Prof. Dr Markus Kröber is an expert in the field of spinal surgery and a specialist who helps people rediscover the joy of movement. As a specialist in the spine, he understands the challenges patients face following an accident or due to wear and tear. He has earned his national reputation not only through his outstanding achievements in the treatment of spinal conditions, but also through his expertise in the treatment of tumors of the nervous system.
As Head of the Department of Orthopedics, Trauma and Spinal Surgery at Helios Klinik Rottweil, Prof. Dr Kröber leads a team of specialists, and his expertise as one of Germany’s leading specialists in the field of the spine is internationally recognized. The Helios Clinic Rottweil is a spine center certified by the German Spine Society, and Prof. Dr Markus Kröber has been awarded the Master’s Certificate by the German Spine Society (DWG), which underscores his outstanding achievements and extensive scientific expertise in spinal surgery. This certification offers patients the assurance that they will be treated to the highest standards, and all levels of severity in spinal surgery can be treated at Helios Clinic Rottweil.
The appointment of Prof. Dr Kröber as Chief Physician at Helios Klinik Rottweil in January 2018 was a boon for the entire region. The spine specialist embodies a modern approach to medicine, in which healthcare is delivered to the highest standard through specialization and interdisciplinary collaboration. His focus on spinal surgery enables him to think beyond traditional treatment methods and offer holistic care that encompasses orthopedics, conservative pain management and surgery.
The editorial team of the Leading Medicine Guide spoke with the spinal expert Prof. Dr Kröber and, in particular, learnt more about degenerative age-related deformities.
Degenerative age-related deformities of the spine are common as people get older. These changes can affect various structures of the spine, including the intervertebral discs, vertebral bodies, facet joints and the surrounding soft tissue. Typical degenerative changes include disc degeneration, vertebral osteoporosis, spondylolisthesis, facet joint osteoarthritis and vertebral fractures.
“To provide a clear definition, we refer to spinal deformities in old age as those occurring after growth has been fully completed. These deformities become clinically significant from the fourth decade of life onwards. As for the causes, there are three types: The first type is primary age-related deformity, which arises from degeneration, particularly of the intervertebral discs, leading to an uneven distribution of load across the individual spinal segments, which is detectable radiologically as a deformity. The second type is secondary age-related deformity, which arises primarily from structural bone changes, for example due to osteoporosis or other diffuse bone diseases. However, they can also result from a previous neurosurgical spinal decompression operation, which can lead to asymmetries and instabilities and ultimately to a deformity. And the third type is progressive idiopathic deformity, which has its origins in youth. The exact cause is not yet known; a genetic component is suspected, but this has not yet been conclusively researched scientifically. The deformity, which therefore began in adolescence, stabilizes, progresses further in old age and then leads to an age-related deformity. Overall, an increasing incidence can be observed, though this is also simply due to the rise in life expectancy in the Western world. Cases of osteoporosis are also rising in industrialised nations, which is linked to an unhealthy diet, too little exercise, excessive alcohol consumption and the use of medication such as steroids, and which contributes to secondary age-related deformity. “This occurs, for example, due to the improper healing of osteopathic fractures in the spine, which then becomes curved,” explains Professor Dr Kröber regarding the various types of deformity.
Disc degeneration is a common condition in which the intervertebral discs lose their natural height and elasticity due to wear and tear and the breakdown of cartilage tissue. This can lead to pain, stiffness and restricted mobility. Vertebral osteoporosis is an age-related bone condition that leads to a reduction in bone density and increases the risk of vertebral fractures. Spondylolisthesis occurs when a vertebra slips forwards or backwards relative to the one below it, caused by instability of the spine. Facet joint osteoarthritis is a form of joint wear and tear that can lead to inflammation, pain and restricted mobility. Vertebral fractures are breaks in the vertebral bodies that can occur due to osteoporosis or traumatic injuries, causing severe pain and reduced spinal stability.
Age-related spinal deformities manifest themselves through a variety of specific symptoms that differ from other back problems.
