Does an interspinous device (Coflex?) improve the outcome of decompressive surgery in lumbar spinal stenosis? One-year follow up of a prospective case control study of 60 patients

A number of interspinous process devices have recently been introduced to the lumbar spinal market as an alternative to conventional surgical procedures in the treatment of symptomatic lumbar stenosis. One of those “dynamic” devices is the Coflex™ device which has been already implanted worldwide more than 14,000 times. The aim of implanting this interspinous device is to unload the facet joints, restore foraminal height and provide stability in order to improve the clinical outcome of surgery. Published information is limited, and there are so far no data of comparison between the implant and traditional surgical approaches such as laminotomy. The purpose of our prospective study is to evaluate the surgical outcome of decompressive surgery in comparison to decompressive surgery and additional implantation of the Coflex™ interspinous Device. 60 patients who were all treated in the Spine Center of Klinikum Neustadt, Germany for a one or two level symptomatic LSS with decompressive surgery were included. Two groups were built. In Group one (UD) we treated 30 patients with decompression surgery alone and group two (CO) in 30 patients a Coflex™ device was additional implanted. Pre- and postoperatively disability and pain scores were measured using the Oswestry disability index (ODI), the Roland–Morris score (RMS), the visual analogue scale (VAS) and the pain-free walking distance (WD). Patients underwent postoperative assessments 3, 6 and 12 month including the above-mentioned scores as well as patient satisfaction. In both groups we could see a significant improve (p < 0.001) in the clinical outcome assessed in the ODI, in the RMS for evaluation of back pain, in the VAS and in the pain-free WD at all times of reinvestigation compared to base line. At 1-year follow up there were no statistically differences between both groups in all ascertained parameters including patient satisfaction and subjective operation decision. Because there is no current evidence of the efficacy of the Coflex™ device we need further data from randomized controlled studies for defining the indications for theses procedures. To the best of our knowledge this is the first prospective controlled study which compares surgical decompression of lumbar spinal stenosis with additional implanting of an interspinous Coflex™ device in the treatment of symptomatic LSS.     

Torquated giant appendix epiploica mimicking intraperitoneal liposarcoma: report of a case

A 49-year-old woman presented with acute abdominal pain in the right iliac fossa in our emergency department. Pain was abrupt in onset and severely colicky in nature. Abnormal laboratory values included a C-reactive protein of 75 mg/L and a CA-125 of 70.3 U/mL. White blood cell count was normal. Abdominal computed tomography (CT) scan revealed an inhomogeneous mass of 9.5 x 3.5 x 5.5 cm in diameter close to the appendix vermiformis and the sigmoid colon. Because of the clinical symptoms of an acute abdomen an explorative laparotomy was performed. Intraoperatively a pedunculated tumor beginning at the serosa of the sigmoid colon was found. The appendix was unremarkable. The macroscopic aspect as well as the backtable incision of the tumor was suspicious of an intraperitoneal liposarcoma. Rapid section and histopathologic examination revealed necrotic fat tissue without any malignancy. The patient was discharged from the hospital 7 days after the operation with normal laboratory parameters and without further complication. When epiploic appendagitis is evident as a big tumor mass in addition to clinical symptoms of an acute abdomen and elevated tumor markers, surgical exploration is mandatory.     

Uveal melanoma: correlation of histopathologic and radiologic findings by using thin-section MR imaging with a surface coil

