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A new discomanometry system was developed and evaluated for application in the lumbar spine. The diagnostic reliability of discography, manometry and discomanometry (a combination of both methods) was assessed in 20 lumbar cadaver spines (95 intervertebral discs) with regard to the diagnosis of non-contained intervertebral discs. The sensitivity was 92% for manometry and 78% for discography. This indicates that 22% of the non-contained discs could not be correctly identified with common discography. The specificity was 98% for manometry and 100% for discography, indicating that contained discs could be easily identified with both methods. A combination of manometry and discography provides a high sensitivity (98%) as well as high specificity (98%). It is concluded that discomanometry is a simple, cost-effective and reliable diagnostic procedure which can precede percutaneous nucleotomy without additional risks or relevant efforts. It allows the differentiation between contained and non-contained intervertrebral discs with a high degree of diagnostic reliability in an experimental setting, which justifies its further application in patients.

From 1985 through 1990, 19 patients with tumorous conditions of the cervical spine and the first two thoracic vertebrae were treated with anterior, posterior, or combined anterior/posterior surgical techniques. Breast metastases were by far the most common condition (42%). Patients usually experienced severe pain, which resisted conservative treatment, sometimes associated with radiculopathies (42%) or neurological deficits (31%). To date, the treatment of spinal tumors is only palliative, and surgery must be considered for cases with unremitting neck pain, major vertebral destruction with loss, or impending loss of cervical spine stability and neurological deficits due to local tumor compression. Contrary to the commonly used posterior wiring stabilizations, we preferred stabilization techniques more closed to those used in traumatology. Our findings suggest anterior surgery alone with vertebrectomy and stabilization with plate and bone cement for tumors involving only one vertebra and localized between C3 and T1. Posterior approach and stabilization is advocated for atlantoaxial lesions. A combined anterior and posterior technique should be reserved for extended tumoral conditions where an anterior fixation does not offer enough stability or where more radical surgery is required. In the present series, immediate good spinal stabilization and neck pain relief was obtained in every case, allowing early mobilization. Improvement of the neurologic deficit was noted in 65% of our patients.

Ten consecutive patients with severe spondylolisthesis were treated with reduction and pedicular fixation (four Internal Fixator instrumentations, six Cotrel-Dubousset instrumentations). There were six Grade III spondylolisthesis and four spondyloptoses at the L5/S1 level. All patients had complete clinical and radiographic evaluation with an average follow-up of 56 months (range, 43-75 months). The percentage of slippage averaged 78.5% preoperatively and 39.6% postoperatively. The slip angle averaged 43 degrees preoperatively and 17 degrees postoperatively. Four patients with spondyloptosis were treated with combined posterolateral and interbody fusion and had solid fusion without loss of reduction. Five of six patients in whom reduction and stabilization was performed by a single posterolateral fusion demonstrated loss of reduction, nonunion, and implant failure. Four of these patients were reoperated. Ultimately all patients had resolution of pain, solid fusion, and no further slip progression. Reduction, pedicular fixation, and combined posterolateral and interbody fusion is a technically demanding procedure, which should be reserved for selected patients. Pedicular fixation systems may only allow permanent reduction and stabilization of high-grade spondylolisthesis in conjunction with a combined interbody and posterolateral fusion.

The influence of diurnal water content variation on T1 and T2 and relative proton density (Nr) in intervertebral disks and vertebral bodies was studied in 10 healthy adult volunteers. T1, T2, and Nr were calculated from a set of 20 images obtained at 1.5 T with five single-section, multiecho sequences at different repetition times. Volunteers were randomized into study (one measurement in the morning and one in the evening) and control (two consecutive measurements in the morning) groups. In the study group, evening mean T1 and Nr in intervertebral disks and in vertebral bodies were significantly (P < .001) less than measured in the morning. Mean T2 in vertebral bodies significantly (P < .05) increased between morning and evening measurements. Diurnal variations were significantly less pronounced in degenerative than in normal intervertebral disks. No significant changes occurred in the control group. Relaxation time and Nr measurements allow sufficiently accurate estimation of diurnal water content variation in cohorts of vertebral bodies and intervertebral disks.

