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XXIV Contents Anterior Lumbar and Lumbosacral Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Posterior Approach to the Cervical Spine . . Posterior Approaches to the Thoracic and Lumbar Spine . . . . . . . . . . . . . . . . . . . . . . . . . Procedure Related Complications . . . . . . . . . . . Decompressive Cervical and Lumbar Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Deformity Correction . . . . . . . . . . . . . . . . . . . Reduction of High-Grade Spondylolisthesis Corpectomy/Osteotomy . . . . . . . . . . . . . . . . . Postoperative Complications . . . . . . . . . . . . . . . Homeostasis Related Complications . . . . . . Neurological Complications . . . . . . . . . . . . . Postoperative Wound Problems . . . . . . . . . . Cerebrospinal Fluid Fistula . . . . . . . . . . . . . . Vascular Complications . . . . . . . . . . . . . . . . . Pulmonary Problems . . . . . . . . . . . . . . . . . . . Gastrointestinal Problems . . . . . . . . . . . . . . . Urogenital Complications . . . . . . . . . . . . . . . Retrograde Ejaculation . . . . . . . . . . . . . . . . . Recapitulation . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Articles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1100 1103 1104 1104 1104 1106 1108 1108 1109 1109 1110 1110 1112 1112 1113 1113 1114 1114 1115 1116 1117 40 Outcome Assessment in Spinal Surgery Mathias Haefeli, Norbert Boos Core Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . 1123 General Concepts of Outcome Assessment . . . 1123 Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1125 General Aspects . . . . . . . . . . . . . . . . . . . . . . . 1125 Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . 1126 Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1128 General Aspects . . . . . . . . . . . . . . . . . . . . . . . 1128 Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . 1128 Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . 1130 General Aspects . . . . . . . . . . . . . . . . . . . . . . . 1130 Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . 1130 Psychosocial Aspects, Work Situation and Fear Avoidance Beliefs . . . . . . . . . . . . . . . . . . . . . . . . 1133 General Aspects . . . . . . . . . . . . . . . . . . . . . . . 1133 Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . 1133 Clinical Feasibility and Practicability . . . . . . . . 1134 Recapitulation . . . . . . . . . . . . . . . . . . . . . . . . . . . 1135 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1136 Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . 1143 The Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1163 The Medical Illustrator . . . . . . . . . . . . . . . . . . . 1164 The Artist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1165 XXV List of Contributors Max Aebi Institut für Evaluative Forschung in Orthopädischer Chirurgie, MEM Forschungszentrum, Universität Bern, Stauffacherstr. 78, 3014 Bern, Schweiz e-mail: max.aebi@MEMcenter.unibe.ch Claudio Affolter Anatomisches Institut, Universität Zürich, Winterthurerstr. 190, 8057 Zürich, Schweiz Vincent Arlet Division of Scoliosis and Spine Surgery, Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA 22908-0159, USA e-mail: va3e@hscmail.mcc.virginia.edu Juan Francisco Asenjo Department of Anaesthesia, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Room D8.132, Montreal (Quebec), H3G 1A4, Canada e-mail: Jfasenjo@yahoo.com Stephan Blumenthal Anästhesie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: stephan.blumenthal@balgrist.ch Thomas Boeni Orthopädie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz Medizinhistorisches Museum, Universität Zürich, Rämistrasse 69, 8091 Zürich, Schweiz e-mail: thomas.boeni@balgrist.ch Norbert Boos Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: norbert.boos@balgrist.ch Alain Borgeat Anästhesie, Universitätsklinik Balgrist, Forchstr. 340, 808 Zürich, Schweiz e-mail: alain.borgeat@balgrist.ch Florian Brunner Rheumatologie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: florian.brunner@balgrist.ch XXVI List of Contributors Armin Curt Spinal Cord Rehabilitation, ICORD, University of British Columbia, 2469–6270 University Blvd., V6T 1Z1, Vancouver, Canada e-mail: curt@icord.org Karim Eid Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: karim.eid.@balgrist.ch Achim Elfering Psychologisches Institut, Universität Bern, Muesmattstr. 43, 3000 Bern 9, Schweiz e-mail: Achim.elfering@psy.unibe.ch Stephen Ferguson Institut für chirurgische Technologien und Biomechanik, MEM Forschungszentrum, Universität Bern, Stauffacherstr. 78, 3014 Bern, Schweiz e-mail: stephen.ferguson@MEMcenter.unibe.ch Bruno Fuchs Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: bruno.fuchs@reasearch.balgrist.ch Dieter Grob Wirbelsäulenzentrum, Schulthessklinik, Lengghalde 2, 8008 Zürich, Schweiz e-mail: dieter.grob@kws Philipp Gruber Orthopädie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz Medizinhistorisches Museum, Universität Zürich, Rämistrasse 69, 8091 Zürich, Schweiz e-mail: ph.gruber@bluewin.ch Mathias Haefeli Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: mhaefeli@research.balgrist.ch Daniel Haschtmann Institut für chirurgische Technologien und Biomechanik, MEM Forschungszentrum, Universität Bern, Stauffacherstr. 78, 3014 Bern, Schweiz e-mail: daniel.haschtmann@MEMcenter.unibe.ch Paul Heini Orthopädische Universitätsklinik, Inselspital Bern, 3010 Bern, Schweiz e-mail: paul.heini@insel.ch Michael Heinzelmann Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Klinik für Unfallchirurgie, Universitätsspital Zürich, Rämistr. 