Zur Bedeutung der MRT-Diagnose „bone bruise“ bei kindlichen Wirbelsäulenverletzungen

ZusammenfassungHintergrund Die MRT stellt ein sensitives, nicht strahlenbelastendes bildgebendes Verfahren dar und bietet sich daher für die Diagnostik kindlicher Wirbelsäulenverletzungen an. Als ein indirektes Verletzungszeichen lässt sich hierbei u. U. ein sog. bone bruise nachweisen, ohne dass weitere Verletzungen sichtbar werden. Ziel der vorliegenden Arbeit war es, die klinische Bedeutung dieser Diagnose bei kindlichen Wirbelsäulenverletzungen zu untersuchen.Patienten und Methoden Zwischen 1998 und 2003 wurden in unserer Klinik insgesamt 66 Kinder mit Wirbelsäulenverletzungen konservativ behandelt. 34 dieser Kinder erhielten während der Primärdiagnostik eine MRT. Im Rahmen einer retrospektiven Studie wurden 20 Kinder, bei welchen die Diagnose einer Wirbelkörperverletzung vorwiegend durch den Nachweis eines bone bruise im initialen MRT geführt worden war, sowohl klinisch als auch mittels MRT nachuntersucht.Ergebnisse Alle 20 Kinder gaben bei der Nachuntersuchung subjektiv weitgehende Beschwerdefreiheit an. Bei der objektiven Untersuchung fanden sich keine klinischen Auffälligkeiten. Bei keinem der Kinder war im Rahmen der Nachuntersuchung MR-tomographisch eine Persistenz des bone bruise feststellbar. Eine sekundäre Sinterung der betroffenen Wirbelkörper war in keinem Fall aufgetreten.Schlussfolgerung Kindliche Wirbelsäulenverletzungen, die mit einem mittels MRT nachgewiesenen bone bruise ohne weitere bildmorphologische knöcherne oder diskoligamentäre Läsionen einhergehen, sind in der Regel als prognostisch günstig einzustufen. Bei entsprechender Therapie, die in einer kurzfristigen, schmerzadaptierten Bettruhe und einer anschließenden frühfunktionellen Behandlung besteht, wurden bei unseren Patienten keine sekundären Sinterungen beobachtet.* Beide Autoren haben gleichen Anteil an dieser Arbeit und teilen sich die Erstautorenschaft.     

Pathophysiologie von Drang-, Belastungs- und Mischinkontinenz

According to the new ICS classification, urinary incontinence is subdivided by symptomatic, clinical, and urodynamic criteria. Understanding the pathophysiological interactions is important to find the correct diagnosis. Disturbances in bladder storage include urge incontinence due to neurogenic or non-neurogenic (idiopathic) detrusor hyperactivity as well as stress urinary incontinence caused by an insufficient urethral closure mechanism due to reduced pressure transmission (active-passive), hypotonic urethra, hyporeactivity of sphincter musculature, or involuntary relaxation of the urethra. Stress and urge incontinence can occur in combination and then be defined as mixed incontinence.     

Radioprotection of normal tissue cells

Improvements of radiotherapy in combination with surgery and systemic therapy have resulted in increased survival rates of tumor patients. However, radiation-induced normal tissue toxicity is still dose limiting. Several strategies have been pursued with the goal to develop substances which may prevent or reduce damage to normal tissue. Drugs applied before radiotherapy are called radioprotectors; those given after radiotherapy to reduce long-term effects are radiomitigators. Despite more than 50 years of research, until now only two substances, amifostine and palifermin, have overcome all obstacles of clinical approval and are applied during radiotherapy of head and neck cancer or total body irradiation, respectively. However, better understanding of the cellular pathways involved in radiation response has allowed the development of several highly promising drugs functioning as scavengers of reactive oxygen species or targeting specific molecules involved in regulation of cell death pathways or cell cycle arrest. The present review describes the major targets for radioprotectors or radiomitigators currently tested in clinical trials.     

Stellenwert der Multidetektor-CT bei Polytrauma

Clinical/methodical issue

Diagnostic imaging of complex multiple trauma remains a challenge for any department providing modern emergency radiology (ER) service. An early and comprehensive approach for ER imaging is crucial for a priority-oriented and timely therapy concept with the aim of identifying potentially life-threatening injuries early and initiating appropriate treatment.

Standard radiological methods

The basic diagnostic approach still consists of focused ultrasound using focused assessment with sonography for trauma (FAST) and conventional radiography (CR), usually limited to a single supine chest x-ray for triaging patients undergoing immediate operations.

