PMMA-Cement-PLIF Is Safe and Effective as a Single-Stage Posterior Procedure in Treating Pyogenic Erosive Lumbar Spondylodiscitis-A Single-Center Retrospective Study of 73 Cases.

BACKGROUND Surgical treatment for erosive pyogenic spondylodiscitis of the lumbar spine is challenging as, following debridement of the intervertebral and bony abscess, a large and irregular defect is created. Sufficient defect reconstruction with conventional implants using a posterior approach is often impossible. Therefore, we developed the "Cement-PLIF", a single-stage posterior lumbar procedure, combining posterior lumbar interbody fusion (PLIF) with defect-filling using antibiotic-loaded polymethylmethacrylate (PMMA). This study first describes and evaluates the procedure's efficacy, safety, and infection eradication rate. Radiological implant stability, bone-regeneration, sagittal profile reconstruction, procedure-related complications, and pre-existing comorbidities were further analyzed. METHODS A retrospective cohort study analyzing 73 consecutive patients with a minimum of a one-year follow-up from 2000-2017. Patient-reported pain levels and improvement in infectious serological parameters evaluated the clinical outcome. Sagittal profile reconstruction, anterior bone-regeneration, and posterior fusion were analyzed in a.p. and lateral radiographs. A Kaplan-Meier analysis was used to determine the impact of pre-existing comorbidities on mortality. Pre-existing comorbidities were quantified using the Charlson-Comorbidity Index (CCI). RESULTS Mean follow-up was 3.3 (range: 1-16; ±3.2) years. There was no evidence of infection persistence in all patients at the one-year follow-up. One patient underwent revision surgery for early local infection recurrence (1.4%). Five (6.9%) patients required an early secondary intervention at the same level due to minor complications. Radiological follow-up revealed implant stability in 70/73 (95.9%) cases. Successful sagittal reconstruction was demonstrated in all patients (p < 0.001). There was a significant correlation between Kaplan-Meier survival and the number of pre-existing comorbidities (24-months-survival: CCI ≤ 3: 100%; CCI ≥ 3: 84.6%; p = 0.005). CONCLUSIONS The Cement-PLIF procedure for pyogenic erosive spondylodiscitis is an effective and safe treatment as evaluated by infection elimination, clinical outcome, restoration, and maintenance of stability and sagittal alignment

Feasibility of postoperative spine stereotactic body radiation therapy in proximity of carbon and titanium hybrid implants using a robotic radiotherapy device.

BACKGROUND AND PURPOSE To assess the feasibility of postoperative stereotactic body radiation therapy (SBRT) for patients with hybrid implants consisting of carbon fiber reinforced polyetheretherketone and titanium (CFP-T) using CyberKnife. MATERIALS AND METHODS All essential steps within a radiation therapy (RT) workflow were evaluated. First, the contouring process of target volumes and organs at risk (OAR) was done for patients with CFP-T implants. Second, after RT-planning, the accuracy of the calculated dose distributions was tested in a slab phantom and an anthropomorphic phantom using film dosimetry. As a third step, the accuracy of the mandatory image guided radiation therapy (IGRT) including automatic matching was assessed using the anthropomorphic phantom. For this goal, a standard quality assurance (QA) test was modified to carry out its IGRT part in presence of CFP-T implants. RESULTS Using CFP-T implants, target volumes could precisely delineated. There was no need for compromising the contours to overcome artifact obstacles. Differences between measured and calculated dose values were below 11% for the slab phantom, and at least 95% of the voxels were within 5% dose difference. The comparisons for the anthropomorphic phantom showed a gamma-passing rate (5%, 1 mm) of at least 97%. Additionally the test results with and without CFP-T implants were comparable. No issues concerning the IGRT were detected. The modified machine QA test resulted in a targeting error of 0.71 mm, which corresponds to the results of the unmodified standard tests. CONCLUSION Dose calculation and delivery of postoperative spine SBRT is feasible in proximity of CFP-T implants using a CyberKnife system

Transoral unilateral lag screw osteosynthesis for coronal split fracture of the lateral mass of the atlas – case report, operative technique and review of the literature

Introduction: Atlas ring fractures, which account for 1.3% of all spinal fractures, are predominantly managed conservatively. However, in certain cases, surgical treatment may be necessary depending on the type of fracture, degree of comminution, fracture location, and associated ligamentous injuries. Surgical stabilization frequently results in a posterior C1-2 or C0-2 fusion, which restricts movement, particularly craniocervical rotation. Coronal split fractures of the lateral mass need to be reduced and fixed due to dislocation, instability and secondary osteoarthritis. The preferred treatment approach involves internal fixation of the reduced fracture fragments, while avoiding restriction of the upper cervical spine's range of motion (ROM). Research question: Is unilateral anterior transoral lag screw for treatment of unstable coronal split fracture of lateral mass of the atlas feasible and a safe treatment option? Case Report: Material and Methods: We report on a 55-year-old female suffering from polytrauma with multiple spinal and extremity injuries. Results: A coronal split fracture of the lateral mass of the atlas was treated minimally invasive with a transoral lag screw technique to reduce and fix the fracture that has a tendency for fracture gap widening. Stable fixation and fracture union and thus restoration of function was achieved. Discussion and conclusion: Transoral lag screw osteosynthesis for coronal split fracture of the lateral mass of the atlas is a potential treatment option in selected cases to preserve mobility in the upper cervical spine after spinal trauma

Thermic effect on metal body piercing by electro-coagulation: An ex vivo study on pig skin and bovine liver.

