring during spine surgery in patients with ankylosing spondylitis. Summary of background data: To our knowledge, this is the first report on this rare complication. Methods: A 39-year-old patient (1) with ankylosing spondylitis was operated on for cervical stenosis due to C1/2 anterolisthesis. Fifteen hours postoperatively, he developed acute quadriplegia. MRI revealed a fracture/dislocation of C6 on C7 and compression of the spinal cord at this level. Revision was performed with decompression and instrumentation from the occiput to T3. A 55-year-old patient (2) with ankylosing spondylitis and thoracic hyperkyphosis underwent a correction procedure consisting of costotransversectomy, anterior cage implantation at T8/9, and posterior instrumentation from T4 to L1. Halo traction was temporarily applied for correction. At the end of the operation, with the patient still under anesthesia, increased mobility of the cervical spine was noticed. Emergent MRI revealed a fracture of the anterior structures of C6/7. Posterior instrumentation from C5 to T1 was then performed. Results: Quadriplegia persisted in patient 1 until his death secondary to further complications. Patient 2 was mobilized without any neurologic deficits. The fracture healed in good alignment. Conclusions: Iatrogenic fractures of the cervical spine during surgery in ankylosing spondylitis patients are a rare but potentially severe complication. Early diagnosis and therapy are necessary before dislocation, cord compression, and subsequent neurologic impairment occur.

Atlantoaxial rotatory dislocation (AARD) represents a rare pathological condition of the upper cervical spine that is frequently misdiagnosed, leading to a delay in therapy. In a long-term assessment of clinical and radiological results, three different therapeutic options with regard to the length of the dislocation-therapy interval (DTI) were evaluated. Twenty-six patients were treated for AARD from December 1988 until April 2000. Proper diagnosis was established after an average interval of 15 months. Three different therapeutical protocols were followed in order to reduce the dislocation: (1) closed transoral reposition under general anesthesia; (2) temporary transoral fixation utilizing the Harms T-plate; (3) definitive transoral fusion. The eight patients treated by closed reduction had the best pain relief. The average visual analogue scale (VAS) score was 96.6 points, while the rotatory motion of the upper cervical spine, as assessed by dynamic MRI, was 25.3 degrees to each side. The length of the dislocation-therapy-interval (DTI) averaged 1.4 months. A mean VAS Score of 92.3 points was recorded in the ten patients treated with a temporary fixation of C1/C2. In this subgroup the DTI had an average length of 5.3 months. The mean rotation to each side was 13.9 degrees . In the eight patients who underwent definitive fusion the mean VAS score was 60.6 points, while the average length of the DTI was 40.5 months. In conclusion, the clinical outcome and the subjective well-being following AARD deteriorates with increasing length of the dislocation-therapy interval.

Study design Retrospective study with clinical and radiologic evaluation of transoral reduction and osteosynthesis of C1 in the treatment of unstable Jefferson fractures. Objective Assessment of a new method, which preserves the function of the C1-C2 joint in young patients. Summary of background data Unstable Jefferson fractures with rupture of the transverse ligament and high-grade dislocation of the lateral masses of C1 are usually treated conservatively by immobilization or traction or surgical by posterior fusion C1-C2. Methods Six patients with Jefferson fractures with rupture of the transverse ligament were treated by a transoral approach. Reduction was performed by direct manipulation followed by the osteosynthesis of the anterior ring and the lateral masses of C1. Results Total average lateral displacement of the lateral masses was 13.5 mm before surgery (range, 8-19 mm) and improved to 4.3 mm after surgery (range 1-8 mm). The total average difference of the atlantal-dens interval in flexion-extension after surgery was 2.0 mm (range 1-3 mm). The average postoperative rotation in the atlantoaxial joint, evaluated by rotation MRI, was in total 39.2 degrees (range 10 degrees - 61 degrees). Conclusions Transoral reduction and osteosynthesis C1 is a new technique that allows maintenance of rotatory mobility in the C1-C2 joint and restoration of congruency in the atlanto-occipital and atlantoaxial joints. None of the patients had symptoms of postoperative instability of C1-C2.

