The adult scoliosis

Adult scoliosis is defined as a spinal deformity in a skeletally mature patient with a Cobb angle of more than 10° in the coronal plain. Adult scoliosis can be separated into four major groups: Type 1: Primary degenerative scoliosis, mostly on the basis of a disc and/or facet joint arthritis, affecting those structures asymmetrically with predominantly back pain symptoms, often accompanied either by signs of spinal stenosis (central as well as lateral stenosis) or without. These curves are often classified as "de novo” scoliosis. Type 2: Idiopathic adolescent scoliosis of the thoracic and/or lumbar spine which progresses in adult life and is usually combined with secondary degeneration and/or imbalance. Some patients had either no surgical treatment or a surgical correction and fusion in adolescence in either the thoracic or thoracolumbar spine. Those patients may develop secondary degeneration and progression of the adjacent curve; in this case those curves belong to the type 3a.Type 3: Secondary adult curves: (a) In the context of an oblique pelvis, for instance, due to a leg length discrepancy or hip pathology or as a secondary curve in idiopathic, neuromuscular and congenital scoliosis, or asymmetrical anomalies at the lumbosacral junction; (b) In the context of a metabolic bone disease (mostly osteoporosis) combined with asymmetric arthritic disease and/or vertebral fractures. Sometimes it is difficult to decide, what exactly the primary cause of the curve was, once it has significantly progressed. However, once an asymmetric load or degeneration occurs, the pathomorphology and pathomechanism in adult scoliosis predominantly located in the lumbar or thoracolumbar spine is quite predictable. Asymmetric degeneration leads to increased asymmetric load and therefore to a progression of the degeneration and deformity, as either scoliosis and/or kyphosis. The progression of a curve is further supported by osteoporosis, particularly in post-menopausal female patients. The destruction of facet joints, joint capsules, discs and ligaments may create mono- or multisegmental instability and finally spinal stenosis. These patients present themselves predominantly with back pain, then leg pain and claudication symptoms, rarely with neurological deficit, and almost never with questions related to cosmetics. The diagnostic evaluation includes static and dynamic imaging, myelo-CT, as well as invasive diagnostic procedures like discograms, facet blocks, epidural and root blocks and immobilization tests. These tests may correlate with the clinical and the pathomorphological findings and may also offer the least invasive and most rational treatment for the patient. The treatment is then tailored to the specific symptomatology of the patient. Surgical management consists of either decompression, correction, stabilization and fusion procedures or a combination of all of these. Surgical procedure is usually complex and has to deal with a whole array of specific problems like the age and the general medical condition of the patient, the length of the fusion, the condition of the adjacent segments, the condition of the lumbosacral junction, osteoporosis and possibly previous scoliosis surgery, and last but not least, usually with a long history of chronified back pain and muscle imbalance which may be very difficult to be influenced. Although this surgery is demanding, the morbidity cannot be considered significantly higher than in other established orthopaedic procedures, like hip replacement, in the same age group of patients. Overall, a satisfactory outcome can be expected in well-differentiated indications and properly tailored surgical procedures, although until today prospective, controlled studies with outcome measures and pre- and post-operative patient's health status are lacking. As patients, who present themselves with significant clinical problems in the context of adult scoliosis, get older, minimal invasive procedures to address exactly the most relevant clinical problem may become more and more important, basically ignoring the overall deformity and degeneration of the spin

Surgical treatment of upper, middle and lower cervical injuries and non-unions by anterior procedures

The goals of any treatment of cervical spine injuries are: return to maximum functional ability, minimum of residual pain, decrease of any neurological deficit, minimum of residual deformity and prevention of further disability. The advantages of surgical treatment are the ability to reach optimal reduction, immediate stability, direct decompression of the cord and the exiting roots, the need for only minimum external fixation, the possibility for early mobilisation and clearly decreased nursing problems. There are some reasons why those goals can be reached better by anterior surgery. Usually the bony compression of the cord and roots comes from the front therefore anterior decompression is usually the procedure of choice. Also, the anterior stabilisation with a plate is usually simpler than a posterior instrumentation. It needs to be stressed that closed reduction by traction can align the fractured spine and indirectly decompress the neural structures in about 70%. The necessary weight is 2.5kg per level of injury. In the upper cervical spine, the odontoid fracture type 2 is an indication for anterior surgery by direct screw fixation. Joint C1/C2 dislocations or fractures or certain odontoid fractures can be treated with a fusion of the C1/C2 joint by anterior transarticular screw fixation. In the lower and middle cervical spine, anterior plating combined with iliac crest or fibular strut graft is the procedure of choice, however, a solid graft can also be replaced by filled solid or expandable vertebral cages. The complication of this surgery is low, when properly executed and anterior surgery may only be contra-indicated in case of a significant lesion or locked joint

Spinal metastasis in the elderly

Bony metastases are a frequent problem in elderly patients affected by cancer, and those with bony metastases involve the spine in approx. 50%. The most frequent spinal metastases (60%) are from breast, lung, or prostate cancer. The chance that an elderly patient (60-79years old) is affected by bony metastases is four times higher in men and three times higher in women than a middle-aged patient (40-59years old). Since the medical treatment with all the adjuvant treatment options prolong the survival of this particular patient group, the spinal metastases may become a mechanical issue, thus requesting surgical treatment. Different classification systems have been proposed to rationalize surgical indications, some concentrating solely on the local spinal tumor involvement and some including the overall clinical situation. Since most of the surgical options are of palliative character, it is more important to base the decision on an overall clinical classification including the different treatment modalities—irradiation, chemotherapy, steroids, bisphosphonates, and surgery—to make a shared decision. In case surgery is indicated—neural compression, pathological fracture, instability, and progressive deformity, nursing reasons—the most straightforward procedures should be chosen, which may not need an intensive care unit stay. In the thoracolumbar spine a posterior decompression and posterolateral vertebral body resection through a posterior approach only, with a concomitant reconstruction and stabilization, has shown to work sufficiently well. In the middle and lower cervical spine the anterior approach with anterior decompression and anterior column reconstruction is most effective and has a low morbidity, whereas the occipitocervical junction can generally be treated by posterior resection and stabilization. The outcome should be determined by the survival time in an ambulatory, independent status, where pain is controlled, and the patient is not hospitalized. Surgical management shows the greatest improvement in pain reduction, but also in other domains of quality of life. Since prospective randomized studies comparing different treatment modalities for spinal metastases including surgery are not available and are ethically difficult to achieve, each case remains an interdisciplinary, shared decision making process for what is considered best for a patient or elderly patient. However, whenever surgery is an option, it should be planned before irradiation since surgery after irradiation has a significant higher complication rat

Classification of thoracolumbar fractures and dislocations

A classification of injuries is necessary in order to develop a common language for treatment indications and outcomes. Several classification systems have been proposed, the most frequently used is the Denis classification. The problem of this classification system is that it is based on an assumption, which is anatomically unidentifiable: the so-called middle column. For this reason, few years ago, a group of spine surgeons has developed a new classification system, which is based on the severity of the injury. The severity is defined by the pathomorphological findings, the prognosis in terms of healing and potential of neurological damage. This classification is based on three major groups: A=isolated anterior column injuries by axial compression, B=disruption of the posterior ligament complex by distraction posteriorly, and group C=corresponding to group B but with rotation. There is an increasing severity from A to C, and within each group, the severity usually increases within the subgroups from .1, .2, .3. All these pathomorphologies are supported by a mechanism of injury, which is responsible for the extent of the injury. The type of injury with its groups and subgroups is able to suggest the treatment modalit