BACKGROUND Piercings are placed at different body sites often invisible to medical staff. They may cause additional injuries in trauma and emergency surgery by electro-cautery. OBJECTIVE To clarify whether electro-coagulation will have a direct damaging effect to the skin around a pierced skin area. METHODS Metallic piercings were fixed at defined distances from the neutral and active electrode on abdominal pig skin. The distance of the active electrode was reduced by 5 mm increments to 0. The respective increases in temperature were determined with a thermal camera. A macroscopic and histological analysis of the area around the piercing to detect thermal damage was carried out. RESULTS Significant increases in temperature and visible changes in the tissue around the piercing only occurred when the active electrode was in direct contact with the piercing (increase of 47.3∘C). Electro-cautery in distance of 5 to 10 mm to the piercing showed only temperature increases of less than 5∘C. CONCLUSIONS If metallic piercings are not directly touched by the active electrode and the distance is more than 5-10 mm, no clinically relevant effect is created on the tissue in direct proximity to the piercings by electro-cautery. In an emergency surgery situation, a piercing not fixed in direct proximity to the surgical field may likely be ignored

Bilateral Hip Dislocation: An Indicator for Emergent Full-Body Computed Tomography Scan in Polytraumatized Patients? A Case Report and Review of the Literature.

We present a rare case of traumatic bilateral asymmetric hip dislocation with pelvic fractures and a traumatic diaphragmatic hernia. A 53-year-old machinist was transferred to our emergency department with the suspicion of a bilateral hip dislocation after he was trapped between an elevator and the roof. Immediate closed reduction of the hips was not performed because of the expected risk of increasing hemodynamic instability with muscular relaxation. An emergent full-body computed tomography (CT) scan was made to assess injuries with need for further operative treatment. Thus, closed reduction of both hips was finally performed in the OR directly before the laparotomy for the diaphragmatic repair and the osteosynthesis of the anterior pelvic ring. A 12-month follow-up showed good general health condition with asymptomatic situation of the hip joints and the abdomen. The diagnostic work-up of patients with severe trauma is still debated, a randomized controlled trial showed no reduction of the in-hospital mortality with immediate full-body CT scan compared to a conventional radiological work-up. Traumatic hip dislocations (THDs) are always due to high-energy trauma and additional injuries are frequent. To attempt a closed reduction of THD, under general anesthesia can be life-threatening with unrecognized associated injuries. Therefore, THD can serve as selection criteria for immediate full-body CT scan to facilitate diagnosis and treatment of associated injuries sustained by the patient

BMP Antagonists - A Possible Cause for Spinal Non-Fusion?

INTRODUCTION:Spinal fusion is a procedure where the intervertebral disc (IVD) is removed and two adjacent vertebrae are forced to fuse by compression. This procedure is the most commonly applied procedure to achieve spinal stability and relief of back pain. However, non-successful fusion leads to pseudo-athrosis and ongoing pain. There is increasing evidence that supraphysiological doses of BMP2 and burst-release of this cytokine did not generate satisfying results in clinical studies. Current hypothesis was raised that IVD cells and/or tissue seem to inhibit the action of BMP2. In this overview we summarize the current evidence that BMPs might be inhibited by the secretome of human IVD cells, i.e., nucleus pulposus cells (NPC), annulus fibrosus cells (AFC) and cartilaginous endplate (CEPC) cells. METHODS:We stimulated low-passage (2-3) human bonemarrow-derived mesenchymal stromal cells (MSCs) and femoral hip-derived osteoblasts (OBs) and co-cultured these with allogeneic IVD cells obtained from spinal surgery. We then stimulated MSCs and the OBs in monolayer and osteogenic medium, whereas IVD cells were kept in 3D alginate bead culture and separated by high density pore culture inserts (0.4 µm pore size). We quantified relative gene expression at bone-relevant genes, alkaline phosphatase (ALP) activity and Alizarin red (ALZR) staining after 21 days. Furthermore, to test the effect of a previously investigated BMP2 analog to block the inhibitors, cells were further stimulated with 100 ng/mL BMP2 and/or L51P. RESULTS:We found significant inhibitory effects of IVD cells onto MSCs undergoing differentiation in presence of NPC, AFC and CEPC as shown in reduced osteogenic gene expression, ALZR staining and ALP activity (N = 11 donors paired on each side). In the case of allogeneic human OBs only a trend towards inhibition could be demonstrated (N = 7 donors on each side). The addition of L51P to the coculture recovered ossification. On the side of the IVD cells BMP2 and/or L51P had a strong chondrogenic effect. DISCUSSION & CONCLUSIONS:Our data suggested evidence for inhibition for MSCs. However, OBs did not show the same inhibitory effects but showed a trend in presence of IVD’s secretome. This warrants for animal models where the donor variance can be better controlled. ACKNOWLEDGEMENTS:This work was supported by a start-up grant from the Center for Applied Biotechnology and Molecular Medicine (CABMM). Further funds were received from the Swiss Society of Orthopaedics (SGOT), the clinical trials unit (CTU) of Bern University Hospital, and by a Eurospine Task Force Research grant #2019_22

Exertional rhabdomyolysis and causes of elevation of creatine kinase.

