A new method for the treatment of scoliosis is described in which a metal system of rods and hooks is implanted, and distraction and compression forces applied, to correct the curve and stabilize the treated segments in the corrected position by skeletal fixation. The technique and principles of this method of treatment and a summary of the preliminary results are given.

JBJS classics: Treatment of scoliosis: Correction and internal fixation by spine instrumentation

Introduction
“Navigation in surgery” spans a broad area, which, depending on the clinical challenge, can have different meanings. Over the past decade, navigation in surgery has evolved beyond imaging modalities and bulky systems into the rich networking of the cloud or devices that are pocket-sized.

/pdf/navigation-in-surgery-365glp5qyx.pdf

Navigation in surgery

Purpose  To review the current literature for the nonoperative and operative treatment for adult spinal deformity. Recent Findings  With more than 11 million baby boomers joining the population of over 60 years of age in the United States, the incidence of lumbar deformity is greatly increasing. Recent literature suggests that a lack of evidence exists to support the effectiveness of nonoperative treatment for adult scoliosis. In regards to operative treatment, current literature reports a varying range of improved clinical outcomes, curve correction, and complication rates. The extension of fusion to S1 compared with L5 and lower thoracic levels compared with L1 remains a highly controversial topic among literature. Summary  Most adult deformity patients never seek nonoperative or operative treatment. Of the few that seek treatment, many can benefit from nonoperative treatment. However, in selected patients who have failed nonoperative treatment and who are candidates for surgical intervention, the literature reflects positive outcomes related to surgical intervention as compared with nonoperative treatment despite varying associated ranges in morbidity and mortality rates. If nonoperative therapy fails in addressing a patient's complaints, then an appropriate surgical procedure that relieves neural compression, corrects excessive sagittal or coronal imbalance, and results in a solidly fused, pain-free spine is warranted.

/pdf/current-status-of-adult-spinal-deformity-4f48h59083.pdf

Current Status of Adult Spinal Deformity

Object Recent years have been marked by efforts to improve the quality and safety of pedicle screw placement in spinal instrumentation. The aim of the present study is to compare the accuracy of the SpineAssist robot system with conventional fluoroscopy-guided pedicle screw placement. Methods Ninety-five patients suffering from degenerative disease and requiring elective lumbar instrumentation were included in the study. The robot cohort (Group I; 55 patients, 244 screws) consisted of an initial open robot-assisted subgroup (Subgroup IA; 17 patients, 83 screws) and a percutaneous cohort (Subgroup IB, 38 patients, 161 screws). In these groups, pedicle screws were placed under robotic guidance and lateral fluoroscopic control. In the fluoroscopy-guided cohort (Group II; 40 patients, 163 screws) screws were inserted using anatomical landmarks and lateral fluoroscopic guidance. The primary outcome measure was accuracy of screw placement on the Gertzbein-Robbins scale (Grade A to E and R [revised]). Secondary ...

Safety and accuracy of robot-assisted versus fluoroscopy-guided pedicle screw insertion for degenerative diseases of the lumbar spine: a matched cohort comparison

Systematic review. The aims of this systematic review were: (1) to determine the most commonly used methods for assessing pedicle screw placement accuracy, and (2) assess the difference in pedicle screw placement accuracy between navigation and free-hand techniques according to the classification method. Pedicle screw fixation and spine surgery have almost become synonymous. However, there is currently no gold standard method to assess pedicle screw placement accuracy. We reviewed the literature to determine current techniques used by spine surgeons for the assessment of pedicle screw accuracy. We systematically reviewed the medical literature (OVID Medline, Embase, PubMed) to identify all articles published between 2010 and 2013 that have assessed pedicle screw placement accuracy in humans. Two independent reviewers with a third independent mediator performed study screening, selection and data extraction using a blinded and objective protocol. A total of 68 relevant articles were included in this systematic review, for a total of 3442 patients, 60 cadavers and 43,305 pedicle screws. The most widely used method (37 articles) was based on 2 mm breach increments measured on computer tomography images. The second most widely used method consisted of an “in” or “out” classification system (16 articles). The remaining 15 articles used variable classification systems. Our result suggests that an average of 91.4 % of pedicle screws placed with free-hand or fluoroscopy technique where within the safe zone (<2 mm breach) in comparison to an average of 97.3 % of pedicle screws using navigation (p < 0.001) for the 2 mm increment method. Similarly, the in or out classification also showed statistically significant difference between free-hand and navigated techniques (p < 0.001). The grading system based on 2 mm increments seems to be the most widely accepted method for determining pedicle screw placement accuracy. All grading systems were based on imaging alone without taking into account the direction of the breach or patient’s symptoms.