Methodical innovations

Multidetector computed tomography (MDCT) has become established as early whole body CT (WBCT) as the undisputable diagnostic method. The detection rate of injuries by WBCT is outstanding and it improves the probability of survival by 20–25?% compared with all other previous methods. At the same time, the spatial and temporal resolution of MDCT was improved resulting in considerably shortened examination times but WBCT is still associated with a significant radiation exposure, even in the acute single use setting. Using modern scanner and dose reduction technology, including iterative reconstruction, a dose reduction of up to 40?% could be achieved. The substantial number of images in WBCT is another challenge; images must be processed priority-oriented, read and transferred to the picture archiving and communications system (PACS). For rapid diagnosis, volume image reading (VIR) offers additional options to keep the diagnostic process on time.

Achievements/practical recommendations

Modern WBCT after multiple trauma is performed early, comprehensively and personalized so that WBCT improves the probability of survival by 20–25?%.     

Radiologische Diagnostik des CUP-Syndroms

Clinical/methodical issue

Imaging plays an essential role in the therapeutic management of cancer of unknown primary (CUP) patients for localizing the primary tumor, for the identification of tumor entities for which a dedicated therapy regimen is available and for the characterization of clinicopathological subentities that direct the subsequent diagnostic and therapeutic strategy.

Standard radiological methods

Modalities include conventional x-ray, computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound as well as positron emission tomography (PET)-CT and MRI-PET.

Performance

In whole body imaging CT has a high sensitivity for tumor entities which frequently present as a metastasized cancer illness. According to the current literature CT is diagnostic in 86% of patients with pancreatic carcinoma, in 36% of patients with colon carcinoma and in 74% of patients with lung carcinoma. Additionally a meta-analysis showed that for patients with squamous cell carcinoma and cervical lymph node metastases a positive diagnosis was possible in 22% of the cases using CT, in 36% using MRI and in 28-57% using 18F-fluorodeoxyglucose PET-CT (¹⁸F-FDG PET-CT). In addition, MRI plays an important role in the localization of primary occult tumors (e.g. breast and prostate) because of its high soft tissue contrast and options for functional imaging.

Achievements

At the beginning of the diagnostic algorithm stands the search for a possible primary tumor and CT of the neck, thorax and abdomen is most frequently used for whole body staging. Subsequent organ-specific imaging examinations follow, e.g. mammography in women with axillary lymphadenopathy. For histological and immunohistochemical characterization of tumor tissue, imaging is also applied to identify the most accessible and representative tumor manifestation for biopsy. Tumor biopsy may be guided by CT, MRI or ultrasound and MRI also plays a central role in the localization of primary occult tumors because of superior soft tissue contrast and options for functional imaging (perfusion, diffusion), e.g. investigation of breast carcinoma or prostate carcinoma.

Practical recommendations

Whole body staging stands at the beginning of the diagnostic algorithm in CUP syndrome to localize a potential primary tumor. Clinically, contrast-enhanced CT of the neck, thorax and abdomen is frequently applied; however, many studies have demonstrated augmented sensitivity of ¹⁸F-FDG PET-CT for the detection of primary tumors and metastatic tumor manifestations.     

Die Bedeutung von Referenzzentren in Diagnose und Therapie von Weichgewebssarkomen der Extremitäten

Correct histopathologic diagnosis is essential for adequate treatment of soft tissue sarcomas. Due to the disorder’s rarity, multitude of subgroups, sometimes varying histopathologic appearance, and occasionally inadequate biopsy specimens, diagnosis and grading are challenging. The records of 603 patients with soft tissue tumors of the extremities were reviewed concerning mismatches in primary and definite diagnoses relating to entity, evaluation of primary or recurrent tumor specimens, and the diagnosing pathology institution. For second opinions we referred to the Institute of Pathology of the Ruhr University at the Bergmannsheil Hospital in Bochum, Germany, and to the Pathology Institute of the University of Jena, also in Germany. Liposarcoma and malignant fibrous histiocytoma were the most often diagnosed subgroups at 24% and 22.6%, respectively. In the eight most frequent sarcoma types, malignant peripheral nerve sheath tumors and leiomyosarcoma had the highest rates of false primary diagnosis, 78.4% and 74.2% of cases, respectively. The diagnostic error ratio for nonspecialized pathologists in practice, community hospital pathologists, and academic medical centers was over 60%. For optimal treatment of soft tissue sarcomas, we suggest obtaining expert second opinion to ensure adequate surgical therapy and precise indications for radiation and chemotherapy.     

