Das akute vertebrale Schmerzsyndrom als Vorbote einer Diskushernie im Verlauf

Delayed presentation of a patient with radiculopathy after acute local vertebral pain syndrome is documented with reference to 102 cases of lumbar pain syndrome and 42 of cervical pain syndrome seen in practice. There is an elevated incidence of herniated lumbar disc among patients with initial impairment of the divergence and/or convergence at the facet joints. We suggest that before any manipulation therapy judged necessary is started patients with acute segmental dysfunction must be fully informed about the fact that radiculopathy or discal hernia can occur subsequently without any causal connection.     

Komplexes regionales Schmerzsyndrom

Complex regional pain syndrome (CRPS) may develop following fractures, limb trauma, or lesions of the peripheral or central nervous system. The clinical picture consists of a triad of symptoms including autonomic, sensory, and motor dysfunction. Diagnosis is based on clinical signs and symptoms according to the Budapest criteria. Therapy is based on an individual and multidisciplinary approach. Distinct methods of physical therapy and pharmacological strategies are the mainstay of therapy. Pharmacotherapy is based on individual symptoms and includes steroids, free radical scavengers, treatment of neuropathic pain, and agents interfering with bone metabolism. In some cases invasive methods may be considered.     

Komplexes regionales Schmerzsyndrom

Complex regional pain syndrome (CRPS) may develop following fractures, limb trauma, or lesions of the peripheral or central nervous system. The clinical picture consists of a triad of symptoms including autonomic, sensory, and motor dysfunction. Diagnosis is based on clinical signs and symptoms according to the Budapest criteria. Therapy is based on an individual and multidisciplinary approach. Distinct methods of physical therapy and pharmacological strategies are the mainstay of therapy. Pharmacotherapy is based on individual symptoms and includes steroids, free radical scavengers, treatment of neuropathic pain, and agents interfering with bone metabolism. In some cases invasive methods may be considered.     

Die Tonusasymmetrie als Schmerzsyndrom

Zusammenfassung Anhaltende Schmerzen durch Funktionsst?rungen im Bereich der Wirbels?ule und der Kopfgelenke k?nnen eine Ursache für exzessives Schreien im S?uglingsalter sein. Meistens wird das exzessive Schreien als Symptom einer Regulationsst?rung angesehen. Eine gest?rte Eltern-Kind-Beziehung wird ebenfalls oft als Ursache angenommen. Der Abkl?rung m?glicher somatischer Ursachen kommt daher eine besondere Bedeutung zu. Im vorliegenden Beitrag werden die klinischen Untersuchungsm?glichkeiten zur Feststellung einer Funktionsst?rung in den übergangsregionen des Achsenskeletts dargestellt. Ebenfalls werden die im Rahmen einer Praxisstudie erfassten Erfahrungen von Müttern mit Schreibabys geschildert sowie die Erfolge verschiedener Therapieformen, die zu Funktionsverbesserungen im Bewegungssystem und zu ?nderungen des Muskeltonus führen, beschrieben.     

Gekreuztes zentral-neuropathisches Schmerzsyndrom nach bakterieller Meningoenzephalitis

We report on a 48 year old female patient who acquired a bacterial meningoencephalitis as a result of a cervical myelography. Examination of the cerebrospinal fluid (CSF) revealed 309 cells per microliter and Streptococcus acidominimus was isolated as the infectious agent. Cranial MRI demonstrated disseminated lesions predominantly in the pontine and medullary brain stem as well as in thalamic nuclei.The patient developed a crossed central neuropathic pain syndrome. Neurological examination showed mechanic allodynia and hyperpathy along the left-sided extremities as well as right-sided neuropathic facial pain. On the MRI a dorsolateral medullary lesion on the right side, in the territory of the posterior inferior cerebellar artery was found. The localization of the lesion is suggestive of involvement of the spinal trigeminal tract or nucleus and the spinothalamic tract that would explain the neuropathic pain syndrome.A combination of gabapentine and amitriptyline reduced the pain markedly whereas opioids failed to provide sufficient analgesia.     

