BackgroundUp to one third of BKP treated cases shows no appreciable height restoration due to loss of both restored height and kyphotic realignment after balloon deflation. This shortcoming has called for an improved method that maintains the height and realignment reached by the fully inflated balloon until stabilization of the vertebral body by PMMA-based cementation. Restoration of the physiological vertebral body height for pain relief and for preventing further fractures of adjacent and distant vertebral bodies must be the main aim for such a method. A new vertebral body stenting system (VBS) stabilizes the vertebral body after balloon deflation until cementation. The radiographic and safety results of the first 100 cases where VBS was applied are presented.MethodsDuring the planning phase of an ongoing international multicenter RCT, radiographic, procedural and followup details were retrospectively transcribed from charts and xrays for developing and testing the case report forms. Radiographs were centrally assessed at the institution of the first/senior author.Results100 patients (62 with osteoporosis) with a total of 103 fractured vertebral bodies were treated with the VBS system. 49 were females with a mean age of 73.2 years; males were 66.7 years old. The mean preoperative anterior-middle-posterior heights were 20.3-17.6-28.0 mm, respectively. The mean local kyphotic angle was 13.1°. The mean preoperative Beck Index (anterior edge height/posterior edge height) was 0.73, the mean alternative Beck Index (middle height/posterior edge height) was 0.63. The mean postoperative heights were restored to 24.5-24.6-30.4 mm, respectively. The mean local kyphotic angle was reduced to 8.9°. The mean postoperative Beck Index was 0.81, the mean alternative one was 0.82. The overall extrusion rate was 29.1%, the symptomatic one was 1%. In the osteoporosis subgroup there were 23.8% extrusions. Within the three months followup interval there were 9% of adjacent and 4% of remote new fractures, all in the osteoporotic group.ConclusionsVBS showed its strengths especially in realignment of crush and biconcave fractures. Given that fracture mobility is present, the realignment potential is sound and increases with the severity of preoperative vertebral body deformation.
Operative treatment of scoliosis with a high degree of correction carries a risk of neurological complications of about 0.5%. Mechanical as well as ischaemic damage to the spinal cord can be detected early by means of consistent intraoperative neuromonitoring.
Kyphosis in myelomeningocele is characterized by a complex pattern of problems during development and therapy. On the one hand, decompensation of upright posture leads to loss of sitting ability and social integration; on the other hand, accompanying malformations and trophic alterations threaten the physical integrity and performance. Neurologic function, cerebrospinal fluid (CSF) circulation, skeletal deformity and the urinary transport system need to be kept in mind and need to be treated with cooperation between the different specialties. Especially during serious surgical interventions such as spinal surgery, neither the nervous system nor the kidneys must be ignored. Sixteen patients underwent kyphectomy in the Orthopedic Department of the University of Mainz between 1993 and 1997, all of them supervised by the Neurosurgical Department. In 13 cases, transversal myelotomy was performed. No insufficiency of CSF circulation was seen; neither were there any CSF fistulae. Particular problems arose from the skin and soft tissue above the gibbus, the lack of muscles and the regeneration deficiency caused by trophic disorders. Therefore, a significantly higher complication rate was found than with other correctional operations.
Lesions of the intervertebral disc accompanying vertebral fractures are the subject of controversy and discussion regarding the extent and manner of surgical intervention. The question of when to perform disc resection and intervertebral fusion, in particular, has not been answered satisfactorily. In order to evaluate short-and medium-term lesions of the discoligamentous complex associated with thoracolumbar burst fractures, magnetic resonance images made after stabilisation and again after implant removal were compared. Between 1997 and 1998, 20 patients who had suffered thoracolumbar burst fractures (AO classification A3 and B1 [26]) underwent posterior reduction and stabilisation using a Universal Spine System (USS, Synthes, Switzerland) titanium internal fixator. The implant was removed after an average of 10 months. Magnetic resonance imaging (MRI) scans were performed 1 week after both operations, allowing the changes in a total of 40 intervertebral discs adjacent to the fractured vertebral body to be investigated. The analysis was based on signal intensity of the intervertebral disc in T 2 -weighted scans and on morphological criteria. A total of 81% of the discs with initially normal T 2 -weighted signal
IntroductionThe myelomeningocele (MMC) is one of the dysraphic disorders of the neural arch. Pathogenically it is caused by the absence of proliferation of neuroectodermal cells after migration is finished. The occult form without neurologic deficit is estimated to have incidence of up to 1%, while a spina bifida aperta cystica with everted myelon and complete paraplegia occurs in 0.005% of live births. With the help of postnatal closure of the sac and the early commencement of hydrocephalus therapy, the life expectancy of patients with myelomeningocele has nearly reached the level of the normal population [3,24]. While therapy during infancy concentrates on taking care of the cerebral and renal function, during growth and adolescence, more and more problems concerning the skeletal system arise, caused by the wish for maximum mobility and improved nursing aspects such as lying in supine position and sitting without support. The clinical appearance is dominated by the spastic or paralytic neurological lesion at different levels. In addition, the increasing spinal deformity in combination with trophic skin and soft tissue disturbances leads to secondary problems, i.e. decubital ulcers and contractures of hips and limbs. Kyphosis appears in 12-28% of the cases, with neurologic damage at the thoracic level [2,15,24, 25]. The gibbus, however, develops usually between L2 and L5 [4]. Problems of the kyphotic spineMyelomeningocele at the thoracic level is in most cases accompanied by other malformations of the neural arch. They can aggravate each other, if for example during progressive kyphosis the dura is pulled caudally by a tethered Abstract The progression of kyphosis in myelomeningocele is independent of skeletal growth and requires early operative correction and stabilization to prevent a loss of sitting ability. In severe cases, only vertebrectomy makes it possible to achieve correction, stability and skin-closure without tension. In 14 patients with myelomeningocele gibbus, kyphectomy was performed, removing two vertebral bodies on average. The average kyphosis angle decreased from 128°to 81°, enabling most of the patients to participate again in social life by restoring wheelchair mobility. Nevertheless, a significantly higher complication rate was found compared to other correctional operations, lengthening the average hospital stay to 41 days. Special problems arose from trophic disorders of the skin and soft tissue and from the dystrophic muscles below the level of neural malfunction. In three cases, kyphosis reappeared cranial to the fused segments, requiring ventral stabilization. With respect to increasing kyphosis angle, an early intervention should be aimed at. A secondary operation can be necessary, if surgery is performed without taking care of the growth potential.
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