100, 8091 Zürich, Schweiz e-mail: michael.heinzelmann@usz.ch Jürg Hodler Radiologie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: juerg.hodler@balgrist.ch List of Contributors Rudolf Kissling Rheumatologie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: rudolf.kissling@balgrist.ch Uta Kliesch Paraplegikerzentrum, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: uta.kliesch@balgrist.ch Dilek Könü-Leblebicioglu Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Neurochirurgische Klinik, Universitätsspital Zürich, Frauenklinikstr. 10, 8091 Zürich, Schweiz e-mail: dilek.koenue@usz.ch Clayton Kraft Orthopädie, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Deutschland e-mail: hemmers@med.uni-duesseldorf.de Rüdiger Krauspe Orthopädie, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Deutschland e-mail: hemmers@med.uni-duesseldorf.de Martin Krismer Universitätsklinik für Orthopädie, Anichstr. 35, 6020 Innsbruck, Österreich e-mail: Martin.Krismer@uibk.ac.at Heike Künzel Zentrum für Psychiatrie, Krumenauerstr. 25, 85049 Ingolstadt, Deutschland e-mail: heike.kuenzel@klinikum-ingolstadt.de Massimo Leonardi Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: massimo.leonardi.@balgrist.ch Thomas Liebscher Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz Anne Mannion Wirbelsäulenzentrum, Schulthessklinik, Lengghalde 2, 808 Zürich, Schweiz e-mail: afm@kws.ch Dante Marchesi Clinique Bois-Cerfs, Avenue d’Ouchy 31, 1006 Lausanne, Schweiz e-mail: dante.marchesi@hirslanden.ch Richard Marugg Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Neurochirurgische Klinik, Universitätsspital Zürich, Frauenklinikstr. 10, 8091 Zürich, Schweiz e-mail: richard.marugg@usz.ch Martin Merkle Klinik für Neurochirurgie, Universitätsklinikum Tübingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Deutschland XXVII XXVIII List of Contributors Kan Min Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Universitätsklinik Balgrist, Forchstr. 340, 808 Zürich, Schweiz e-mail: kan.min@balgrist.ch Andreas Nerlich Pathologisches Institut, Krankenhaus München-Bogenhausen, Englschalkinger Strasse 77, 81925 München, Deutschland e-mail: andreas.nerlich@extern.lrz-muenchen.de Margareta Nordin Department of Orthopaedic and Environmental Medicine, School of Medicine, New York University, OIOC, Hospital for Joint Diseases, Mount Sinai NYU, 63 Downing Street, New York, USA e-mail: margareta.nordin@nyu.edu Jean Ouellet Department of Orthopedics, Montreal Children’s Hospital, 2300 Tupper, C521 Montreal, H3H 1P3, Canada e-mail: jaouellet@hotmail.com Günther Paesold Universitätsklinik Balgrist, Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Forchstr. 340, 8008 Zürich, Schweiz e-mail: gpaesold@research.balgrist.ch Christian Pfirrmann Radiologie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: christian.pfirrmann@balgrist.ch Albrecht Popp Poliklinik für Osteoporose, Inselspital, Universität Bern, 3010 Bern, Schweiz Youri Reiland Orthopädie, Universitätsklinik Balgrist, Forchstr. 340, 808 Zürich, Schweiz e-mail: youri.reiland@balgrist.ch Frank Ruehli Anatomisches Institut, Universität Zürich, Winterthurerstr. 190, 8057 Zürich, Schweiz e-mail: fr@anatom.unizh.ch Shira Schecter-Weiner Occupational and Industrial Orthopaedic Center, Hospital for Joint Diseases, New York University Medical Center, 63 Downing Street, New York, NY 20014, USA e-mail: sswpt@aol.com Dietrich Schlenzka Orton Orthopaedic Hospital, Invalid Foundation, Tenholantie 10, 00280 Helsinki, Finland e-mail: dietrich.schlenzka@invalidisaatio.fi Annina Schmid Physiotherapie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: annina.schmid@balgrist.ch Marius Schmid Radiologie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: marius.schmid@balgrist.ch List of Contributors Francis H. Shen Department of Orthopaedic Surgery, Division of Spine Surgery, University of Virginia, PO Box 800159, Charlottesville, VA 22908, USA e-mail: fhs2g@virginia.edu Atul Sukthankar Orthopädie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: atul.sukthankar@balgrist.ch Beat Wälchli Spital Zollikerberg, Aerztezentrum Prisma, Trichtenhauserstr. 12, 8125 Zollikerberg, Schweiz e-mail: info@beatwaelchli.ch Guido Wanner Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Klinik für Unfallchirurgie, Universitätsspital Zürich, Rämistr. 100, 8091 Zürich, Schweiz e-mail: guido.wanner@usz.ch Sherri Weiser Department of Orthopaedic and Environmental Medicine, School of Medicine, New York University, OIOC, Hospital for Joint Diseases, Mount Sinai NYU, 63 Downing Street, New York, NY 10014, USA e-mail: sherri.weiser@nyu.edu Clément Werner Orthopädie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: cwerner@gmx.ch Yasuhiro Yonekawa Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Neurochirurgische Klinik, Universitätsspital Zürich, Frauenklinikstr. 10, 8091 Zürich, Schweiz e-mail: yasuhiro.yonekawa@usz.ch Patrick Zingg Orthopädie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: patrick.zingg@balgrist.ch XXIX XXXI Guided Tour The aim of this textbook is not to provide the most comprehensive overview of spinal disorders, but rather to give a thorough grounding in the basic knowledge and general principles of the subject. The didactic concept of all the chapters of the book is therefore based on a consistent style and layout, and follows three basic principles of sustained learning, i.e.: ) less is more ) repetition enhances sustained learning ) case study learning This didactic concept is enhanced by many learning aids to highlight and repeat core messages throughout all chapters. The ample use of visual aids mediates the core messages and allows for a gradual and repetition-based learning approach starting with the core messages and going on to an in-depth reading of each chapter. Marginal notes and a short recapitulation facilitate the learning by repetition. A pictorial and anecdotal learning method is enabled by the many case studies, which exemplify the core messages. Fractures Section 883 884 Section Fractures Thoracolumbar Spinal Injuries 31 Core messages highlight the most important learning objectives