Endoskopische Triple-Neurektomie bei tumorbedingtem,inguinalem Schmerzsyndrom

We report on an endoscopic triple neurectomy in a female patient with vulvar carcinoma metastasized to the left groin with refractory neuropathic inguinodynia. Using a retroperitoneoscopic approach we resected the ilioinguinal, iliohypogastric, and genitofemoral nerves. The inguinodynia improved significantly; especially the reduced ability to walk was enhanced considerably. Endoscopic triple neurectomy could be a useful therapeutic option in refractory inguinal pain caused by local tumor manifestation.     

Motorkortikale Repräsentation beim komplex regionalen Schmerzsyndrom Typ I

Zusammenfassung In einer Gruppe von Patienten mit akutem und chronischem (>6 Monate) Verlauf eines komplex regionalen Schmerzsyndroms Typ I (CRPS I) wurde mittels transkranieller Magnetstimulation (TMS) die Ausdehnung der motorkortikalen Repräsentation betroffener und nichtbetroffener Handmuskeln vermessen. Hierzu wurde mit überschwelligen Einzelreizen (120% der Muskelerregungsschwelle) die Größenausdehnung über dem primär-motorischen Kortex auf dem Schädel detektiert. Diese wurde mit der gesunder Probanden verglichen. Es zeigte sich bei den Patienten eine größere kortikale Repräsentation für Muskeln der nichtbetroffenen Hand im Vergleich zur betroffenen Seite. Diese Asymmetrie fand sich sowohl bei akutem als auch chronischem Verlauf. Eine Veränderung der kortikalen Repräsentation betroffener Muskelgruppen kann, wie schon früher diskutiert wurde, als Folge einer veränderten sensomotorischen Repräsentation gewertet werden. Es müssen jedoch ebenfalls der reduzierte Gebrauch der betroffenen Hand und das Vorhandensein von Schmerz als kortikale Einflussgrößen berücksichtigt werden. Der eigentliche Mechanismus bleibt daher vorerst eine Spekulation.     

Das Vojta-Prinzip

Motor disturbances of every kind are evaluated and treated independently from the age of the patient according to the patterns of motor development. The Vojta principle relies on a facilitation system that uses the patterns of the genetic, species-specific program referred to as motor ontogenesis. Automatic control of the body position (of the trunk) is the prerequisite for free and targeted use of the limbs when grasping and supporting oneself. This procedure reduces the patient??s avoidance strategies and enables a more differentiated performance of muscle activities. The issue of muscle function differentiation, which is challenged when switching from support to purposeful motor functions, plays an important role. Influence is exerted on all levels of the entire organism, such as the cardiovascular system, autonomic nervous system and metabolic processes.     

Das DRESS-Syndrom

A 64-year-old man with chronic low back pain had been treated with tramadol, meloxicam and metamizole for several years. Due to additional neuropathic pain in the lower extremities, the medication was complemented with carbamazepine. After 5 weeks of treatment, the patient developed maculopapulose exanthema and fever, followed by hepatitis, leukocytosis and eosinophilia. The patient was diagnosed with so-called DRESS (drug rash with eosinophilia and systemic symptoms) syndrome, a severe anaphylactic reaction to carbamazepine treatment. Immunosuppressive therapy was complicated by an additional septic reaction. After recovery, the patient was referred to our clinic for a multimodal pain therapy. Fear, depressive episodes and fear-avoidance behavior were additional social factors responsible for the chronic pain syndrome of the patient. The previously diagnosed neuropathic pain syndrome cannot be verified. After appropriate modification of therapy, the patient’s pain perception was significantly reduced, allowing for complete withdrawal of pain-relieving medication. This case report illustrates that merely pharmacological treatment of chronic pain syndromes bears only little prospect of success but increased risk of side effects.     

Das Fibromyalgiesyndrom

Background

The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies (“Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften”, AWMF; registration number 041/004) was planned starting in March 2011.