Wurde HIV/AIDS zunachst als Bedrohung fur homosexuelle Manner gesehen, sind heute global Frauen und Manner gleichermasen infiziert. Das Virus ubertragt sich heute weltweit uberwiegend durch Geschlechtsverkehr zwischen Mannern und Frauen. Im vorliegenden Artikel mochte ich deutlich machen, dass die Einbeziehung der Kategorie Gender in den AIDS-Diskurs entscheidend fur ein umfassendes Verstehen und eine wirkungsvolle Bekampfung der Krankheit ist. Ich werde zeigen, dass die Analyse der Ansteckungsgefahren und Infektionsursachen fur Frauen ein erheblich anderes Bild liefert als die Untersuchung der Ansteckungsgrunde fur Manner. Daraus ergeben sich Formen der Pravention, die anstatt geschlechtsblind zu sein, Manner und Frauen unterschiedlich ansprechen.

Study Design. A retrospective study of 19 consecutive cases (1991–2001) where 91 thoracic and lumbar pedicle screws were used in the treatment of various pediatric spinal disorders in 1- and 2-year-old children. Objectives. To determine the effectiveness and safety of pedicle screw fixation in very young children and to evaluate the effect of pedicle screw insertion on further growth of the vertebra. Summary of Background Data. Although many studies exist about the use of pedicle screws and its advantages in spinal fixation in adults and older children, no study has been published about the use of pedicle screws in 1- and 2-year-old children. Methods. A retrospective review of 19 consecutive operations in 16 patients with insertion of 91 pedicle screws for various spinal disorders in 1- and 2-year-old children was performed. The technique of screw insertion was described. Complications were divided into those directly related to screw placement and general complications and short- and long-term complications. In three cases with more than 6 years follow-up, the effect of pedicle screw insertion on further growth was evaluated by radiographic measurements. Results. Short-term complications occurred in two patients (one pedicle fracture, one infection) and long-term complications in three patients (one screw breakage, two failures of screw connection). Three of 91 screws were misplaced without any neurologic symptoms. Measurements of the vertebral growth in long-term follow-up did not show any adverse effect related to pedicle screw insertion. Conclusion. The results suggest that pedicle screw fixation can be performed safely in 1- and 2-year-old children without negative effects on vertebral growth. In various pediatric spinal disorders, transpedicular screw fixation is the only procedure that provides a secure anchorage in short-segment instrumentation.

Study design A retrospective study was conducted, with clinical evaluation of hemivertebra resection using transpedicular instrumentation by a posterior approach in young children. Objective To assess a new method of early intervention in congenital scoliosis by a posterior approach. Summary of background data Previously described surgical procedures are fusion in situ, hemiepiphyseodesis and arthrodesis, "growing" instrumentations, and hemivertebra resections performed by a combined anterior and posterior approach. Methods For this study, 21 consecutive cases of congenital scoliosis managed by hemivertebra resection using a posterior approach only with transpedicular instrumentation were investigated retrospectively, with at least a 2-year follow-up period. Surgery was performed in patients who had congenital scoliosis with proven or expected deterioration, or pain resulting from the malformation. Results The mean Cobb angle of the main curve was 41 degrees before surgery, 14 degrees after surgery, and 15 degrees at the latest follow-up assessment. The angle of kyphosis was 24 degrees before surgery, but improved to 11 degrees after surgery. There was one infection, one pedicle fracture, and two failures of the initially used wire instrumentation. Conclusions Posterior resection of hemivertebrae with transpedicular instrumentation is a safe and promising procedure that offers significant advantages for controlling congenital deformity: excellent correction in both the frontal and sagittal planes, short segment of fusion, high stability, no need for an anterior approach, and low neurologic risk. Surgery should be performed as early as possible to avert severe local deformities, to prevent secondary structural changes, and to avert extensive fusions.