Multilevel Instrumentation Research Articles

A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery

Major spine surgery with multilevel instrumentation is followed by large amount of opioid consumption, significant pain and difficult mobilization in a population of predominantly chronic pain patients. This case-control study investigated if a standardized comprehensive pain and postoperative nausea and vomiting (PONV) treatment protocol would improve pain treatment in this population. A new regimen with acetaminophen, NSAIDs, gabapentin, S-ketamine, dexamethasone, ondansetron and epidural local anesthetic infusion or patient controlled analgesia with morphine, was introduced in a post-intervention group of 41 consecutive patients undergoing multilevel (median 10) instrumented spinal fusions and compared with 44 patients in a pre-intervention group. Compared to patients in the pre-intervention group, patients treated according to the new protocol consumed less opioid on postoperative day (POD) 1 (P = 0.024) and 2 (P = 0.048), they were mobilized earlier from bed (P = 0.003) and ambulation was earlier both with and without a walking frame (P = 0.027 and P = 0.027, respectively). Finally, patients following the new protocol experienced low intensities of nausea, sedation and dizziness on POD 1-6. In this study of patients scheduled for multilevel spine surgery, it was demonstrated that compared to a historic group of patients receiving usual care, a comprehensive and standardized multimodal pain and PONV protocol significantly reduced opioid consumption, improved postoperative mobilization and presented concomitant low levels of nausea, sedation and dizziness.

Posterior C1-2 fusion with C1 lateral mass and C2 isthmic screws: accuracy of screw position, alignment and patient outcome

Transarticular screw fixation is seen as the "gold standard" in instrumented fusion of C1 and C2. However, drawbacks are the necessity of a reduction before instrumentation and a risk of vertebral artery injury. Therefore, C1 lateral mass and C2 isthmic screws are an alternative. The present study assessed the feasibility of C1-2 stabilization with C1 lateral mass and C2 isthmic screws and evaluated quality of life. All data of 35 consecutive patients treated from May 2006 to September 2009 were collected. Patients had C1 lateral mass and C2 isthmic screws. Twenty patients were operated on for traumatic instabilities, six for neoplastic instabilities, five for infectious instabilities and two each for degenerative and congenital instabilities. Sixty-six of 70 C1 screws had an ideal position, while four were placed suboptimal without the need for revision. Twelve of 68 C2 screws were not ideal but acceptable; one screw needed a surgical revision. There was one non-surgery related case of neurological deterioration after multilevel instrumentation. No vascular injuries occurred. Realignment was correct in all patients. After a median follow-up of 12 months, patients showed a reduction of pain, disability and improvements in EQ-5D items. SF36 data compared with a normative population and a historical cohort showed lower levels of function in all domains. C1-C2 instrumented fusion with lateral mass and isthmic screws is a safe procedure. Sufficient screw position and alignment was possible in all cases. Therefore, at our institution transarticular screws were abandoned in favor of C1 lateral mass and C2 isthmic screws.

Moral Complexity

An attending orthopaedic surgeon, an orthopaedic resident, and a spine Fellow are scheduled to perform a multilevel spinal decompression and instrumentation from L3 to S1. The case is delayed for several hours and begins in the late afternoon. The attending orthopaedist chooses not to wait for localization radiographs and proceeds with the decompression and four-level pedicle screw instrumentation with posterior-lateral fusion. The Fellow suggests several times during the procedure that radiographs should be obtained, but the attending surgeon is late for a meeting and declines to obtain radiographs. The attending surgeon leaves the resident and Fellow to close the wound after spinal instrumentation and fusion is complete. Radiographs are obtained prior to closure of the wound, and these indicate that the decompression has been performed at the appropriate levels but that the spinal instrumentation and fusion was from L2 to L5 rather than from L3 to S1. The Fellow notifies the attending surgeon, who has already left the hospital. The Fellow offers to remove the L2 screws, place S1 screws, and reconfigure the instrumentation prior to closing. The attending surgeon forbids the Fellow to do this and tells her, "Everything will be fine." He also states that he will discuss the surgery with the patient and family in the morning. As ordered, the Fellow and the resident close the wound.