PURPOSE: To evaluate whether the different signal intensities at magnetic resonance (MR) imaging of melanoma are associated with a higher content of melanin. MATERIALS AND METHODS: In a prospective study, MR imaging and ophthalmoscopic examination findings in 42 patients (19 women, 23 men; age range, 30-87 years) with uveal melanoma were compared with histopathologic examination findings obtained after enucleation. MR imaging was performed with 2-mm sections by using a 5-cm surface coil. T1- and T2-weighted images were obtained before and after contrast material administration. RESULTS: In 33 (79%) of the patients, there was homogeneous tumor pigmentation, whereas in nine (21%) patients, there was inhomogeneous bipartite tumor pigmentation. Compared with the histopathologic data, the results of qualitative evaluation were accurate in 29 (58%) of 50 and in 26 (53%) of 49 tumorous areas on T1- and T2-weighted images, respectively. Quantitative evaluation yielded better results, especially at T1-weighted imaging; an 86% correlation was found. Because of methodological reasons, only the superficial pigmentation of inhomogeneous tumors could be evaluated with ophthalmoscopy. CONCLUSION: Thin-section MR imaging of the eye enables an accurate prediction of melanomatous pigmentation with quantitative evaluation of plain T1-weighted images and is superior to ophthalmoscopy in cases of inhomogeneous pigmentation.     

Accuracy of pedicle screw insertion in the cervical spine for internal fixation using frameless stereotactic guidance

OBJECT: Although transpedicular fixation is a biomechanically superior technique, it is not routinely used in the cervical spine. The risk of neurovascular injury in this region is considered high because the diameter of cervical pedicles is very small and their angle of insertion into the vertebral body varies. This study was conducted to analyze the clinical accuracy of stereotactically guided transpedicular screw insertion into the cervical spine. METHODS: Twenty-seven patients underwent posterior stabilization of the cervical spine for degenerative instability resulting from myelopathy, fracture/dislocation, tumor, rheumatoid arthritis, and pyogenic spondylitis. Fixation included 1-6 motion segments (mean 2.2 segments). Transpedicular screws (3.5-mm diameter) were placed using 1 of 2 computer-assisted guidance systems and lateral fluoroscopic control. The intraoperative mean deviation of frameless stereotaxy was < 1.9 mm for all procedures. RESULTS: No neurovascular complications resulted from screw insertion. Postoperative computed tomography (CT) scans revealed satisfactory positioning in 104 (90%) of 116 cervical pedicles and in all 12 thoracic pedicles. A noncritical lateral or inferior cortical breach was seen with 7 screws (6%). Critical malplacement (4%) was always lateral: 5 screws encroached into the vertebral artery foramen by 40-60% of its diameter; Doppler sonographic controls revealed no vascular compromise. Screw malplacement was mostly due to a small pedicle diameter that required a steep trajectory angle, which could not be achieved because of anatomical limitation in the exposure of the surgical field. CONCLUSIONS: Despite the use of frameless stereotaxy, there remains some risk of critical transpedicular screw malpositioning in the subaxial cervical spine. Results may be improved by the use of intraoperative CT scanning and navigated percutaneous screw insertion, which allow optimization of the transpedicular trajectory.     

Effect of oral creatine supplementation on human muscle GLUT4 protein content after immobilization

The purpose of this study was to investigate the effect of oral creatine supplementation on muscle GLUT4 protein content and total creatine and glycogen content during muscle disuse and subsequent training. A double-blind placebo-controlled trial was performed with 22 young healthy volunteers. The right leg of each subject was immobilized using a cast for 2 weeks, after which subjects participated in a 10-week heavy resistance training program involving the knee-extensor muscles (three sessions per week). Half of the subjects received creatine monohydrate supplements (20 g daily during the immobilization period and 15 and 5 g daily during the first 3 and the last 7 weeks of rehabilitation training, respectively), whereas the other 11 subjects ingested placebo (maltodextrine). Muscle GLUT4 protein content and glycogen and total creatine concentrations were assayed in needle biopsy samples from the vastus lateralis muscle before and after immobilization and after 3 and 10 weeks of training. Immobilization decreased GLUT4 in the placebo group (-20%, P < 0.05), but not in the creatine group (+9% NS). Glycogen and total creatine were unchanged in both groups during the immobilization period. In the placebo group, during training, GLUT4 was normalized, and glycogen and total creatine were stable. Conversely, in the creatine group, GLUT4 increased by approximately 40% (P < 0.05) during rehabilitation. Muscle glycogen and total creatine levels were higher in the creatine group after 3 weeks of rehabilitation (P < 0.05), but not after 10 weeks of rehabilitation. We concluded that 1) oral creatine supplementation offsets the decline in muscle GLUT4 protein content that occurs during immobilization, and 2) oral creatine supplementation increases GLUT4 protein content during subsequent rehabilitation training in healthy subjects.     