and guide the reader through the chapter. Michael Heinzelmann, Guido A. Wanner a b c d e f g h i j k l Core Messages ✔ Spinal fractures are frequently located at the thoracolumbar junction for biomechanical reasons ✔ The AO classification has gained widespread acceptance in Europe for the grading of thoracolumbar fractures: Type A: vertebral compression fractures; Type B: anterior and posterior column injuries with distraction; Type C: anterior and posterior element injury with rotation ✔ The initial focus of the physical examination of a patient with a spinal injury is on the vital and neurological functions, because effective resuscitation is critical to the management of polytraumatized patients and patients with spinal cord injury ✔ The imaging modalities of choice are standard radiographs and CT scans. A CT scan should routinely be made to visualize bony injury. MRI is helpful to diagnose discoligamentous injuries and to identify a possible cord lesion ✔ Primary goals of treatment are prevention and limitation of neurological injury as well as restoration of spinal stability, regardless of whether operative or non-operative therapy is chosen ✔ Secondary goals consist of correction of deformities, minimizing the loss of motion, and facilitating rapid rehabilitation ✔ Early stabilization and fusion is generally accepted for patients with unstable fractures and neurological deficits ✔ The optimal treatment for patients with less instability, moderate deformity and absence of neurological compromise is not based on scientific evidence and remains a matter of debate. ✔ Good clinical outcome can be achieved with non-operative as well as operative treatment This 23-year-old female sustained a motor vehicle accident as an unrestrained passenger. Clinically, she presented with an incomplete paraplegia (ASIA C) and an incomplete conus-cauda syndrome. The initial CT (a–d) scan demonstrates an unstable complete burst fracture of L1 (Type A3.3). The 3D reconstruction (a, b) gives a good overview of the degree of comminution and the deformity; the posterior fragment is best visualized in the lateral 2D reconstruction (c) and the axial view (d). In an emergency procedure, the myelon was decompressed by laminectomy and the fracture was reduced and stabilized with an internal fixator (e–h). Interestingly, the prone position alone (e) reduced the fracture to a certain degree when compared to the CT scan taken with the patient in a supine position. With the internal fixator (RecoFix), the anatomical height and physiological alignment was restored (f ) and the posterior fragment was partially reduced (g, h). This indirect reduction of bony fragments, called ligamentotaxis, is possible if the posterior ligaments and the attachment to the anulus fibrosus are intact. We performed a complete clearance of the spinal canal by an anterior approach 5 days later (i–l). In this minimally invasive technique, the spine is approached by a small thoracotomy from the left, the ruptured disc and bony fragments are removed, and an expandable cage is inserted. One of the first steps in this technique is the positioning of a K-wire in the upper disc space of the fractured vertebra (i). In this figure, the four retractors of the Synframe and the endoscopic light source are seen. The final result after 9 months (j–l) demonstrates the cage (Synex), the physiological alignment without signs of implant failure or kyphosis, a good clearance of the spinal canal from anterior and the laminectomy from posterior (k), and a bony healing of the local bone transplant of the lateral side of the cage (l). Fortunately, the patient completely recovered from her neurological deficit (ASIA E). Epidemiology Systematic epidemiologic data on traumatic thoracolumbar fractures are rare and differ depending on the area studied and on the treating center. The studies available from western countries reveal typical and comparable data on incidence, localization, and mechanisms of injury. Thoracolumbar fractures are more frequent in men (2/3) than in women (1/3) and peak between the ages of 20 and 40 years [30, 47, 65, 81, 94]. Approximately, 160 000 patients/year sustain an injury of the spinal column in the United States. The majority of these injuries comprise cervical and lumbar (L3–L5) spine fractures. However, between 15 % and 20 % of traumatic fractures occur at the thoracolumbar junction (T11–L2), whereas 9 – 16 % occur in the thoracic spine (T1–T10) [36, 46]. Hu and coworkers [56] studied the total population of a Canadian province over a period of 3 years. The incidence of spine injuries was 64/ 100 000 inhabitants per year, predominantly younger men and older women. A total of 2 063 patients were registered and 944 patients were treated in hospital: 182 patients (20 %) with a cervical spine injury, 286 patients (30 %) with a thoracic spine injury and 403 patients (50 %) with an injury of the lumbosacral spine. Traumatic cross-section spinal cord injury occurred in 40 out of 1 million inhabitants. About Case Introduction Fractures most frequently affect the thoracolumbar junction 50 – 60 % of thoracolumbar fractures affect the transition T11–L2, 25 – 40 % the thoracic spine and 10 – 14 % the lower lumbar spine and sacrum [80, 86]. In a study by Magerl and Engelhardt [81] on 1 446 thoracolumbar fractures, most injuries concerned the first lumbar vertebra, i.e., 28 % (n = 402), followed by T12 (17 %, n = 246) and L2 (14 %, n = 208). The epidemiologic multicenter study on fractures of the thoracolumbar transition (T10–L2) by the German Trauma Society studied 682 patients and revealed 50 % (n = 336) L1 fractures, 25 % Introductory cases introduce the topic by reporting typical cases representative of the specific pathology. These cases are intended to serve as a stand-alone tool in mediating core messages of each chapter. XXXII Guided Tour Thoracolumbar