Der Orthopäde
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Total disc replacement and posterior dynamic stabilization represent alternatives to lumbar spinal fusion which should reduce the risk of adjacent segment degeneration. Disc replacement is indicated for pure discopathy without facet joint degeneration. Spinopelvic balance influences the implant's biomechanics. ⋯ Dynamic stabilization is indicated in moderate discopathy and facet joint degeneration, in degenerative spondylolisthesis grade I with a hypermobile segment and in dynamic lumbar stenosis. The combination of caudal fusion and cranial dynamic stabilization allows a better maintenance of lordosis with multiple level instrumentation and prevents adjacent segment degeneration. If pelvic incidence and sacral slope are high, L5-S1 should be fused because of elevated shear forces.
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Review Case Reports
[Sagittal deformity. Basic principles of surgical strategies].
There is a large body of literature supporting the importance of restoring sagittal balance to the spine. The main message is this: regardless of the specific surgical strategy and treatment or pathology, rebalancing results in a positive patient outcome. Complex deformity patients need to be evaluated with attention to the global balance and the operative planning and strategy must be adapted accordingly. ⋯ The reason for the outcome may be sagittal imbalance and osteotomy techniques as well as fusion extension may be needed. The postoperative outcome can only be improved when the sagittal balance is already considered in the planning and treatment strategy during initial correction surgery. Concerning sagittal balance a paradigm shift seems to occur.
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We report on the results of 246 Bryan cervical discs, which were implanted between June 2002 and September 2010 in 146 patients. Of the patients 74 (128 prostheses) could be followed up for more than 1 year and the average follow-up period was 2.6 years. Of the patients 18 were operated on at one level (group 1), 77 prostheses were multilevel surgery (group 2) and with 33 patients arthroplasty was combined with fusion (hybrid, group 3). ⋯ The overall mobility improved in all 3 subgroups and 2 cases (group 3) fused. With 5 patients the prosthesis had to be removed and the segment had to be fused in the postoperative course. As a conclusion a meticulous preoperative planning as well as a subtle surgical technique is the main prerequisite for long-lasting mobility of the Bryan prosthesis.
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Posttraumatic kyphosis (PTK) is a possible consequence of a missed fracture, a wrong indication for conservative therapy or an inadequate surgical technique but PTK can also be a complication after adequate surgery. Avoidance of PTK is of importance because subsequent surgical therapy can be extensive. ⋯ Knowledge of the principles of sagittal balance and spinopelvic parameters are indispensable in the treatment of PTK. Our experience and results from the literature show that a good long-term outcome with limited complications can only be achieved when considering the biomechanical principles as well as restoration of sagittal balance.