Bromodeoxyuridine Labeling Index as an Indicator of Early Tumor Response to Preoperative Radiotherapy in Patients with Rectal Cancer

Purpose Assessment of tumor proliferation rate using Bromodeoxyuridine labeling index (BrdUrdLI) as a possible predictor of rectal cancer response to preoperative radiotherapy (RT). Methods and material Ninety-two patients were qualified either to short RT (5 Gy/fraction/5 days) and surgery about 1 week after RT (schedule I), or to short RT and 4–5 weeks interval before surgery (schedule II). Tumor samples were taken twice from each patient: before RT and at the time of surgery. The samples were incubated with BrdUrd for 1 h at 37°C, and the BrdUrdLI was calculated as a percentage of BrdUrd-labeled cells. Results Thirty-eight patients were treated according to schedule I and 54 patients according to schedule II. Mean BrdUrdLI before RT was 8.5% and its value did not differ between the patients in the two compared groups. After RT tumors showed statistically significant growth inhibition (reduction of BrdUrdLI). As the pretreatment BrdUrd LI was not predictive for early clinical and pathologic tumor response, prognostic role of the ratio of BrdUrdLI after to BrdUrdLI before RT was considered. The ratios were calculated separately for fast (BrdUrd LI > 8.5%) and slowly (BrdUrd LI ≤ 8.5%) proliferating tumors and correlated with overall treatment time (OTT, i.e., time from the first day of RT to surgery). One month after RT, accelerated proliferation was observed only in slowly proliferating tumors. Conclusions Pretreatment BrdUrdLI was not predictive for early clinical and pathologic tumor response. The ratio after/before RT BrdUrdLI was correlated to inhibition of proliferation in responsive tumors. The paper was presented at ECCO 13, October 30 to November 03, 2005 in Paris, France     

„Einklemmungstrauma“ im Straßenverkehr

AIM: Crash mechanisms, injury patterns, and severity of injury of entrapped motor vehicle occupants were analysed by the Accident Research Unit's scientific teams between 1983 and 2003. RESULTS: Of the 1281 vehicle passenger entrapments in our study, 18.3% happened on highways, 25.6% on federal roads, 35.9% on country roads, and 18.3% on city roads. Of those involved, 69.9% were drivers, 19.4% were front passengers, and 8.5% were rear passengers. Coinvolved objects in car collisions were: other cars 30.9%, trucks 50.2%, objects 18.6%, and motorbikes 0.3%. Coinvolved objects in truck collisions were: other trucks 61.8% and objects 38.2%. The mean Delta-V was 42 km/h (cars 46.2, trucks 32.2). Maximum AIS levels were 31% I, 25.2% II, 19.4% III, 7.8% IV, 7.8% V, and 8.6% VI. Of injuries, 68.7% were to the head, 23.5% to the neck, 50.8% to the chest, 43.6% to upper extremities, 15.4% to the abdomen, 16.4% to the pelvis, and 52.9% to lower extremities. The incidence of multiple injuries (ISS>16) was 23.7%, and mortality was 15.9%. CONCLUSION: Car drivers are more at risk of accidents with entrapment on rural streets, and truck drivers are more at risk on highways. In most cases car occupants crash with trucks or other cars, and truck drivers collide more frequently with other trucks or objects. Besides a high degree of severe single injuries, there is also a high incidence of multiple injury victims and high mortality. Of the fatalities, 74.5% occur during the preclinical course and 24.5% during the clinical course.     