Spinal Injuries b a Figures illustrate and exemplify essential knowledge and stimulate a pictorial learning. Chapter 31 897 908 Section Fractures c Figure 5. CT fracture assessment The axial CT scan reveals: a significant spinal canal compromise by a retropulsed bony fragment. Note the double contour of the vertebral body indicating a “burst” component. b Sagittal 2D image reformation demonstrating fracture subluxation. Note the bony fragment behind the vertebral body which may cause neural compression when the fracture is reduced. c Severe luxation fracture of the spine. d The 3D CT reformation nicely demonstrates the rotation component indicating a Type C lesion a b c d d radiographs in high-risk trauma patients who require screening. In their prospective series of 222 patients with 63 thoracic and lumbar injuries, the results of conventional X-ray compared to initial CT scan were as follows: sensitivity 58 % vs. 97 %, specificity 93 % vs. 99 %, positive predictive value 64 % vs. 97 %, negative predictive value 92 % vs. 99 %, respectively. The axial view allows an accurate assessment of the comminution of the fracture and dislocation of fragments into the spinal canal (Fig. 5a). Sagittal and coronal 2D or 3D reconstructions are helpful for determining the fracture pattern (Fig. 5b–d). The canal at the injured segment should be measured in the anteroposterior and transverse planes and compared with the cephalad and caudal segments. Figure 8. Surgical technique of two-level fracture reduction and stabilization CT is the imaging study of choice to demonstrate bony injuries The technique demonstrates the use of the Fracture Module of Universal Spine System (Synthes) but the general principles similarly apply to other fracture systems. a Schanz screws are inserted in the pedicles of the vertebral bodies superior and inferior to the fracture. b Screw clamps connected with the rods are mounted and fixed (arrow). c The fracture can be reduced by lordosing both screwdrivers. However, it is often better to first tighten the two lower screws and reduce the fracture simultaneously by lordosing the cranial screw bilaterally with the help of the screwdriver. d If this reduction maneuver does not suffice to restore vertebral height, a temporary C-clamp can be mounted and the fracture distracted after loosening the upper screws. Care must be taken not to overdistract the fracture because of the inherent neurological risks. Finally, the Schanz screws are cut with a special screwcutter (not shown). Dependent on canal clearance and anterior vertebral column restoration, an additional anterior approach can be added (preferably in a second stage) Magnetic Resonance Imaging In the presence of neurological deficits, MRI is recommended to identify a possible cord lesion or a cord compression that may be due to disc or fracture fragments or to an epidural hematoma (Fig. 6a). In the absence of neurological deficits, MRI of the thoracolumbar area is usually not necessary in the acute phase. However, MRI can be helpful in determining the integrity of the posterior ligamentous structures and thereby differentiate between a Type A and an unstable Type B lesion. For this purpose a fluid sensitive sequence (e.g., STIR) is frequently used to determine edema (Fig. 6b). MRI is helpful in ruling out discoligamentous lesions Marginal notes summarize important facts and allow for a rapid repetition of learning objectives. 892 Section Tables summarize important facts such as classifications, treatment objectives and indications for non-operative and surgical treatment. Transpedicular cancellous bone grafting is insufficient to stabilize the anterior column Figures provide a schematic illustration of surgical procedures. Thoracolumbar Spinal Injuries Fractures Table 4. Frequency of neurological deficits Types and groups Number of injuries Neurological deficit (%) Type A A1 A2 A3 Type B B1 B2 B3 Type C C1 C2 C3 Total 890 501 45 344 145 61 82 2 177 99 62 16 1 212 14 2 4 32 32 30 33 50 55 53 60 50 22 Based on an analysis of 1 212 cases (Magerl et al. [80]) Authors Cases Study design Fracture type (numbers) Burke and Murray (1976) [17] 115 retro(140) spective flexion/rota- 89 non-opera- 62 % tive (postural tion (80) reduction) compression fractures 26 operative (27) (posterior pure ligastabilization mentous ± laminecinjuries (3) tomy) hyperextension (2) other (3) Rechtine et al. (1999) [93] 235 chart 117 operative unstable review thoracolum- 118 non-operafor bar fractures tive 6 weeks bed rest) complications Cross references facilitate a quick orientation throughout the textbook. Neuro- Follow-up Outcome logical (months) deficit Shen et al. (2001) [105] 80 prospective single-level burst fractures T11– L2, no fracture dislocations or pedicle fractures 47 non-operative: using a hyperextension brace 33 operative: posterior fixation It is obvious that the management and the priorities differ between a life-threatening polytrauma that includes a spinal injury and a monotrauma of the spine. In the case of a polytrauma, about one-fourth to one-third of patients have a spinal injury [120]. In our institution, we found spinal injuries in 22 % of polytraumatized patients. In a series of 147 consecutive patients with multiple trauma, Dai et al. [24] found a delayed diagnosis of thoracolumbar fractures in 19 %, confirming an earlier study by Anderson et al. [5], in which 23 % of patients with major thoracolumbar fractures were diagnosed after the patient had left the emergency department. A delay in the diagnosis of thoracolumbar fractures is frequently associated with an unstable patient condition that necessitates higher-priority procedures than thoracolumbar spine radiographs in the emergency department. However, with the routine use of multi-slice computed tomography (CT) in polytraumatized patients, the diagnostic work-up is usually