We retrospectively analyzed the frequency and clinical consequences of pedicular fixation system failure in 50 patients who underwent Cotrel-Dubousset transpedicular instrumentation (CDI), and 46 patients who underwent AO internal fixator (IF) instrumentation for similar indications. After 2 years, 14 implants in the CDI group and 13 in the IF group had failed. The overall probability of implant survival was similar in both groups (CDI, 71.9% versus IF, 71.7%). However, more implant failures were associated with nonunion, loss of reduction, and nerve-root compromise in the IF group (four versus none) than in the CDI group. Implant failure usually occurred after solid fusion, and did not significantly affect the short-term clinical results. Therefore, implant failure does not a priori indicate failure of the operation.

From 1984 to 1988, 70 consecutive lumbar and lumbosacral spine fusions enhanced with translaminar facet joint screws were performed for segmental degenerative disease. Twenty patients had partial decompression of central stenosis, 15 concomitant discectomy, and 19 lateral nerve root decompression. The mean time to fusion was 4.5 months (range 2-7 months). At followup (average 45 months; range 24-74 months) 98.5% were judged to have solid fusion. Satisfactory results were observed in 84% of cases, 91% without previous surgery and 75% after previous discectomy. Supplementation of posterolateral fusion by translaminar facet screws significantly improved time to fusion, fusion rate, and clinical outcomes with no significant increased complications.

The correction of posttraumatic kyphosis in the thoracolumbar region almost always requires a combined anterior and posterior approach because of the particular anatomic situation and the pathomorphologic changes. We suggest that the patient be placed in a right lateral decubitus position. This allows dual access to the spine by a posterior midline approach and a retroperitoneal thoracolumbar approach, so that simultaneous anterior and posterior manipulation, correction and stabilization of the spine are possible with no need to turn the patient intraoperatively. Thus, compared with two-or three-stage procedures, the duration of the operation and of stay in hospital can be reduced. This is a retrospective review of the first six patients (average age: 35 years) treated with this approach between 1987 and 1990. All patients suffered from incapacitating back pain that was unresponsive to nonoperative treatment. The surgical procedure was performed at an average of 29 months (range, 5 months to 7 years) after fracture. The average postoperative correction of kyphosis (18 degrees to 45 degrees) was 75%. In addition, two patients had posttraumatic scoliosis (10 degrees and 12 degrees), which was completely corrected. The only complication was partial fracture of a vertebral body in one case, which occurred during the reduction manoeuvre but had no consequences. Three of the patients had complete relief of pain. The remaining three reported persistent pain, although they had good objective clinical and radiological results. The failure to eliminate pain in these patients is thought to be a result of their long-standing (2-7 years) symptomatic posttraumatic deformities. Therefore, we feel that early correction of symptomatic kyphosis is mandatory.

Thirty-two consecutive adults with low-grade spondylolisthesis treated by stabilisation with the AO Internal Fixator and posterolateral fusion have been retrospectively reviewed with a mean follow-up time of 4 years (range, 24 to 71 months). There were 17 grade I and 15 grade II spondylolisthesis. Eight patients had degenerative and 24 patients had isthmic spondylolisthesis. An unisegmental fusion was performed in 4 cases, a bisegmental fusion in 25 cases and 3 patients had a multisegmental fusion. There was one deep infection and one nerve root compromise (3 per 100). Satisfactory results were achieved in 84 per 100 of the patients. There was non-union. This study suggests that transpedicular fixation and posterolateral fusion significantly enhances the rate of solid union to an extent which outweighs the risk of neurological complications due to the screw insertion. Fusion in situ in patients with low-grade spondylolisthesis is recommended as well as nerve root revision for all adults with concomitant radioculopathy. However, this review does not specifically support the use of the AO-internal fixator, but rather that of transpedicular fixation in general.