Background: Rhabdomyolysis is a potentially fatal condition that can be triggered by a variety of inciting events, including excessive muscular exertion. The purpose of this study was to investigate the causes of creatine kinase elevation (CK≥1000U/L) to determine what percentage result from exRML, the etiology, and kinetics of CK levels, as well as the complications of exRML and comorbidities that may predispose an individual to this condition. Methods: We performed a cross-sectional analysis of the emergency department database for patients with CK≥1000U/L between 2012 and 2017. In total, there were 1957 cases of rhabdomyolysis diagnosed based on laboratory data and documentation. Trauma was the most common cause for rhabdomyolysis (n = 726/1957; 37.1%, respectively). Results: ExRML was identified in 2.1% (n = 42/1957) of the total cases. Patients with ExRML were significantly younger (30.1 ± 10.6 years) with a significantly higher maximal level of CK compared to the non-exertional causes of rhabdomyolysis, (CK = 16,884.4 ± 41,645.6U/L; both p < 0.005). The far majority of cases were sport or exercise related (n = 35/42; 83.3%), with strength training at the gym making up the largest group of athletes (n = 16/42; 38.1%). The main complication amongst the ExRML group was acute kidney insufficiency, which was observed in 42.9% of patients. The CK levels of the patients in the ExRML cohort steadily decreased after initiation of aggressive hydration. Conclusion: ExRML may be more prevalent than the current literature predicts, which is important to recognize as it has the potential to cause kidney failure, irregular heart rhythm, and death. Therefore, physicians and active individuals should be sensitized to the signs and symptoms that may lead to earlier recognition and proper treatment in exercising individuals

First Results of a New Vacuum Plasma Sprayed (VPS) Titanium-Coated Carbon/PEEK Composite Cage for Lumbar Interbody Fusion.

The aim of this study was to assess the performance of a new vacuum plasma sprayed (VPS) titanium-coated carbon/polyetheretherketone (PEEK) cage under first use clinical conditions. Forty-two patients who underwent a one or two segment transforaminal lumbar interbody fusion (TLIF) procedure with a new Ca/PEEK composite cage between 2012 and 2016 were retrospectively identified by an electronic patient chart review. Fusion rates (using X-ray), patient's satisfaction, and complications were followed up for two years. A total of 90.4% of the patients were pain-free and satisfied after a follow up (FU) period of 29.1 ± 9 (range 24-39) months. A mean increase of 3° in segmental lordosis in the early period ( = 0.002) returned to preoperative levels at final follow-ups. According to the Bridwell classification, the mean 24-month G1 fusion rate was calculated as 93.6% and the G2 as 6.4%. No radiolucency around the cage (G3) or clear pseudarthrosis could be seen (G4). In conclusion, biological properties of the inert, hydrophobic surface, which is the main disadvantage of PEEK, can be improved with VPS titanium coating, so that the carbon/PEEK composite cage, which has great advantages in respect of biomechanical properties, can be used safely in TLIF surgery. High fusion rates, good clinical outcome, and low implant-related complication rates without the need to use rhBMP or additional iliac bone graft can be achieved

Return to sports/activity level after 360° thoracolumbar fusion after burst fractures in young patients

Introduction: Traumatic thoracolumbar burst fractures are the most common spinal injuries and the proper treatment is controversial. In central Europe in particular, these fractures are often treated with minimally invasive anterior-posterior reduction and fusion, whereas a conservative approach is preferred in the USA. Independent of the treatment strategy, no data exists regarding the outcome related to return to activity level/sport. Research question: The aim of this study was to evaluate the return to sports and activity levels after 360° fusion in patients with thoracolumbar burst fractures without neurological deficits. Methods: Between January 2013 and December 2022, 46 patients aged 18 to 40 years underwent partial or complete vertebral body replacement in the thoracolumbar region due to traumatic burst fractures without neurologic deficit as an isolated injury. Patients were contacted retrospectively by phone calls to assess their activities using a modified version of the Tegner activity scale at different time points: Before trauma, 3, 6, and 12 months post-surgery. Results: After applying exclusion criteria, data collection was complete for 28 patients. The median modified Tegner activity scale was 5.4 before sustaining the fracture, declined to 2.9 at three months post-trauma, improved to 4.2 at six months, and reached 5.0 at 12 months. The majority (83%) of patients achieved their pre-accident activity level within 12 months. No significant differences were observed between patients with partial or complete corpectomy. Conclusion: This is the first study assessing return to sports/physical activity based on the modified Tegner scale in young patients undergoing 360° fusion for spinal burst fractures. The majority of patients (83%) return to the pre-injury activity level within 12 months after surgery