adequate [57, 106] and delayed diagnosis of spine fractures should become rare. Multiple burst fractures occur in approximately 10 – 34 % [10, 11, 53]. Wood et al. (2003) [121] 47 prospective, randomized single thora- 24 operative: posterior or columbar burst anterior fractures instru(T10–L2) mented fusion 23 non-operative: body cast or orthosis An accurate and well-documented neurological examination is of great importance. With an inaccurate or incomplete examination and a subsequent variation of the patient’s neurological deficit, it will be unclear if the situation has changed or if the initial assessment was simply inappropriate. In the case of a progressive neurological deficit, this may hinder urgent further management, i.e., the need for a surgical intervention with spinal decompression. Neurological assessment is usually done according to the guidelines of the American Spinal Injury Association (see Chapter 11 ). Importantly, the examination has to include the “search for a sacral sparing” which will determine the completeness of the deficit and the prognosis. Conclusion N/A the indication for early conservative: secondary spinal fusion surgery might be still n=3 further restricted. severe chronic pain: 2 neurological improvement 35 % operative: severe chronic pain n = 8 Neurological improvement 38 % N/A comparable rates of decubitus, deep venous thrombosis, pulmonary emboli, and mortality between both groups 8 % deep wound infections after operative treatment shorter hospital stay after operative treatment both treatment modalities are viable alternatives none 288 less pain in the surgical group after 3 and months. Complications after surgery: 1 superficial infection and 2 broken screws hospital charges were 4 times higher in the operative group posterior fixation provides partial kyphosis correction and earlier pain relief. Functional outcome at 2 years is similar none 44 no difference between groups was found in terms of pain, and return to work. Non-operatively treated patients reported less disability no long-term advantage for operative treatment of burst fractures compared with nonoperative treatment The clinical assessment of patients with a putative trauma to the spine has three major objectives, i.e., to identify: Neurological Deficit Sacral sparing indicates an incomplete lesion with a better prognosis Type of treatment Clinical Presentation Spinal Injuries Polytraumatized patients should be screened for spinal fracture by CT Chapter 31 Table 9. Operative vs. non-operative treatment ) the spinal injury ) neurological deficits ) concomitant non-spinal injuries About 30 % of polytraumatized patients have a spinal injury breakage or loosening. These results indicate the need for an adequate anterior column support and an optimal anterior-posterior column load sharing environment. If no anterior stabilization is planned, a posterolateral fusion [78, 88] is mandatory. In addition, transpedicular bone grafting in the disrupted disc space has been a treatment option [26, 78, 90]. However, transpedicular bone grafting could not prevent kyphosis after dorsal removal on implants [1, 68, 108]. Knop et al. [68] studied 56 patients after implant removal and concluded that, because retention in a cast according to Böhler’s principles was performed. A repositioning was possible in 90 %; however, only 50 % could be maintained over the treatment period, 20 % returned to the initial kyphotic level and 5 % had a worse result. Reinhold et al. [95] reviewed 43 patients 16.3 years after thoracolumbar fracture and non-operative therapy. On average, patients showed a radiologic increase in the kyphosis angle of 5.2° compared to the time of injury. No difference was noted between early functional therapy and treatment with closed reduction and immobilization by cast. Results of validated psychometric questionnaires such as SF-36 and VAS showed the characteristic pattern of a population with chronic back pain. The authors conclude that a radiologic increase in the traumatic kyphotic deformity in patients with a non-operative treatment protocol has to be expected and that measurable negative physical and social long-term consequences can be anticipated after sustaining a Type A fracture of thoracolumbar vertebral bodies. However, no correlation between radiologic and functional results was observed. Tables also provide a topical stateof-the-art review of the literature and stimulate evidence based learning 915 Guided Tour Thoracolumbar Spinal Injuries Chapter 31 911 918 Section Fractures Recapitulation Epidemiology. About 60 % of thoracic and lumbar spine fractures are located at the transition T11–L2, 30 % in the thoracic spine and 10 % in the lower lumbar spine. Spinal cord injury occurs in about 10 – 30 % of traumatic spinal fractures. Case studies aim to mediate the fundamentals and basic principles of the chapters and enhance recollection by the principle of case study learning. a b c d e f g h Pathogenesis. The most relevant forces that produce structural damage to the spine are axial compression, flexion/distraction, hyperextension, rotation, and shear. Axial load may result in a burst fracture; the posterior elements are usually intact. In flexion/distraction injuries, the posterior ligamentous and osseous elements fail in tension; a wedge compression fracture of the vertebral body is often associated. Hyperextension may result in rupture of the anterior ligament and the disc as well as in compression injuries of the posterior elements, i.e., fracture of the facets, the laminae, or the spinous processes. Rotational injuries combine compressive forces and flexion/distraction mechanisms and are highly unstable injuries. Shear forces produce severe ligamentous disruption and usually result in complete spinal cord injury. Case Study 3 This 48-year-old female fell from a horse and presented with an