Prof. Dr Kröber explains the noticeable symptoms of age-related spinal deformity, which can vary in severity: “The development of age-related deformities is, of course, a long and gradual process that unfolds over many years. The most obvious symptom is pain, which is often described as dull or stabbing and can extend along the spine or into the surrounding muscles and tissues and the lumbar region. 100% of patients with age-related spinal deformities experience pain. This pain can intensify throughout the day and be exacerbated by certain activities such as prolonged sitting or standing, heavy lifting or bending the spine. It is a clear strain-related pain that subsides when at rest. As the deformity progresses further, nerve pain may also occur, which is not localized to the spine but radiates, usually into the legs. The pain is then caused by nerves being pinched within the spinal canal. This can lead to a tingling sensation in the legs, and nerve-related deficits may occur, manifesting as the legs occasionally giving way, which ultimately constitutes paralysis and occurs in cases of advanced deformity. In this case, the nerves no longer provide the necessary signals to the muscles. A third symptom is misalignment resulting from a pronounced deformity. This manifests as a hump, or the patient may lean to one side, a condition known as scoliosis. This progression ultimately leads to those affected needing a walking aid, as they can no longer maintain an upright posture otherwise. It can take years for such a pronounced deformity to develop. If an acute vertebral body fracture occurs, this leads immediately to a deformity.”
Non-surgical treatment options for older patients with degenerative age-related deformities are often the first choice, particularly when symptoms are mild to moderate or when surgical procedures pose a higher risk.
“Firstly, it is very important to analyze exactly what is causing the deformity. This requires a specialist assessment, and various diagnostic tools such as imaging techniques are used to determine the specific type of degenerative condition involved. As for conservative treatment options, we have a whole range available. We can start with strengthening physiotherapy to stabilize the core muscles. We can offer medication for pain management, which is initially administered orally but can also be given systemically, and there is infiltration therapy, where injections of local anesthetics are administered into the spine. In addition, there is corset treatment to halt the known deformity. “If the patient sees a doctor early on with their symptoms, treatment can usually be 100% conservative. If the deformity is advanced, these measures are no longer sufficient. Then surgery remains the only option,” says Prof. Dr Kröber on the conservative treatment options.
Some patients find relief from back pain through alternative therapies such as acupuncture, chiropractic, osteopathy or massage. These can help to relieve muscle tension, improve blood circulation and enhance general well-being. Lifestyle changes such as weight management, regular exercise, correct posture and ergonomic adjustments at work or at home can help to reduce the strain on the spine and improve symptoms. However, all of this only works if the deformity is not too advanced.
Planning for surgery to treat degenerative age-related deformities involves close collaboration between the patient and the treating surgeon.
The planned operation is discussed individually with the patient, and they are informed about all the steps involved. As with any surgical procedure, there are risks and complications associated with spinal surgery. The surgeon will also discuss these risks in detail with the patient and explore possible measures to mitigate them. “Patients who come to see me have usually already had several medical appointments, and conservative treatments have been exhausted without any improvement in their condition. The option of surgery is therefore viewed quite positively. In conversation with the patient, I can then largely allay the fears that most people have regarding spinal surgery. These fears are understandable – after all, important nerve pathways run along the spine. However, surgical procedures and options have changed dramatically over the last 10–15 years. This is particularly evident in the fact that we now have much better implants available, which can, for example, be inserted into osteoporotic bone and provide excellent stability. Anesthesia has also advanced, making it possible to perform lengthy operations on older patients, even those with pre-existing conditions. Chronological age is no longer a factor in this respect, meaning that in some cases we can safely operate on patients in their 80s or 90s without significant risks,” explains Prof. Dr Kröber, outlining the current state of surgical safety.