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

Image-guided spinal instrumentation may reduce complications in spinal instrumentation. To assess accuracy, time efficiency, and staff radiation exposure during thoracolumbar screw instrumentation guided by intraoperative computed tomography (iCT)-based neuronavigation (iCT-N). 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. 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 mm (grade 1), and 1% of lumbar screws deviated by >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. 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 I: Cervicothoracic Spine

Image-guided spinal instrumentation reduces the incidence of implant misplacement. To assess the accuracy of intraoperative computed tomography (iCT)-based neuronavigation (iCT-N). In 35 patients (age range, 18-87 years), a total of 248 pedicle screws were placed in the cervical (C1-C7) and upper and midthoracic (T1-T8) spine. An automated iCT registration sequence was used for multisegmental instrumentation, with the reference frame fixed to either a Mayfield head clamp and/or the most distal spinous process within the instrumentation. Pediculation was performed with navigated drill guides or Jamshidi cannulas. The angular deviation between navigated tool trajectory and final implant positions (evaluated on postinstrumentation iCT or postoperative CT scans) was calculated to assess the accuracy of iCT-N. Final screw positions were also graded according to established classification systems. Mean follow-up was 16.7 months. Clinically significant screw misplacement or iCT-N failure mandating conversion to conventional technique did not occur. A total of 71.4% of patients self-rated their outcome as excellent or good at 12 months; 99.3% of cervical screws were compliant with Neo classification grades 0 and 1 (grade 2, 0.7%), and neurovascular injury did not occur. In addition, 97.8% of thoracic pedicle screws were assigned grades I to III of the Heary classification, with 2.2% grade IV placement. Accuracy of iCT-N progressively deteriorated with increasing distance from the spinal reference clamp but allowed safe instrumentation of up to 10 segments. Image-guided spinal instrumentation using iCT-N with automated referencing allows safe, highly accurate multilevel instrumentation of the cervical and upper and midthoracic spine. In addition, iCT-N significantly reduces the need for reregistration in multilevel surgery.

Stabilization of the osteoporotic spine from a biomechanical viewpoint

The altered trabecular structure of the osteoporotic spine leads to an increased vulnerability of its biomechanical characteristics and reduction of load resistance. Therefore, any surgical procedure must account for these circumstances. In cement-augmented vertebrae, both the overall stability and load transfer to the adjacent structures are influenced by a variety of factors. This has been demonstrated by different findings regarding volume, special characteristics, choice of approach and application, as well as distribution of the cement within the vertebral body. Independent of the well-known good clinical results, these features leave the discussion regarding the most appropriate form of cement-augmenting technique open. In cases where implants are required, there are increasing data to allow for an appropriate choice of stabilizing devices to fit the biomechanical demands in poor bone quality. Thereby, multilevel instrumentation, additive stabilization techniques, cement-augmented pedicle screws and adapted implant designs ensure and increase patient safety. However, regardless of the procedure chosen to stabilize the osteoporotic spine, reconstruction of the column profile appears to be of pre-eminent importance.

Prävalenz von Mangelernährung, Maßnahmen und Qualitätsindikatoren in deutschen Altenpflegeheimen - erste Ergebnisse einer landesweiten Pilotstudie

The aims of this study were to test the transfer and feasibility of a Dutch annual survey on malnutrition into German nursing homes and to gather first data about the prevalence of malnutrition, treatment and quality indicators in German resident homes. A cross-sectional multicentre study, using a standardised multilevel instrument (observation, questionnaire) developed in the University of Maastricht was applied. Variables are indicators for malnutrition and its risks, quality indicators, care dependency and treatment initiatives. The sample consisted of 32 nursing homes with 2,444 participating residents. 26% of the residents show indicators of malnutrition, a risk of malnutrition can be found in another 28%. Only one quarter of the nursing homes use a standardised nutritional screening instrument. Significantly more people with dementia have indicators of malnutrition. Most facilities provide a protocol or a guideline for the prevention and treatment of malnutrition. Also most are training their staff regularly in questions of malnutrition, half the institutions employ dieticians or nutritionists. Special treatment was initiated in half of all residents having indicators of malnutrition or showing a risk. The Dutch instrument is applicable in German nursing homes. Its utilisation shows that malnutrition is still a problem in German nursing homes. The standardised assessment of nutritional status is the exception; the interventions carried out should be improved.