incomplete burst fracture of L2 (Type A3.1) without neurological deficits (ASIA E). The MRI scan (a, b) was performed to evaluate the integrity of the dorsal elements. The coronal view (a) shows the T1 sequence and demonstrates a cranial fracture of L2 and a rupture of the disc L1/L2. The STIR sequence (b), which is very sensitive to edema, confirms the fracture of the vertebral body but does not show any evidence of a posterior injury. This allows the distinction between a Type A injury and an unstable Type B injury and helped us to choose the operative approach. We performed a monosegmental anterior stabilization with an expandable cage (Stryker) and an angular stable implant (MACS), which was especially designed for the thoracoscopic technique (c, d). After a small diaphragmatic split, one of the first steps is the positioning of a K-wire just above the endplate of L2 (c); in this figure, the retractor (left), the suctioning device (middle) and the aiming device for the K-wire (right) can be distinguished. The polyaxial screws are inserted under fluoroscopic control, the ruptured disc and the cranial part of the fractured vertebral body are removed, and the cage is inserted (d). The postoperative control radiographs (e–g) demonstrate a correct positioning of the screws in the anteroposterior view (e) and lateral view (f ); in addition, the local bone transplant on the right side of the cage is seen in e. The conventional X-rays (g, h) demonstrate a physiologic alignment and a correct positioning of the implants. Thoracoscopic spinal surgery is another technique that reduces the morbidity of extensive surgical approaches while it still achieves the primary goals of spinal decompression, reconstruction, and stabilization. Since the development of specially designed instruments and implants, the “pure” thoracoscopic operation technique has become possible and feasible. Through the transdiaphragmatic approach it was also possible to open up the thoracolumbar junction, including the retroperitoneal segments of the spine, to the endoscopic technique. In an early series, Bühren et al. [19] analyzed 38 patients. The authors conclude that, compared to the open method, minimally invasive surgery had the benefit of reducing postoperative pain, shortening hospitalization, leading to early recovery of function and reducing the morbidity of the operative approach. These findings have been confirmed in later reports [8, 9, 62]. The rate of severe complications was low (1.3 %), with one case each of aortic injury, splenic contusion, neurological deterioration, cerebrospinal fluid leak, and severe wound infection [62]. Overall, the complication rate was not increased when compared to the Clinical presentation. In the case of a polytrauma, about 30 % of the patients have a spinal injury. The neurological examination has to include the “search for a sacral sparing” which determines the completeness of the deficit and the prognosis. About one-third of all spinal injuries have concomitant injuries; the most frequent are: head injuries, chest injuries and long bone injuries. The history should include the type of trauma (high vs. low energy injuries) and the time course of a possible neurological deficit. The initial focus of the physical examination is on the assessment of vital functions and neurological deficits. Because the spinal cord usually terminates at the level of L1, injuries to the thoracolumbar junction may result in various neurological symptoms: e.g., complete/incomplete paraplegia (distal spinal cord), malfunction of the vegetative system (conus medullaris), or cauda equina syndrome. Minimally invasive anterior access technologies offer perioperative advantages Diagnostic work-up. Static imaging studies are “snapshots in time” and do not reveal the real degree of spinal canal compromise that may have happened during the injury. A posterior cortical disruption seen in the lateral view or an interpedicular widening seen in the anteroposterior view suggests a burst fracture that should be further ana- lyzed by CT scan. CT is the imaging study of choice to demonstrate bony destruction. MRI is recommended to identify a possible cord lesion or a cord compression in patients with neurological deficits. MRI can be helpful in determining the integrity of the posterior ligamentous structures and thereby in differentiating between a Type A and a Type B lesion. Non-operative treatment. Management of thoracolumbar and sacral spinal fractures remains a controversial area in modern spinal surgery. The literature demonstrates a wide range of conflicting results and recommendations. Unfortunately, the vast majority of clinical studies can be criticized because of their retrospective design, heterogeneous patient populations and treatment strategies, limited follow-up, and poorly defined outcome measures. The main advantage of non-operative treatment of thoracolumbar fracture is the avoidance of surgery-related complications. According to Böhler, the time of immobilization in a cast is usually 3 – 5 months depending on the fracture type. Importantly, skillful physical therapy is paramount to achieve good results. Because thoracolumbar fractures are bound to return to the initial deformity, functional bracing without repositioning is an alternative to Böhler’s concept of repositioning and stabilization with a cast if the initial deformity is acceptable. Many studies were not able to prove a substantial difference in functional outcome between the operative and non-operative treatment, regardless of the neurological injury. Operative treatment. There is a general trend towards operative treatment of unstable fractures mostly because surgical stabilizing procedures result in early mobilization, diminished pain, facilitated nursing care, earlier return to work, and avoidance of late neurological complications. In