Session 7: Spine
Torsdag den 24. oktober
13:30 – 15:00
lokale: Stockholm/Copenhagen
Chairmen: Thomas Andersen / Martin Gehrchen
61. Dural tears influence on length of admission and outcome in spinal surgery
Randi Holm, Dorte Clemmensen, Mikkel Andersen
Sector for Spine Surgery and Research, Region of Southern Denmark, Vejle Sygehus; Sector for Spine Surgery and Research, Region of southern Denmark, Vejle Sygehus
Background: Decompression of lumbar spinal canal is
one of the most frequent operations on
the spine. The most common complication
seems to be a peroperative dural lesion.
Purpose / Aim of Study: The aim of this study is to determine
the frequency of iatrogenic dural tear,
influence on the length of hospital
admission and outcome one year
postoperative.
Materials and Methods: The Danish Spine Register “DaneSpine”
documents the majority (99.6 %) of
lumbar spine operations at the Sector
for Spine Surgery and Research, Region
of Southern Denmark. Within the
framework of this register, consecutive
operations involving decompression of
the lumbar spinal canal were studied
regarding the incidence of Iatrogenic
dural lesion, length of hospital
admission and one year postoperative
outcome.
Findings / Results: A total of 1419 patients had lumbar
neural decompressive surgery - 738
patients were treated for spinal
stenosis and 681 for herniated disc. The
overall incidence of dural tear was 7.7
% (109 dural tear). Patients with spinal
stenosis accounted for 81 of the lesions
(incidence 11%) and the remaining 28
lesions (incidence 3 %) occurred while
operating patients with herniated disc.
The risk of dural tear after secondary
surgery was 11.9% versus 6.2% for primary.
The length of hospital admission
increased from 2.9 to 4.5 days (p =
0.00) among patients with a dural tear.
In the patient-based outcome parameters
there were no significant differences in
outcome between patients with and
without a dural lesion.
Conclusions: The incidence of iatrogenic dural tears
was 7.7 %. The incidence of dural tear
was almost doubled in secondary surgery.
Patients with dural tear were
hospitalized 1.6 days longer. However,
this did not affect the one year outcome
negatively.
62. Intervertebral disc degeneration followed by interference of endplate nutritional pathway in adolescent porcine models
Ran Kang, Haisheng Li, Steffen Ringgaard, Kresten Rickers, Lin Xie, Cody Eric B¨¹nger
Orthopedic Research Lab, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital; MRI center, Skejby Hospital; Orthopedic Research Lab., University Hospital of Aarhus; Department of Orthopedic surgery, Jiangsu Province Hospital on Integration of Chinese and Western Medicine
Background: Insufficient nutritional supply has
been proposed as the final common
pathway of intervertebral disc
degeneration (IDD). Inconsistently,
Polymethylmethacrylate (PMMA)
bone cement blocking the pathway
did not result in IDD in mature
animal models. As nowadays there
is a tendency to apply vertebroplasty
treatments in younger patients, thus
we investigated this PMMA blocking
affect in adolescent animal models.
Purpose / Aim of Study: To examine the intervertebral disc
changes after interference of endplate
nutritional pathway.
Materials and Methods: In each of 8 adolescent pigs, two
lumbar intervertebral discs were either
blocked by cement in both endplate
pathway, or stabbed by scalpel in
annulus fibrosus, with intact disc as
normal control. Magnetic resonance
imaging (MRI) including T1, T2-
weighted, T2-weighted 3D, sagittal T2
mapping, was performed pre and 3
months post intervention. Postcontrast
series T1-weighted MRI also performed
at the end.
Findings / Results: The cement blocking area was
38.92¡À10.05 % (from 27.09% to
50.56%) of vertebral bodies on both
sides of disc. After 3 months, these
cement blocked discs showed
severe IDD, with the percentage of
disc height index (%DHI) and
Nucleus Pulposus area (%NP-area)
significantly lower than the normal
controls. And the NP T2 value was
188.43¡À75.66 ms also significantly
lower than the normal control
356.71¡À38.99 ms (P=0.0089).
Similar results were found in
positive controls of annulus injury
discs. Further post-contrast MRI
showed damaged nutrient transport
pathway in the cement blocked
discs.
Conclusions: Severely interfering endplate nutritional
pathway in adolescent porcine models
caused IDD. More concern about
adjacent IDD needs to be taken when
PMMA bone cement is used in
vertebroplasty or balloon kyphoplasty
treatments, especially in younger
patients.