We treated 50 consecutive patients with Cotrel-Dubousset instrumentation (CDI) for symptomatic spondylolisthesis. Average follow-up was 25 months. Fusion in situ was performed in 32 of 44 patients with mild spondylolisthesis, while 12 patients had reduction in conjunction with neural decompression. Two of six patients with severe spondylolisthesis who were treated via a single posterior approach had loss of reduction and nonunion. In another patient a Grade III spondylolisthesis could not be reduced via a posterior approach. Seventy-six percent of the patients had a good clinical result. The rate of solid fusion was 96%. One nerve root compromise recovered completely. One superficial wound infection healed uneventfully. This study suggests that combined anterior and posterior fusion is required for permanent and sufficient correction of severe spondylolisthesis even with CDI. Low-grade spondylolisthesis should be reduced only in conjunction with neural decompression.

This series includes 59 consecutive patients, 51 of whom had a minimum follow up of 2 years. The diagnosis was mechanical instability in 39, deformity in 11, and infection or tumor in 9 patients. The overall clinical results of the total group were good or fair in 88% of the patients. Pseudarthrosis occurred twice. We had on postoperative infection, one persistent and two reversible neurological complications. We found 13 broken screws and one rod breakage which had no clinical relevance. None of these asymptomatic complications required revision. The internal fixator has a great potential of correction in scoliotic and kyphotic deformities of the spine. It has not been shown to have the same potential in spondylolisthesis. A combined anterior and posterior stabilisation is needed in severe spondylolisthesis. We have found the internal fixator to provide satisfactory stability to allow fusion and good clinical results with a low rate of relevant complications.

The vertebral column is a common site of metastatic disease to the bone. The incidence is very high and varies with tumor type. Radiation therapy is effective in the treatment of most cases of spinal metastases. Pathologic fractures of the vertebral body occur in 30-50% of the patients affected, indicating an operative intervention. The ultimate aim of the operation is to increase the patients' quality of life. The tumor mass is normally located in the vertebral body. Therefore, only with an anterior approach can excellent decompression of the spinal cord and reduction of the tumorous tissue be achieved. In patients with advanced metastatic disease, however, in whom an anterior approach is not practicable, tumor decompression may be accomplished through a costotransversectomy combined with posterior stabilization of the spine. Laminectomy is rarely indicated, and then for posteriorly located tumor tissue, and should be combined with dorsal stabilization of the spine. With reference to a few actual cases, we present the approaches and stabilization methods currently in use at our clinic.

This report deals with 51 acute tibial fractures treated between 1981 and 1987 with a interlocking intramedullary nail. All fractures were extraarticular and located in the distal third. Fourty-four patients were followed up for an average of 32 months. The reduction was anatomic in 84%, with the remaining patients having angulation (valgus/antecurvation) of less than 5 degrees and shortening by less than 1 cm. The rate of local complications was 18%, and a secondary operation was required in 12%. There were no cases of deep infection. Bony union was achieved in every case. Overall, the results were judged to be excellent or good in 96% of the tibias. In this series we saw no poor results.

In each of 73 patients with acute knee injuries, both menisci were examined by means of 7.5-MHz sector-scan sonography before arthroscopy was performed. In 87% of the cases the sonographic and arthroscopic diagnoses were identical. The results were better for the lateral meniscus. Overall, the sensitivity was 80% and the specificity, 90%. False-positive and false-negative results each accounted for 6%. In this series there was no correlation between the accuracy of the sonographic diagnosis and the type of meniscal lesion or its location within the meniscus.

Three special cases of tabic arthropathy are reported. The disease is displayed in detail. One case showed an aneurysma of the arteria ulnaris. After resection of the aneurysma conservative treatment was performed. In a second case with active not yet diagnosed tabic hip a cemented total hip was implanted, which failed only 9 weeks later. The third case was an inactive tabic hip joint. The implantation of a cementless Autophor hip proved well. Total joint replacement has not to be performed in an active state of the disease, but can be done after consolidation. The significance of the VDRL-test for justing the activity of the disease is displayed.