experimental animal models, persistent compression of the spinal cord is potentially reversible from a secondary injury by early decompression. Most investigators recommend a surgical decompression in the setting of major neurological deficit, progressive neurological loss, and substantial compromise of the spinal canal. Currently, there are no gold standards regarding the role and timing of decompression in acute spinal cord injury. Posterior bisegmental reduction and stabilization is the “working horse” of the posterior approach technique that allows for fracture reduction and stable Recapitulations summarize the essential teaching objectives and provide a quick overview for the busy reader. Thoracolumbar Spinal Injuries fixation. Depending on the persistence of spinal canal compromise or comminution of the fractured vertebral body, an additional anterior approach is needed. Transpedicular cancellous bone grafting for interbody fusion after posterior stabilization is not recommended in complete or incomplete burst fractures. Only incomplete Type A burst fractures with intact pedicles and a lower endplate should be considered for posterior monosegmental reduction and stabilization. Compared to the open method, minimally invasive surgery reduces postoperative pain, shortens hospitalization, leads to early recovery of function and reduces morbidity of Key articles introduce landmark papers which had a substantial impact on our current understanding of the pathology, diagnosis or non-operative and surgical treatment. Chapter 31 the operative approach. A combined posterior and anterior approach is used to reduce and stabilize severely comminuted vertebral body fractures and to decompress the spinal canal. In Type C lesions often multisegmental instrumentation is needed to reliably stabilize the spine. Complications. The reported complication rate in the literature varies largely and ranges from 3.6 % to 10 %. Postoperative neurological complications range from 0.1 % to 0.7 %. Only honest and accurate assessment of complications will lead to scientific and clinical progress. Key Articles Böhler L (1951) Die Technik der Knochenbruchbehandlung. Maudrich, Vienna Lorenz Böhler was one of the first to advocate a conservative treatment with fracture reduction and retention in a cast. Roaf R (1960) A study of the mechanics of spinal injuries. J Bone Joint Surg Br 42B:810 – 23 In this article Roaf studies the biomechanics of spinal injuries and describes the results of studies of spinal units when subjected to forces of different magnitude and direction, i.e., compression, flexion, extension, lateral flexion, rotation, and horizontal shear. Denis F (1983) The three column spine and its significance in the classification of acute thoraco-lumbar spinal injuries. Spine 8:817 – 31 This article is a presentation of the concept of the three-column spine. The concept evolved from a retrospective review of 412 thoracolumbar spine injuries and observations on spinal instability. The posterior column consists of what Holdsworth described as the posterior ligamentous complex. The middle column includes the posterior longitudinal ligament, posterior anulus fibrosus, and posterior wall of the vertebral body. The anterior column consists of the anterior vertebral body, anterior anulus fibrosus, and anterior longitudinal ligament. Dick W (1987) The “fixateur interne” as a versatile implant for spine surgery. Spine 12:882 – 900 This article introduced a new angle-stable fixation device which first allowed a short segmental reduction and fixation of fractures. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S (1994) A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 3:184 – 201 This article describes a classification of thoracic and lumbar injuries. As a result of more than a decade of consideration of the subject matter and a review of 1 445 consecutive thoracolumbar injuries, a comprehensive classification of thoracic and lumbar injuries is proposed. The classification is primarily based on pathomorphological criteria. Three mechanisms classify the injury pattern according to the AO classification: axial compression (Type A), flexion distraction (Type B) and rotational/shear injuries (Type C). Kaneda K, Taneichi H, Abumi K, Hashimoto T, Satoh S, Fujiya M (1997) Anterior decompression and stabilization with the Kaneda device for thoracolumbar burst fractures associated with neurological deficits. J Bone Joint Surg Am 79:69 – 83 One hundred and fifty consecutive patients who had a burst fracture of the thoracolumbar spine and associated neurological deficits were managed with a single-stage anterior spinal decompression, strut-grafting, and Kaneda spinal instrumentation. The authors conclude that anterior decompression, strut-grafting, and fixation with the Kaneda 919 920 Section Fractures device in patients who had a burst fracture of the thoracolumbar spine and associated neurological deficits yielded good radiographic and functional results. This article established the single stage anterior approach for this fracture type. Knop C, Blauth M, Bühren V, Hax PM, Kinzl L, Mutschler W, Pommer A, Ulrich C, Wagner S, Weckbach A, Wentzensen A, Wörsdörfer O (1999) Surgical treatment of injuries of the thoracolumbar transition. 1: Epidemiology. Unfallchirurg 102:924 – 35 Knop C, Blauth M, Bühren V, Hax PM, Kinzl L, Mutschler W, Pommer A, Ulrich C, Wagner S, Weckbach A, Wentzensen A, Wörsdörfer O (2000) Surgical treatment of injuries of the thoracolumbar transition. 