Finanzierbarkeit der modernen Skoliosechirurgie unter den Bedingungen des DRG-Systems

In the German health system the payment of a hospital stay is standardised. The common basis is the G-DRG System (German diagnosis-related groups) in which every stay is paid by a lump sum. Scoliosis correction in our times means pedicle screw-based multilevel double rod instrumentation or anterior plate-rod instrumentation with primary stability. The outcome of those methods has improved the results of correction and decreased the complication rate but also means high costs due to the implants. Scoliosis correction is covered by DRG I06. Due to constant efforts a general improvement took place in the assessment of DRG I06. That is the reason why the losses incurred in DRG I06C could be lowered to 38% and in I06D to 22% in 2008. For an appropriate assessment further improvements are required.

A Novel Concept for the Best Coronal Alignment of Pedicle Screws in Multilevel Lumbar Posterior Instrumentation - A Technical Note -

Correct alignment of pedicle screws is imperative in multilevel instrumentation. However, there has been no report addressing the technical aspects of this subject. If the head diameter of a pedicle screw is D, the head height is H, and the convergence angle of the screw being inserted is α, then the distance between the extension line of the medial borders of the inserted screw heads and the insertion point of the adjacent screw (A) is described by the following formula: A = 1⁄2Dcos αHsin α If an L3 pedicle screw (D=13 mm, H=15 mm) is to be inserted with a convergence angle of 14 degrees after the insertion of L4 and L5 screws, its insertion point should be 3.6 mm medial to the extension line of the centers of the L4 and L5 screws and 2.7 mm lateral to the extension line of their medial borders for all screw heads, so it can be aligned in the coronal plane. In order to achieve the best alignment, a pedicle screw is inserted between the extended line of the centers and that of the medial borders of the inserted adjacent screw heads. For the routine range of convergence angles, it is essential to move the entry point medially toward the extended line connecting the medial borders of the inserted adjacent screw heads.

Overall-effective measures for sustainable water resources management in the coastal areas of Shandong Province, China

The Huangshui River basin, located in the Northeast of Shandong Province, PR China, is an outstanding example for water conflicts arising from piecemeal action as well as rapid growth of population, industry and agriculture that can only be solved by an integrated water resources management approach. Over-exploitation causes eminent problems for water resources management and agriculture resulting from saltwater intrusion into the groundwater system. The development not only of industry but also of agriculture as the population’s main source of income is seriously impeded by water shortage, and water pollution causes negative consequences for ecology and the people’s quality of life. In order to contribute to a sustainable water management in this region, a joint Chinese-German research project within the IWRM funding priority of BMBF was initiated. The paper introduces the methodological concept developed and major project results for the study area. These include socio-economic analysis, a multi-level decision support system, monitoring concepts and instruments, and concepts for water saving and reuse including pilot projects.

Augmentation of a Loosened Sacral Pedicle Screw With Percutaneous Polymethylmethacrylate Injection

Case report describing augmentation of a loosened sacral screw with percutaneous injection of polymethylmethacrylate. To highlight the advantages of percutaneous injection of polymethylmethacrylate in treatment of loosened pedicle screws. Turkey. Lumbosacral instrumentation with pedicle screws is a commonly used procedure for correcting deformity and stabilizing the spine until bony fusion occurs. Loosening of the screws is a complication of this procedure and is seen more frequently in multilevel instrumentation, particularly in those instrumentations using sacral screws. We present the case of a woman who had had L3-L4-L5-S1 instrumentation with pedicle screws who developed severe low back pain radiating to the left hip 2 months after the operation. Radiologic and clinical examination revealed that the left pedicle screw of the sacrum had loosened, and revision surgery was planned. The left sacral screw was augmented with percutaneous injection of polymethylmethacrylate. The patient was free of pain after the operation. We suggest that percutaneous polymethylmethacrylate injection around a loosened screw may be an alternative to major open revision surgery in cases of sacral screw failure in multisegmental instrumentation.

Soundoff: Coaching versus Competence

Recently educators have been beset by complaints from parents and businesses—and the news media has run related stories—that educational standards are falling. In partial response to these complaints and stories, some states now demand, as a condition for a high school diploma, a passing score on a standardized elementary mathematical competency test. The introduction of these tests could represent a positive step in the present reform movement in mathematics education—but only if the tests are integrated into the overall framework of that movement. A recent incident in my local school system suggests that a competency test can actually undercut the reform movement if the test is allowed to impose its own reference frame. The discussion that follows derives from that specific incident, but I believe it applies, in principle, to the handling of any standardized test imposed solely to establish a minimum competency requirement. Broader spectrum, multilevel instruments, such as the New York State Regents Examination, raise more complex issues that cannot be addressed here.