Versorgungsstrategien in der ersten operativen Phase nach Verletzung langer Röhrenknochen der unteren Extremität beim Polytrauma

Objective

Lower extremity injuries make up a substantial proportion of the injuries in multiply injured patients. The aim of this systematic literature analysis was to give an overview of the levels of evidence for different management strategies in the first operative phase after long-bone injuries of the lower extremity in multiply injured patients to enable, in the presence of adequate evidence, the development of clinical management corridors or, if the evidence was found to be inadequate, to document the necessity for scientific proof.

Methods

Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (EL 1 to 5 according to the Oxford system).

Results

The necessity for primary or secondary definitive osteosynthesis of femur/tibia shaft fractures is still a matter of discussion. Intramedullary nailing is the preferred operative procedure for definitive treatment of femur shaft fractures. Stabilization of proximal and distal femur and tibia fractures is predominantly based on expert opinion. According to the literature, perioperative antibiotic prophylaxis is essential in fracture treatment.

Conclusion

Numerous comparative studies (EL 2) dealing with management strategies in the first operative phase after long-bone injuries of the lower extremity in multiply injured patients are available, but there are only a few randomized studies. Based on the available data, it is possible to develop a rational therapy for this patient population.     

Operative Versorgung von Achillessehnenverletzungen

Rupture of the Achilles tendon is typically associated with sportive activities with increasing tendency; it occurs most commonly in the third to fourth decade of life with a male-to-female ratio of 5–10:1. Ruptures are caused predominantly by a sudden, unexpected overextension of the tendon while direct trauma is less frequent. The recommended treatment of the injury remains controversial. In Germany, due to the good functional results, the open surgical repair represents the standard therapy since many years. The open suture technique offers the advantage of a lower re-rupture rate but is associated with the risk of wound-related complications including infection. By percutaneous suture techniques a significant decrease in the rate of infections and complications in wound healing could be achieved by minimal-access with reduced soft tissue trauma; on the other hand an increased rate of lesions of the sural nerve is reported. Dynamic imaging assessment of ultrasound or MRI allows a more accurate localisation of the ruptured ends of the tendons which is the prerequisite for the non-operative primary functional treatment of Achilles tendon ruptures. This conservative treatment regime is recommended when adaptation of the ends of the ruptured tendon is possible in 20° plantar flexion of the foot. Moreover, the desired level of daily activity and the patients’ degree of compliance has to be considered. Operative management should be avoided in the elderly patient or patients with risk factors like immunosuppressive therapy, diabetes mellitus, steroid use or failure to comply.     

Intraoperative Echokardiographie

Since the introduction of intraoperative echocardiography into clinical practice in the 1970’s its use and utility in the perioperative period has become increasingly more evident. Especially in patients undergoing cardiac surgical procedures intraoperative echocardiography has gained great diagnostic importance. Intraoperative transesophageal echocardiography (TEE) and epiaortic ultrasound are two important and complementing diagnostic modalities in this patient population. The clinical information obtained with intraoperative TEE in certain cases might have a direct impact on surgical decision-making and therefore may positively influence patient outcome. In patients undergoing non-cardiac surgical procedures, TEE can be a valuable tool in high-risk patients, in patients experiencing hemodynamic instability or in those suffering intraoperative cardiac arrest. Intraoperative TEE might allow a primary diagnosis of the underlying etiology and facilitate the institution of further therapeutic interventions. In addition TEE can be performed during ongoing cardiopulmonary resuscitation and does not interfere with patient management. This review introduces the clinician to the current evidence of the impact of intraoperative echocardiography on intraoperative surgical decisions during surgical procedures. It helps the clinician to identify indications and realize the potential applications of intraoperative echocardiography.     

Verteilungsplanung von Verletzten beim MANV oder Katastrophenfall

Relevant changes have occurred in disaster management in Germany due to legal alterations and the introduction of the diagnosis-related groups (DRG) system. This has resulted in a reduction in bed capacities and an increase in bed utilization. In addition to the preclinical deployment strategy the provisional aspects of disaster medicine with the problem of the emergency service/hospital interface will be described. A suggestion for a solution for optimization of patient allocation in mass disasters or catastrophes will be demonstrated with the catastrophe network of the German Society for Trauma Surgery (DGU).