2: Operation and roentgenologic findings. Unfallchirurg 103:1032 – 47 Knop C, Blauth M, Bühren V, Arand M, Egbers HJ, Hax PM, Nothwang J, Oestern HJ, Pizanis A, Roth R, Weckbach A, Wentzensen A (2001) Surgical treatment of injuries of the thoracolumbar transition – 3: Follow-up examination. Results of a prospective multi-center study by the “Spinal” Study Group of the German Society of Trauma Surgery. Unfallchirurg 104:583 – 600 These three reports summarize the experience based on 682 patients included in a prospective multicenter study by the “Spinal” Study Group of the German Society of Trauma Surgery. All treatment methods under study were appropriate for achieving comparable clinical and functional outcome. The internal fixator was found superior in restoration of the spinal alignment. Best radiological outcomes were achieved by combined stabilization. Merely by direct reconstruction of the anterior column the postoperative re-kyphosing is prevented and a gain in segmental angle is achieved. However, this benefit was not reflected in the clinical outcome. Fehlings MG, Perrin RG (2005) The role and timing of early decompression for cervical spinal cord injury: Update with a review of recent clinical evidence. Injury S-B13–S-B26 Evidence-based recommendations regarding spinal cord decompression in patients with acute spinal cord injury. Beisse R (2006) Endoscopic surgery on the thoracolumbar junction of the spine. Eur Spine J 15:687 – 704 This article summarizes the technique and results based on a large patient group from a German trauma center: A now standardized operating technique, instruments and implants specially developed for the endoscopic procedure, from angle stable plate and screw implants to endoscopically implantable vertebral body replacements, have gradually opened up the entire spectrum of anterior spine surgery to endoscopic techniques. References 1. Alanay A, Acaroglu E, Yazici M, Oznur A, Surat A (2001) Short-segment pedicle instrumentation of thoracolumbar burst fractures: does transpedicular intracorporeal grafting prevent early failure? Spine 26:213 – 7 2. Anderson PA, Henley MB, Rivara FP, Maier RV (1991) Flexion distraction and chance injuries to the thoracolumbar spine. J Orthop Trauma 5:153 – 60 3. Anderson PA, Rivara FP, Maier RV, Drake C (1991) The epidemiology of seatbelt-associated injuries. J Trauma 31:60 – 7 4. Anderson PA, Bohlman HH (1992) Anterior decompression and arthrodesis of the cervical spine: long-term motor improvement. Part II – Improvement in complete traumatic quadriplegia. J Bone Joint Surg Am 74:683 – 92 5. Anderson S, Biros MH, Reardon RF (1996) Delayed diagnosis of thoracolumbar fractures in multiple-trauma patients. Acad Emerg Med 3:832 – 9 6. Bagley LJ (2006) Imaging of spinal trauma. Radiol Clin North Am 44:1 – 12, vii 7. Been HD, Bouma GJ (1999) Comparison of two types of surgery for thoraco-lumbar burst fractures: combined anterior and posterior stabilisation vs. posterior instrumentation only. Acta Neurochir (Wien) 141:349 – 57 8. Beisse R, Muckley T, Schmidt MH, Hauschild M, Buhren V (2005) Surgical technique and results of endoscopic anterior spinal canal decompression. J Neurosurg Spine 2:128 – 36 9. Beisse R (2006) Endoscopic surgery on the thoracolumbar junction of the spine. Eur Spine J 15:687 – 704 References provide an in-depth library for further reading. XXXIII History of Spinal Disorders Section History of Spinal Disorders 1 Philipp Gruber, Thomas Boeni Core Messages ✔ Paleopathological investigators have found clear evidence of spinal disorders in prehistoric times ✔ Full and accurate descriptions of spinal disorders and various treatment attempts survive from antiquity ✔ At the end of antiquity (7th century A.D.), Paulus of Aegina (625 – 690 A.D.) performed the first successful laminectomies ✔ During the whole of the Middle Ages, there was little progress in the diagnosis and treatment of spinal disorders ✔ At the end of the 18th century and the beginning of the 19th century, the first advanced attempts at spinal surgery were performed in Europe ✔ At the end of the 19th century, with the new techniques of anesthesia, radiology and aseptic surgery, more sophisticated and even more successful spinal surgery became possible ✔ In the middle of the 20th century, low back pain disability became an increasing socioeconomic problem ✔ In the 1970s and 1980s, powerful imaging systems (CT/MRI) improved the diagnosis for spinal disorders but also led to some overdiagnosis of spinal disorders ✔ In the 1980s and 1990s, spinal instrumentation became widely available and enabled even complex spinal disorders to be tackled ✔ During the 20th century, the focus on spinal disorders dramatically changed: at the beginning of the 20th century spinal disorders were predominantly caused by infectious diseases; nowadays the focus is more on degenerative spinal disorders ✔ At the beginning of the 21st century, spinal surgery has become more evidence based, but it is still technology driven in many areas A Brief Etymology The French pediatrician Nicholas Andry (1658 – 1742), considered the father of orthopedics, coined the word “orthopaedic”, which is made up of two Greek words, “orthos”, meaning straight, and “paidion”, meaning child (Fig. 1a) [3]. The term “orthopaedic” was used for the first time in the epoch-making textbook of Andry published in 1741. The origin of the word spine derives from the Latin word “spina” meaning “backbone”. The word vertebra, first found in the medical texts of Celsus (34 B.C.– 14 A.D.), a Roman encyclopedist, derives from the Latin word “vertebra”, which is related to the Latin verb “vertere” meaning “to turn”. The great anatomist Andreas Vesalius (1514 – 1564) finally introduced the word “vertebra” as an anatomical term [116]. The term scoliosis is derived from the Greek word “scolios” meaning “curvature” and was coined by the Greek physician Galen of Pergamon (130 – 200 A.D.) (Fig. 1b) [36]. Nowadays, it is used to describe a specific clinical condition consisting of lateral deviations of the spine associated with vertebral rotation. Nicholas Andry coined the word “orthopaedic” in 1741 Andreas Vesalius coined the word “vertebra” The Greek word “scoliosis” means curvature 1