63. Short-Term Mortality and Morbidity after Surgical Treatment of Fixed Spinal Deformities. Two-Years Experience in 102 Adult Patients
Tanvir Bari, Martin Gehrchen, Sven Karstensen, Sidsel Fruergaard, Benny Dahl
Rygsektionen, Rigshospitalet
Background: Increasing evidence suggests that improved sagittal balance is of major importance to
obtain improved health related quality of life in the surgical treatment of adult spinal
deformities. The two primary surgical techniques used are pedicle subtraction
osteotomy (PSO) and vertebral columna resection (VCR).
Purpose / Aim of Study: To assess short-term complications after surgical treatment of fixed spinal deformities.
Materials and Methods: In a prospective cohort study, all complications in adult patients
undergoing posterior correction of fixed spinal deformities in the
thoracolumbar region from February 1st 2010 through January 31st 2012
were included. Patients were excluded if they had undergone previous
posterior instrumentation on more than five levels for a degenerative
condition. Also, patients with previous malignant, infectious or traumatic
conditions of the spine were excluded . Survival status and the neurologic
condition was assessed at the one-year follow-up.
Findings / Results: A total of 102 patients were operated with a mean age of 61 at the time of surgery
(range 19 - 86). 52 were men and 50 women. A median number of 10 levels were
instrumented with pedicle screws (range 5 - 17). 81 % of the patients underwent
PSO and 19% VCR. The 30-day mortality was 1.2% and the primary complication
was dura lesion (16%). Two patients (2 %) had permanent neurological deficit
corresponding to 1 ASIA motor grade deterioration and four patients (4 %) patients
had persisting sensory deficits.
Conclusions: This prospective one-center study confirms recent national database reports
suggesting that surgical treatment of fixed spinal deformities carries a relatively low
risk of short-term mortality and severe neurological complications.
64. TLIF surgery results in slightly higher risk of neurogenic leg pain 2 years after surgery compared to standard instrumented posterolateral fusion. Results from a randomized clinical trial.
Kristian Høy, Blazej Grycel, Thomas Andersen, Peter Helmig, Ebbe Stender Hansen, Cody Bünger
Orthopedic, Spine Section, Århus University Hospital; Orthopedich, Spine Section, Århus University Hospital
Background: TLIF has gained increasing popularity
obtaining circumferential fusion using a
posterior procedure only
Purpose / Aim of Study: Due to cage insertion close to the
exiting nerve root concerns has been
raised whether the procedure carries
an increased risk of subsequent
neurogenic pain due to damage of the
dorsal nerve root ganglion.
Materials and Methods: Pain drawings from 100 pat. (40 male,
58 female) included in a RCT
comparing TLIF to posterolateral
instrumented fusion (PLF) was
analyzed. 51 had TLIF, 47 PLF. Mean
age 49(TLIF)/45(PLF). Pain drawings
were completed preoperatively,1y, 2y
follow-up. The pain drawing consisted
of a front and back outline of a person
as well as the area under the feet. Six
different symbols could be used for
marking pain: dull/aching, burning,
numbness, pins and needles,
stabbing/cutting and muscular cramps.
Pain drawing analysis were done
assessing presence and type of pain
marks in both legs.
Findings / Results: A slightly higher number of pats. in the
TLIF group reported any leg pain at
2y: No leg pain 47% (PLF) 37% (TLIF),
Unilateral leg pain 31% (PLF) 25%
(TLIF), Bilateral leg pain 22% (PLF)
37% (TLIF), p=0.270. Likewise looking
at pain radiating below the knee: No
leg pain 55% (PLF) 45% (TLIF),
Unilateral leg pain 29% (PLF) 25%
(TLIF), Bilateral leg pain 16% (PLF)
29% (TLIF), p=0.294. Numbness and
pins & needles on the anterior aspect
of the lower leg were marked by 10%
and 12% of TLIF patients compared to
6% and 4% in PLF pats.
(p=0.498/0.197). Looking at the
posterior aspect of the lower leg
numbness and pins & needles were
marked by 10% and 10% of TLIF pat.
compared to 16% and 8% in PLF
(p=0.332/0.774).
Conclusions: TLIF pats. were more likely to have
bilateral leg pain 2y after surgery and a
used pain symbols more commonly
associated with neurogenic pain to a
slightly higher extent than patients with
PLF
65. A Comparison of the Tokuhashi Revised and the Tomita Scoring Systems in a prospective Cohort of Patients with Metastatic Epidural Spinal Cord Compression (MESCC)
Søren Schmidt Morgen
Spine Section, Department of Orthopedic Surgery, Copenhagen University Hospital, Rigshospitalet
Background: Expected survival time in patients with acute
symptoms of MESCC is a crucial element in
the pre-operative evaluation. Consequently,
expected survival is a variable in
preoperative scoring systems such as the
Tokuhashi Revised score (TRS) and the
Tomita score (TS). Because of the improved
survival among cancer patients it is relevant
to reassess the validity of these two
systems in a prospective, consecutive, and
large cohort of patients with MESCC.