Materials and methods

The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy (“Deutsche Interdisziplinären Vereinigung für Schmerztherapie”, DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies.

Results and conclusion

A diagnosis of FMS should be explicitly communicated with the afflicted individual. A step-wise treatment, depending on the severity of FMS and the responses to therapeutic measures, is recommended. Therapy should only be continued if the positive effects outweigh the side effects. The English full-text version of this article is available at SpringerLink (under “Supplemental”).     

Das Brugada-Syndrom

Zusammenfassung Hintergrund: Ein hoher ST-Strecken-Abgang mit zeltförmig deszendierenden Verlauf verbunden mit einer rechtsschenkelblockartigen Deformierung des Kammerkomplexes ist das typische EKG-Kriterium des Brugada-Brugada-Syndroms. Es führt familiär gehäuft zu Kammerflimmern bzw. Synkopen. Fallbeschreibung: Es wird die Krankengeschichte eines 56-jährigen Patienten vorgestellt, bei dem erst die orale Gabe von Prajmaliumbitartrat (40 mg/d) zur Demaskierung des Brugada-Brugada-Syndroms führte. Die weiterführende invasive Diagnostik ließ das gleichzeitige Vorliegen einer rechtsventrikulären Dysplasie vermuten. Präventiv erhielt der Patient einen ICD-Schrittmacher. Abstract Background: A high take-off descending ST segment associated with right bundle branch block is the typical ECG criterion of the Brugada-Brugada syndrome. It leads to ventricular fibrillation or syncopes in case of a familiar disposition. Case Report: We describe a 56-year-old man in whom oral prajmaliumbitartrate therapy previously prescibed for symptomatic ventricular extrasystoles unmasked an electrographic pattern characteristic of a Brugada syndrome. After the ongoing invasive diagnostic a right ventricular dysplasia in the same case is possible. The patient was treated with an ICD pacemaker.     

Das Fibromyalgiesyndrom

Background

The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies (“Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften”, AWMF; registration number 041/004) was planned starting in March 2011.

Materials and methods

The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy (“Deutsche Interdisziplinären Vereinigung für Schmerztherapie”, DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies.

Results and conclusion

The clinical diagnosis of FMS can be established by the American College of Rheumatology (ACR) 1990 classification criteria (with tender point examination), by the modified preliminary diagnostic ACR 2010 criteria or by the diagnostic criteria of the German interdisciplinary guideline (AWMF) on FMS. The English full-text version of this article is available at SpringerLink (under “Supplemental”).     

Das kleinzellige Bronchialkarzinom

With about 20% of all lung cancers small cell lung cancer (SCLC) represents a major subset of this entity. Although therapeutic improvements did not receive as much attention as in non small cell lung cancer (NSCLC), many small steps of clinical progress have been achieved within the last 20 years. An optimal treatment should be based on an interdisciplinary treatment plan. The standard treatment in localized stages represents combined radiation and chemotherapy. Cisplatin and etoposide are in this concern considered as a gold standard. 3D-planned conformal radiotherapy should start as early as possible and should be applied concomitantly to chemotherapy and in certain cases even in a hyperfractionated treatment protocol. In very early stages surgical resection could be an option in selected cases. In advanced stages a platinum-based doublet offers high response rates. As already established in limited disease prophylactic cranial irradiation is now also indicated in extensive disease in case of any tumor remission. In the second line treatment and in patients with reduced performance status topotecan is recommended. Similar as in NSCLC pemetrexed might become an alternative treatment option in the second line setting. In the field of new targeted therapies bevacizumab achieved the most promising results. The present review highlights historical milestones and up-to-date trends in radiotherapy, chemotherapy and surgery. Furthermore, the role of experimental strategies and the management of certain special clinical situations are discussed.     

Das Sterbehilfegesetz verunsichert

Pflegezeitschrift - Im Dezember 2015 wurde das „Gesetz zur Strafbarkeit der geschäftsmäßigen Förderung der Selbsttötung“ beschlossen. Leider verunklart es die...