Methods to determine pedicle screw placement accuracy in spine surgery: a systematic review

BACKGROUND Image-guided spinal instrumentation may reduce complications in spinal instrumentation. OBJECTIVE To assess accuracy, time efficiency, and staff radiation exposure during thoracolumbar screw instrumentation guided by intraoperative computed tomography (iCT)-based neuronavigation (iCT-N). METHODS In 55 patients treated for idiopathic and degenerative deformities, 826 screws were inserted in the thoracic (T2-T12; n = 243) and lumbosacral (L1-S1; n = 545) spine, as well as ilium (n = 38) guided by iCT-N. Up to 17 segments were instrumented following a single automated registration sequence with the dynamic reference arc (DRA) uniformly attached to L5. Accuracy of iCT-N was assessed by calculating angular deviations between individual navigated tool trajectories and final implant positions. Final screw positions were also graded according to established classification systems. Clinical and radiological outcome was assessed at 12 to 14 months. RESULTS Additional intraoperative fluoroscopy was unnecessary, eliminating staff radiation exposure. Unisegmental K-wire insertion required 4.6 ± 2.9 minutes. Of the thoracic pedicle screws 98.4% were assigned grades I to III according to the Heary classification, with 1.6% grade IV placement. In the lumbar spine, 94.4% of screws were completely contained (Gertzbein classification grade 0), 4.6% displayed minor pedicle breaches 2 to <4 mm (grade 2). The accuracy of iCT-N progressively deteriorates with increasing distance from the DRA, but allows safe instrumentation of up to 12 segments. CONCLUSION iCT-N using automated referencing allows for safe, highly accurate multilevel instrumentation of the entire thoracolumbosacral spine and ilium, rendering additional intraoperative imaging dispensable. In addition, automated registration is time-efficient and significantly reduces the need for re-registration in multilevel surgery.

Accuracy of Image-Guided Pedicle Screw Placement Using Intraoperative Computed Tomography-Based Navigation With Automated Referencing. Part II: Thoracolumbar Spine

BACKGROUND: Adult scoliosis is a condition with increasing prevalence and medical and socioeconomic importance. Surgery is fraught with a significant complication rate in an elderly multimorbid patient population. OBJECTIVE: To assess technical feasibility and radiographic results of image-guided less invasive correction of adult degenerative scoliosis. METHODS: Thirty individuals (age, 64-88 years) with progressive deformity (coronal Cobb angles > 25 degrees and < 85 degrees), intractable back pain, radiculopathy, or neurogenic claudication were treated by less invasive decompression and fusion (unilateral transforaminal interbody cage instrumentation and bilateral facet fusions) with recombinant human bone morphogenetic protein-2, spanning 3 to 8 segments (average, 6 segments), using biplanar fluoroscopy or intraoperative computed tomography (iCT)-based navigation. Accuracy of screw placement, curve correction, and fusion rate were evaluated during a mean follow-up of 19.6 months. RESULTS: With 415 screws implanted, misplacement (grade II or greater) was not observed, and no implants required revision. Spinal iCT with automated registration required 17.5 +/- 8.5 minutes (single registration for all segments); monosegmental bilateral screw insertion required 6.8 +/- 3.4 minutes. Mean sagittal (coronal) Cobb angle correction was 44.8 +/- 10.7 degrees (31.7 +/- 13.7 degrees). Mean lumbar lordosis increased from 8.8 +/- 8.9 degrees to -36 +/- 6.9 degrees, and sagittal balance was reduced from 31.6 +/- 15.2 to 8 +/- 8.4 mm. Solid fusion was confirmed in 90% of instrumented segments at 16 months. Average radiation dose to the surgeon was 0.025 mSv for single-level transforaminal lumbar interbody fusion with fluoroscopic guidance vs 0 mSv with iCT navigation. CONCLUSION: Instrumented correction of adult deformity was significantly facilitated by iCT navigation, eliminating radiation exposure to the surgeon. Intraoperative biplanar CT scout views including pelvis and shoulders allow comprehensive assessment of multiplanar deformity correction. Fusion rates obtained with less invasive access equal those of conventional open technique.