Purpose / Aim of Study: To validate and compare the TRS and the
TS in patients with MESCC.
Materials and Methods: During 2011 we included 544 patients with
acute symptoms of MESCC. All patients
were scored with the TRS and with the TS
and were divided into the corresponding
prognostic groups. One-year survival status
was obtained in all patients and compared to
the estimated survival of each group as
predicted by the scoring systems. Survival
curves were estimated with the Kaplan
Meyer methods and were evaluated with the
Log Rank test.
Findings / Results: The mean age was 65 years (range 20- 95)
and 57% of the patients were men. The
most common primary tumors were lungs
(23%), prostate (21%), and breast (18%).
The positive predictive values regarding
one-year survival were 47% for the TRS
and 14% for the TS. The actual survival for
each of the TRS prognostic groups was
significantly different (P < 0.0001). The same
applied to the TS groups but with some
overlap of CI’s. In both the TRS and the TS
groups the survival was shorter than
estimated (P < 0.0001).
Conclusions: The TRS and TS accurately separated the
patients into groups according to survival
but the estimated survival was, contrary to
what we expected, longer than in our cohort
and a modification of the scoring systems
may be necessary to improve prediction
regarding survival. The TRS was more
accurate than the TS in predicting one-year
survival.
66. Implementing DaneSpine
Karen Højmark, Ane Simony, Carsten Ernst, Mikkel Andersen
Sector for Spine Surgery and Research, Region of Southern Denmark, Vejle Sygehus; Sector for Spine Surgery and Research, Region of southern Denmark, Vejle Sygehus
Background: During several years, the Danish helath
system lacks proper documentation of
spinal surgery outcome.
The first attempt to establish a
national database – DiscusBasen -
supported by the Danish National Board
of Health was closed down in 2005 due to
a coverage rate of less than 20% . In
2009 The Danish Society of Spinal
Surgery (DRKS) acquired DaneSpine (DS),
with the ambition to establish a
national Danish spine database. Sector
for Spine Surgery and Research (SSSR),
Region of Southern Denmark implemented
DS in June 2010.
Purpose / Aim of Study: The aim of this study was to investigate
the registration rate and follow-up of
surgical procedures in DaneSpine, and
estimate the cost of running DS at a
centre of our size.
Materials and Methods: Surgical procedure codes registered in
the patient administration system was
compared to the number of operations
recorded in DaneSpine in 2010. Time and
costs required for collection and data
entry were estimated.
Findings / Results: 486 spinal interventions at SSSR were
performed in the second half of 2010.
In DS 484 interventions (99.8%) were
recorded. At follow-up after one and
two years data were available from 406
and 372 patients, corresponding to 84/77
%. The annual cost of administering DS
is approximately DDK. 380 000 with an
expected output of 1,200 interventions -
equivalent of DDK. 300 per patient.
Conclusions: With our setup DaneSpine is a reliable
tool, to collect data and monitor our
activity and surgical outcome.
67. Vertebroplasty for treating painful vertebral body fractures, in patients with multipel myeloma
Ane Simony, Mikkel Østerheden Andersen, Niels Abildgaard, Marius Gaurilcikas
Rygkirurgisk Afdeling, Middelfart Sygehus; Hæmatologisk Afdeling, Odense Universitets Hospital
Background: Multiple myeloma is a disease that
causes osteolytic destruction of the
bones and has a incidents of
6/100000, with causes 300 new
patients a year. 40 % of the patients
have painful vertebral body fractures,
at the time they are diagnosed with the
disease.
Vertebroplasty (VBP) is an invasive
procedure with cement augmentation
of vertebral fractures. It was introduced
in France, by radiologist, in the 90’s as
a treatment for haemangiomas in the
vertebral bodies. It is now used for
treating osteoporotic fractures and
fractures caused by cancer.
Purpose / Aim of Study: The aim of this study was to assess
the safety and efficacy of VBP for
vertebral body fractures in myeloma
patients
Materials and Methods: This is a retrospective review of 18
patients with multiple myeloma, treated
with PVP at the Spine Center at
Odense University Hospital, from 2004-
2010.
The median age of the patients was
62,5 years, 11 males and 7 females.
The PVP procedure was performed at
71 levels, from TH6-S2.
The procedure was performed in local
anesthetic, and the patients could
leave the hospital after 4 hours.
