Study Design: Review article. Objectives: A review of literature on the treatment of pyogenic spondylodiscitis in geriatric patients was performed with the aim to give an overview about these special patients and a recommendation on necessary diagnostics as well as conservative and operative treatment options. Methods: A systematic computerized literature search was done by the spondylodiscitis working group of the German Society for Orthopedics and Trauma Surgery. Results: Spondylodiscitis has an increasing incidence by age with a peak at 75 years or older. The 1-year mortality without an appropriate treatment is with 15 to 20% extremely high. Pathogen detection is the essential diagnostic step and the basis for a sufficient antibiotic treatment. Geriatric patients have initially less elevated inflammatory parameters. Compared to younger patients. They have a longer length of hospital stay and take longer for CRP normalization. Even the outcome between conservative and operative treatment is comparable after one year. Patients with spinal instability, immobilizing pain, epidural abscess, and newly emerged neurological deficits should be considered for operative treatment. Conclusions: The treatment of geriatric patients with pyogenic spondylodiscitis must take into account that these patients usually have multiple comorbidities. The main goals are resistance-based antibiotics and the shortest possible time of immobilization of the patient.

Background: Pedicle screw insertion in osteoporotic patients is challenging. Achieving more screw-cortical bone purchase and invasiveness minimization, the cortical bone trajectory and the midline cortical techniques represent alternatives to traditional pedicle screws. This study compares the fatigue behavior and fixation strength of the cement-augmented traditional trajectory (TT), the cortical bone trajectory (CBT), and the midline cortical (MC). Methods: Ten human cadaveric spine specimens (L1 - L5) were examined. The average age was 86.3 ± 7.2 years. CT scans were provided for preoperative planning. CBT and MC were implanted by using the patient-specific 3D-printed placement guide (MySpine®, Medacta International), TT were implanted freehand. All ten cadaveric specimens were randomized to group A (CBT vs. MC) or group B (MC vs. TT). Each screw was loaded for 10,000 cycles. The failure criterion was doubling of the initial screw displacement resulting from the compressive force (60 N) at the first cycle, the stop criterion was a doubling of the initial screw displacement. After dynamic testing, screws were pulled out axially at 5 mm/min to determine their remaining fixation strength. Results: The mean pull-out forces did not differ significantly. Concerning the fatigue performance, only one out of ten MC of group A failed prematurely due to loosening after 1500 cycles (L3). Five CBT already loosened during the first 500 cycles. The mean displacement was always lower in the MC. In group B, all TT showed no signs of failure or loosening. Three MC failed already after 26 cycles, 1510 cycles or 2144 cycles. The TT showed always a lower mean displacement. In the subsequent pull-out tests, the remaining mean fixation strength of the MC (449.6 ± 298.9 N) was slightly higher compared to the mean pull-out force of the CBT (401.2 ± 261.4 N). However, MC (714.5 ± 488.0 N) were inferior to TT (990.2 ± 451.9 N). Conclusion: The current study demonstrated that cement-augmented TT have the best fatigue and pull-out characteristics in osteoporotic lumbar vertebrae, followed by the MC and CBT. MC represent a promising alternative in osteoporotic bone if cement augmentation should be avoided. Using the patient-specific placement guide contributes to the improvement of screws’ biomechanical properties.

Study Design: Systematic review. Objectives: Spinal orthoses are frequently used to non-operatively treat osteoporotic vertebral fractures (OVF), despite the available evidence is rare. Previously systematic reviews were carried out, presenting controversial recommendations. The present study aimed to systematic review the recent and current literature on available evidence for the use of orthoses in OVF. Methods: A systematic review was conducted using PubMed, Medline, EMBASE and CENTRAL databases. Identified articles including previous systematic reviews were screened and selected by three authors. The results of retrieved articles were presented in a narrative form, quality assessment was performed by two authors using scores according to the study type. Results: Thirteen studies (n = 5 randomized controlled trials, n = 3 non- randomized controlled trials and n = 5 prospective studies without control group) and eight systematic reviews were analyzed. Studies without comparison group reported improvements in pain, function and quality of life during the follow-up. Studies comparing different types of orthoses favor non-rigid orthoses. In comparison to patients not wearing an orthosis three studies were unable to detect beneficial effects and two studies reported about a significant improvement using an orthosis. In the obtained quality assessment, three studies yielded good to excellent results. Previous reviews detected the low evidence for spinal orthoses but recommended them. Conclusion: Based on the study quality and the affection of included studies in previous systematic reviews a general recommendation for the use of a spinal orthosis when treating OVF is not possible. Currently, no superiority for spinal orthoses in OVF treatment was found.

The stand-alone treatment of degenerative cervical spine pathologies is a proven method in clinical practice. However, its impact on subsidence, the resulting changes to the profile of the cervical spine and the possible influence of clinical results compared to treatment with additive plate osteosynthesis remain under discussion until present. This study was designed as a retrospective observational cohort study to test the hypothesis that radiographic subsidence of cervical cages is not associated with adverse clinical outcomes. 33 cervical segments were treated surgically by ACDF with stand-alone cage in 17 patients (11 female, 6 male), mean age 56 years (33–82 years), and re-examined after eight and twenty-six months (mean) by means of radiology and score assessment (Medical Outcomes Study Short Form (MOS-SF 36), Oswestry Neck Disability Index (ONDI), painDETECT questionnaire and the visual analogue scale (VAS)). Subsidence was observed in 50.5% of segments (18/33) and 70.6% of patients (12/17). 36.3% of cases of subsidence (12/33) were observed after eight months during mean time of follow-up 1. After 26 months during mean time of follow-up 2, full radiographic fusion was seen in 100%. MOS-SF 36, ONDI and VAS did not show any significant difference between cases with and without subsidence in the two-sample t-test. Only in one type of scoring (painDETECT questionnaire) did a statistically significant difference in t-Test emerge between the two groups (p = 0.03; α = 0.05). However, preoperative painDETECT score differ significantly between patients with subsidence (13.3 falling to 12.6) and patients without subsidence (7.8 dropped to 6.3). The radiological findings indicated 100% healing after stand-alone treatment with ACDF. Subsidence occurred in 50% of the segments treated. No impact on the clinical results was detected in the medium-term study period.

Purpose: The purpose of this study was to determine the extent to which magnetic resonance imaging (MRI) performed in patients with ankylosing spondylitis (AS) after low- and no-energy trauma leads to an improved diagnosis and, as a result, to a change in the therapeutic strategy. Methods: All patients with AS, who underwent surgery after minor traumas (low-energy traumas, LETs) and patients without trauma history (NET: no-energy trauma), were retrospectively analysed. The diagnostic and planned surgical procedure was examined initially and again after total spine MRI in patients with persistent and/or new complaints. Results: One hundred and thirty-six patients with AS after trauma were surgically treated. A total of 92 patients with LETs and 12 patients with NETs were included. After initial diagnostics (CT and X-ray) were performed in 15.4% of the patients with LET or NET (n = 16), we found occult fractures on MRI scans. In ten of these patients (6 LET, 4 NET) in which a previous decision was made to follow conservative therapy, no fracture indication was found on CT or X-ray. Two fracture heights were observed in six patients who experienced LET. However, on X-ray and CT, the fractures were only visible at one height. All fractures were treated surgically with stabilization and decompression if indicated. Conclusion: Considering the high percentage of our patient population with occult fractures, we recommend supplementing the basic diagnostic procedures with an MRI of the entire spinal column in patients with painful spinal column findings after minor trauma and for those with persistent pain without trauma. Graphic These slides can be retrieved under Electronic Supplementary Material.