Less invasive surgical correction of adult degenerative scoliosis, part I: technique and radiographic results.

BACKGROUND: Surgical correction of adult degenerative scoliosis is a technically demanding procedure with a considerable complication rate. Extensive blood loss has been identified as a significant factor linked to unfavorable outcome. OBJECTIVE: To report on the complication profile and clinical outcomes obtained with less invasive image-guided surgical correction of degenerative (de novo) scoliosis in a high-risk population. METHODS: Thirty patients (age, 64-88 years) with progressive postural impairment, back pain, radiculopathy, and neurogenic claudication caused by degenerative scoliosis were treated by less invasive image-guided correction (3-8 segments) by multisegmental transforaminal lumbar interbody fusion and facet fusions. With a mean follow-up of 19.6 months, intraoperative blood loss, curve correction, fusion and complication rates, duration of hospitalization, incidence of hardware-related problems, and clinical outcome parameters were assessed using multivariate analysis. RESULTS: Satisfactory multiplanar correction was obtained in all patients. Mean intra-operative blood loss was 771.7 ± 231.9 mL, time to full ambulation was 0.8 ± 0.6 days, and length of stay was 8.2 ± 2.9 days. After 12 months, preoperative SF12v2 physical component summary scores (20.2 ± 2.6), visual analog scale scores (7.5 ± 0.8), and Oswestry disability index (57.2 ± 6.9) improved to 34.6 ± 3.9, 2.63 ± 0.6, and 24.8 ± 7.1, respectively. The rate of major and minor complications was 23.4% and 59.9%, respectively. Ninety percent of patients rated treatment success as excellent, good, or fair. CONCLUSION: Less invasive image-guided correction of degenerative scoliosis in elderly patients with significant comorbidity yields a favorable complication profile. Significant improvements in spinal balance, pain, and functional scores mirrored expedited ambulation and early resumption of daily activities. Less invasive techniques appear suitable to reduce periprocedural morbidity, especially in elderly patients and individuals with significant medical risk factors.

Less invasive surgical correction of adult degenerative scoliosis. Part II: Complications and clinical outcome.

Die Wirbelsaule entsteht aus der Chorda dorsalis. Die Chorda bildet den spateren Gallertkern der Bandscheiben. Bei Geburt ist die Wirbelsaule in ihrer Anlage voll entwickelt. Vor dem 4. Lebensjahr ist die Bandscheibe bis in den auseren Faserring vaskularisiert. Nach dem 4. Lebensjahr erfolgt die Ernahrung der Bandscheibe ausschlieslich per Diffusion, Gefase sind dann nicht mehr nachweisbar. Die Wirbelsaule durchlauft einen naturlichen Alterungsprozess. Schon mit dem 30. Lebensjahr treten beim Menschen physiologischerweise degenerative Veranderungen der Bandscheibe auf. Der Nucl. pulposus hat einen hohen Proteoglykan- und damit einen hohen Wassergehalt. Bei der kindlichen Bandscheibe liegt der Wassergehalt bei 90%, dieser nimmt im Alter auf ca. 70% ab (Gower u. Pedrini 1969). Er ist von einem kraftigen Anulus fibrosus und von Poren enthaltenden kartilaginaren Endplatten umgeben. Nach innen verlaufen die Fasern in einem Winkel von ca. 60°, wodurch die Wirbelsaule eine wesentliche Stabilitat fur Rotationsbewegungen erhalt (Krismer et al. 1997). Der intradiskale Ruhedruck einer intakten Bandscheibe betragt ca. 500 kPa, kann aber in Abhangigkeit von der Belastung bis auf 2300 kPa ansteigen (Eysel et al. 2000, Wilke et al. 2001). Unter Belastung verliert die Bandscheibe Wasser, der osmotische Druck nimmt umgekehrt proportional zur Belastung zu (Kolditz et al. 1985).

https://link.springer.com/content/pdf/10.1007%2F978-3-540-88507-8_5.pdf

Therapeutische Möglichkeiten – interventionelle und operative Verfahren

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Accuracy of Image-Guided Pedicle Screw Placement Using Intraoperative Computed Tomography-Based Navigation With Automated Referencing. Part II: Thoracolumbar Spine

Less invasive surgical correction of adult degenerative scoliosis, part I: technique and radiographic results.

Less invasive surgical correction of adult degenerative scoliosis. Part II: Complications and clinical outcome.

Therapeutische Möglichkeiten – interventionelle und operative Verfahren