All patients had a preop X-ray and MRI
scan with STIR. The patients had a
postop X-ray after 3 months and Visual
Analog Scale was used, preop and
after 3 months, as assessment for
pain.
Findings / Results: The median VAS(back) was preop 7,6
and 3,2 post op after 3 months. (p
<0,05).
5 patients didn’t participate in the 12
weeks follow up, 1 had died, 4 was
admitted to hospital.
The patients had a significant
reduction of the back pain.
We had leakage in 8 of the 71 treated
levels (12,5%), none of them causing
any neurological symptoms. There
were no cases of infections, pulmonary
embolisms or other complications.
Conclusions: PVP is an effective and safe procedure
in the treatment of painful vertebral
Fractures, in patients with multiple
myeloma.
68. Long term outcome and health care utilizations following surgical treatment of adult spine deformity
Shallu Sharma, Thomas Andersen, Cody Eric Bunger, Rikke Soegaard
Deparment of Othropedics, Aarhus Univeristy Hospital , Noerrebrogade; Senior reasearcher at Region Midt, Aarhus Univeristy Hospital , Skejby
Background: The long term effects of scoliosis
surgery in adults on health and heath
care use is undetermined
Purpose / Aim of Study: To assess the long term impact of
deformity surgery on the pain,
employment, self reported benefits and
health-care use and investigate if any
process/patient variables influence the
health improvement and degree of
healthcare use
Materials and Methods: 123 patients having undergone deformity
correction surgery between 1992- 2009
(mean age 42.45 years) were included.
They filled Scoliosis life
quality,-Dallas Pain and EQ-5D
questionnaires at follow up. Data on
primary and hospital based health care
sectors use were obtained from The
National Health Insurance Service
Registry and The National Patient
Registry. Follow-up ranged between
1.4-18.6 years
Findings / Results: A significant reduction in use of pain
medication was seen (p=0.00). Long term
employment status was maintained in
level to pre-surgery without
deterioration. Activity related
endurance improved in 38% patients.
Perceived emotional-cosmetic improvement
ranged between 40-77%. EQ-5D score was
significantly poorer (0.6 vs. 0.8) in
operated patients compared to matched
controls.Surgery had highest impact on
health care use for the first 2 years
after surgery. Spine related hospital
use decreased in the followup.
Primary-sector use increased in the
follow-up due to increasing visits to
the general practitioners (GP) and
physical therapists (PT). Education
level was significantly associated with
the variability in EQ-5D and hospital
utilization. Unemployed work status was
associated with higher visitations to
the GP and PT.
Conclusions: Deformity correction surgery in adults
does not lead to an alarming rise in the
long-term hospital use but primary care
use increases. Patients experience
maintenance of working status and
improved activity with low complication
rate.
69. Moderate to Almost Perfect Inter- and Intrarater Agreement in Assessment of Adult Spinal Deformity using the SRS-Schwab Classification
Dennis Hallager Nielsen
Spine Unit, Dept. of Orthopaedic Surgery, Rigshospitalet
Background: The lack of consensus regarding
classification of adult spinal deformities
constitutes a challenge in choosing the
optimal treatment for each patient.
Recently the Scoliosis Research Society-
Schwab Adult Spinal Deformity
Classification (SRS-Schwab) has been
proposed. This system includes four
coronal curve types and three sagittal
modifiers that are correlated to health
related quality of life: Pelvic incidence
minus Lumbar lordosis (PI-LL), Pelvic tilt
(PT) and Global alignment based on
Sagittal vertical axis (SVA). Each
modifier has three grades: 0, + and ++.
Purpose / Aim of Study: To analyze inter- and intrarater agreement in
a large consecutive series of patients using
unmarked radiographs classified by spine
surgeons with different levels of
experience.
Materials and Methods: SRS-Schwab classification of 67
consecutive adult patients referred for
surgical evaluation of a spinal deformity was
done blinded by two senior spine surgeons,
one attending, and one spine fellow. After
two weeks the classifications were
repeated on re-coded radiographs. Crude
agreement (%) and Fleiss’ Kappa
coefficients (k) were calculated.
Findings / Results: Interrater agreement averaged 67% (k =
0.70) for curve type, 72% (k = 0.70) for
PI-LL, 81% (k = 0.80) for PT, 90% (k =
0.90) for Global alignment and 39% (k =
0.55) for Entire grade.
Intrarater agreement averaged 86% (k =
0.79) for curve type, 89% (k = 0.78) for
PI-LL, 94% (k = 0.88) for PT, 96% (k =
0.93) for Global alignment and 70% (k =
0.67) for Entire grade.