“Patients who have exhausted conservative treatment options and have been referred come to the clinic twice before the operation – once for diagnosis and once for an individual pre-operative assessment. And one to two days before the procedure, the patient comes in again for a pre-operative briefing, in which the anesthesiology team is also involved. The operation itself then consists of four key steps, and these give rise to the individual challenges. In the first step, the deformity must be corrected, i.e. a curved spine must be straightened. If the deformity has already become rigid, which is often the case, then the vertebrae must be loosened. The second step involves decompressing the nerves, i.e. relieving nerve compression. The third step involves attaching the implants to the bone so that the correction can be stabilized, and the fourth step involves bone grafting. For this, bone is harvested from another site and grafted onto the spine to achieve good bone integration and ensure the corrective result is maintained in the long term. For some steps, we can use navigation systems, particularly to place screws with exceptional precision. We also use intraoperative neuromonitoring so that we can take immediate countermeasures if it becomes apparent that nerves are at risk,” says Prof. Dr Kröber, describing the surgical procedure and providing some further information on the potential risks associated with all four stages of the operation:
“During the correction of the deformity and the decompression of the nerves, the spinal cord could theoretically be injured. When inserting the implants, the greatest challenge lies in their fixation, particularly when the bones are osteoporotic. And during bone grafting in the fourth step, it is crucial that the bone heals properly – the biological process must work here! In around 70% of cases, the surgical outcome is optimal, meaning the implants hold well and the patient’s spine is stable again. In 30% of cases, however, a second or even third operation is required, due to the specific risks mentioned earlier, but also to general surgical risks such as impaired wound healing, post-operative bleeding or infections. These risks are higher in older patients and are also linked to the duration of the operation, which usually lasts 5–8 hours. Post-operatively, the patient always spends 2–3 days in the intensive care unit for monitoring and remains in hospital for around 10 days. The patient is encouraged to move around as early as the second day after the operation. After discharge from hospital, the patient must take it easy at home for around 6 weeks and then undergo a three-week rehabilitation program.
Physical activity plays a crucial role in maintaining spinal health in old age.
Regular exercise can help improve the flexibility, strength and endurance of the muscles surrounding the spine. This increases spinal stability and reduces the risk of degenerative changes. Targeted exercises to strengthen the core muscles, such as planks, back extensions or side planks, can help to stabilize the spine and reduce pressure on the intervertebral discs. Regular stretching can also relieve tension and improve the flexibility of the spine. It is particularly important for young people to adopt an active lifestyle early on and to incorporate regular exercise into their daily routine.
“As a general rule, it is important to avoid overexertion to protect the spine. Attention should also be paid to body weight and a diet that is beneficial for bones. Calcium is a key nutrient here, which can also be taken as a dietary supplement. Smoking always has a negative effect on bones and can contribute to osteoporosis, and alcohol should only be consumed in moderation. Regular core muscle training is also beneficial to protect against degenerative changes,” advises Prof. Dr Kröber regarding prevention.
Recommended activities include sports such as swimming, yoga or Pilates, which strengthen the spine and keep it flexible. Endurance training such as running, cycling or dancing also contributes to general fitness and reduces the risk of becoming overweight, which in turn reduces the strain on the spine. By taking a proactive approach to their own spinal health and engaging in regular physical activity, young people can help maintain a healthy and strong spine in the long term, protecting them from degenerative changes and back problems in old age.
Significant progress has been made in modern medicine to offer older patients with age-related degenerative deformities an improved quality of life.
“The most groundbreaking changes lie in the surgical options available to us today, and the fact that we can now operate on elderly people with their deformities. In the past, to put it somewhat disrespectfully, people used to talk about the ‘old woman’s hump’, which is simply no longer the case today because you no longer see this, as older people can maintain a more stable quality of life thanks to medical advances. And this, of course, has a secondary impact on life expectancy, because people remain mobile for longer. Whereas in the past people used to be bedridden due to untreated deformities, the mortality rate also rose significantly. And we can prevent that today. “My hope for the future is that, through more public education, people will lose their fear of back surgery. The myth that back operations are bad still persists,” says Prof. Dr Kröber, bringing our interesting conversation to a close.