The current injury situation of bicyclists--a medical and technical crash analysis

BACKGROUND: The purpose of the study was to analyze the actual injury situation of bicyclists in Germany to create a basis for effective preventive measures. METHODS: Technical and medical data were prospectively collected shortly after the crash at the crash scenes. RESULTS: Included were 4,264 injured bicyclists from 1985 to 2003. Fifty-five percent of the bicyclists were male and 45% were women. The mean age of bicyclists was 52.0 years. The crashes took place in urban areas in 95.2% of the cases, and in rural areas in 4.8% of the cases. Collision opponents were cars in 65.8%, trucks in 7.2%, bicyclists in 7.4%, standing objects in 8.8%, multiple opponents or objects in 4.3%, and others in 6.5%. The mean collision speed was 21.3 km/h. The helmet use rate was 1.7%. Fifty-five percent of bicyclists used bicycle traffic lanes before the crash. The mean Maximum Abbreviated Injury Scale/Injury Severity Score (ISS) was 1.45 of 3.9. The incidence of multiple injuries (ISS>16)/death was 2.0%/1.5%. The ISS/Maximum Abbreviated Injury Scale score was higher in bicyclists without a helmet than in bicyclists with a helmet, and in bicyclists who had not used bicycle traffic lanes than in bicyclists who had used bicycle traffic lanes (t test, p<0.05). CONCLUSION: In bicyclists, head and extremities are at high risk for injuries. The helmet use rate is unsatisfactorily low. Remarkably, two-thirds of the head injuries could have been prevented by helmets. More consequent helmet use and an extension of bicycle traffic lanes for a better separation of bicyclists and motorized vehicles would be simple but very effective preventive measures.     

Clinical relevance of autoantibodies after pediatric liver transplantation

BACKGROUND: The presence of autoantibodies and development of autoimmune hepatitis after liver transplantation has recently been reported as one of the causes for chronic graft dysfunction. The pathogenesis and clinical significance of this disease still remains unclear. METHODS: We evaluate 96 patients for the prevalence of autoantibodies and autoimmune hepatitis after pediatric liver transplantation and review their clinical follow-up including virus serologies, ultrasound examination and liver biopsies. RESULTS: Positive autoantibodies were detected in 74% of the patients after pediatric OLT. Graft dysfunction was observed in 46% of these children, and in 35% of the transplant recipients seronegative for autoantibodies. None of the patients showed histological signs or fulfilled clinical criteria for de novo autoimmune hepatitis. One child with negative autoantibodies was diagnosed to have a histologically proven de novo AIH two yr following OLT. CONCLUSIONS: There is a high prevalence of autoantibodies after pediatric OLT, but the incidence of de novo AIH is very rare. In transplant recipients showing elevated liver function tests de novo autoimmune hepatitis has to be excluded by liver biopsy even if the patient is seronegative for autoantibodies.     

Developments in pediatric liver transplantation since implementation of the new allocation rules in Eurotransplant

Liver allocation in the Eurotransplant (ET) region has changed from a waiting time to an urgency‐based system using the model of end‐stage liver disease (MELD) score in 2006. To allow timely transplantation, pediatric recipients are allocated by an assigned pediatric MELD independent of severity of illness. Consequences for children listed at our center were evaluated by retrospective analysis of all primary pediatric liver transplantation (LTX) from deceased donors between 2002 and 2010 (110 LTX before/50 LTX after new allocation). Of 50 children transplanted in the MELD era, 17 (34%) underwent LTX with a high‐urgent status that was real in five patients (median lab MELD 22, waiting time five d) and assigned in 12 patients (lab MELD 7, waiting time 35 d). Thirty‐three children received a liver by their assigned pediatric MELD (lab MELD 15, waiting time 255 d). Waiting time in the two periods was similar, whereas the wait‐list mortality decreased (from about four children/yr to about one child/yr). One‐ and three‐yr patient survival showed no significant difference (94.5/97.7%; p = 0.385) as did one‐ and three‐yr graft survival (80.7/75.2%; and 86.5/82%; p = 0.436 before/after). Introduction of a MELD‐based allocation system in ET with assignment of a granted score for pediatric recipients has led to a clear priorization of children resulting in a low wait‐list mortality and good clinical outcome.