According to Landis and Koch the
observed agreements were considered
substantial to almost perfect for curve
type and sagittal modifiers (PI-LL, PT,
SVA) and moderate for Entire Grade.
Conclusions: Our results correspond to previous findings
and support the use of the SRS-Schwab
classification system in assessment of adult
spinal deformities.
70. 3D correction by novel growth instrumentation in severe deformities of the immature spinal
Cody Eric Bünger, Barbara Jensen, Haisheng Li, Ebbe Stender Hansen , Haolin Sun, Kristian Hoy
Spine Section Dept of Orthopedics E, Aarhus University Hospital, Aarhus University Hospital; Orthopedic Research Lab, Aarhus University Hospital; Orthopaedic Dept E, , Aarhus University Hospital; Orthopaedic Dept E, Aarhus University Hospital ; Dept of Orthopedics E, Aarhus University Hospital
Background: In surgical management of severe
spinal deformity in the Infant ideally
spinal growth and 3D correction should
be preserved. The current techniques
do not fulfill these goals. We
developed a new double rod growth
system based on 3 platforms and
multiple growth tubes applied by MIS
as a stand alone or with osteotomy.
Purpose / Aim of Study: Aims of study were 1)to analyze 3D
correction. and truncal height at index
surgery 2) To measure spinal growth
per year in relation to different
underlying pathologies.. 3) To monitor
adverse events.
Materials and Methods: In total 32 children aged mean 8 years
(3 - 11), with mean 78 degrees (55 -
124) scoliosis , 50 degrees (10-105)
kyphosis and up to 30 degrees rotation
were operated using pedicle screws,
hooks and double growth tubes
mounted on a cranial, apical and
caudal platform. Scoliosis correction is
achieved by distraction,, rotation by
apical compression and distraction,
whereas the sagittal contour is
created outside the growth tube areas.
Underlying pathology were
neuromuscular (8), congenital (7),
syndromic 6,juvenile idiopathic 7 and
miscellaneous 4. Lengthening
procedures in GA were one day
admissions undertaken every 5 -6
months.
Findings / Results: Mean index OR time was 175 min
(100 - 240). the lengthenings 30 min
(10 - 120). The index surgery resulted
in a mean 60% frontal Cobb
correction, and a 70% correction of
kyphosis. In 3 cases osteotomies
were integrated. Truncal lengthening
was up to 22 cm over 3 years,
instrumented growth after index
surgery, mean 1.8cm/year.
Complications were loss of screw/rod
lock 3 pat, hygroma formation 3 pat.
necessitating 6 reoperations and.
asymptomátic metal debris.
Conclusions: Our hybrid double rod growth system
has radically improved management of
severe spinal deformities. Major
improvements of the implants to
minimize debris are needed..
71. Physical and mental outcome of 500 patients with spinal stenosis operated by decompression alone.
Rikke Rousing, Frederik Busch, Henrik Grønvall
Sector for Spine Surgery and Research, Region of Southern Denmark, Vejle Sygehus
Background: Spinal stenosis, an abnormal narrowing
of the spinal canal, is very common
among elderly people. Symptoms include
pain, numbness, parasthesia and loss of
motor control and are often worsened by
walking and standing. The condition may
be disabling for the patients and some
will need decompression surgery, to
relive the symptoms. In case of
instability fusion may be considered.
The outcome after decompression alone is
not well described in the literature.
Purpose / Aim of Study: The purpose of this study is to describe
quality of life and the physical and
mental outcome of the first 500 patients
with spinal stenosis operated at the
Sector for Spine Surgery and Research,
Region of Southern Denmark, by
decompression alone.
Materials and Methods: All patients are operated at the Sector
for Spine Surgery and Research, Region
of Southern Denmark. The data is
collected in DaneSpine, the Danish
national database for spine operated
patients. STATA is used for statistical
work. The operations are performed by
specialists in spine surgery.
Well-known and validated questionnaires
are used for assessment of mental and
physical health and for quality of life,
SF-36, ODI, and EuroQol. VAS used for
pain estimation and the walking distance
is assessed by questionnaire.
Findings / Results: The VAS score for back pain and leg pain
is reduced significantly one year after
surgery.
Furthermore the mental and physical
score of SF-36 and the ODI is improved,
the distance of walking is increased and
the quality of life, estimated by
EuroQol, is improved significantly one
year after surgery.
Conclusions: For patients with spinal stenosis and
disabling symptoms as pain, numbness,
parasthesia and loss of motor control,
decompression relieves the symptoms and
the patients improve in both mental and
physical health.