In vivo detection of the lumbar intraforaminal ligaments by MRI

Purpose

Intraforaminal ligaments (IFL) are of great interest to anatomists and clinicians to fully understand the detailed anatomy of the neuroforamina and to diagnose unclear radicular symptoms. Studies published until now have described radiological imaging of the IFLs using magnetic resonance imaging (MRI) on donor bodies. In the present study, we investigated the detectability of lumbar IFLs in vivo in adults using the high spatial resolution of the constructive interference in steady state (CISS) sequence.

Methods

A total of 14 patients were studied using a 1.5 T MRI scanner. The lumbar spine was imaged using the parasagittal CISS sequence, and the detectability of the IFLs was assessed for each lumbar level. All image datasets were analyzed by a radiologist, an orthopedic surgeon, and an anatomist. Interrater reliability was expressed as Fleiss’ Kappa. Using a single data set, a three-dimensional (3D) model was created to map the location of the IFLs within the intervertebral foramen (IF) and the immediate surrounding vessels.

Results

Overall, the radiologist was able to detect IFLs in 60% of all imaged IFs, the orthopedic surgeon in 62%, and the anatomist in 66%. Fleiss’ Kappa for the various segments varies from 0.71 for L4/5 up to 0.90 for L3/4.

Conclusion

Lumbar IFLs were successfully detected in vivo in every patient. The detection frequency varied from 42–86% per IF. We demonstrated reproducible imaging of the IFLs on MRI, with good interrater reliability. The present study was a launching point for further clinical studies investigating the potential impact of altered IFLs on radicular pain.

     

Muscle activity in the partially paralyzed face after placement of a fascial sling: a preliminary report

Neuromuscular re-education (ie, physical therapy) is often the first treatment given to patients with a partial facial paralysis. The purpose of this paper was to examine whether by repositioning and supporting partially paretic muscles with a fascial sling, one could improve facial movement in patients for whom the benefits of physical therapy had plateaued. Six patients with a history of unilateral, partial facial paralysis were assessed using the Facial Grading System (FGS) and surface electromyography (EMG) recordings of facial muscle activity. Automated facial analysis (AFA) was used to measure the facial excursions of the most recent patient. The FGS composite scores indicated improvement following static sling placement in all patients. The FGS subscale scores for voluntary movement indicated that the excursion of facial movement increased in 4 of the 6 patients. Surface EMG data demonstrated increased muscle activity in the zygomaticus major muscle in all patients. AFA demonstrated that following sling placement, the excursion of the lip commissure nearly doubled. The sling procedure, traditionally considered an intervention for improving static symmetry of the face, may also be useful for enhancing movement in some patients with a partial facial paralysis. Additional data, such as measurements provided by AFA, are needed to correlate facial displacement with EMG muscle activity.     

An interactive system for point dose optimization

An interactive system has been developed to aid in determining optimal photon and electron beams and beam weights for radiotherapy treatment planning. Dose constraints at various points are selected and an algorithm searches for a set of beams and weighting factors that satisfy these constraints. In the event that no combination of beam weights satisfies the choice of treatment modalities and dose constraints, the treatment modalities and dose constraints can be modified interactively. The goal of this procedure is different from that of more conventional optimization schemes in which optimal dose values are specified and the optimization algorithm determines the set of beam weights that yields a dose distribution closest to optimal.     

Target burn-up corrected specific activity of 177Lu produced via 176Lu(n, gamma) 177Lu nuclear reactions.

Nuclear transformation of the target material is considered as an essential parameter for the specific activity of (177)Lu produced via (176)Lu(n, gamma)(177)Lu nuclear reactions. It is shown that (176)Lu burn-up has to be taken into account to estimate the (177)Lu specific activity related to the total mass or amount of lutetium in the system.     

Gerinnungstherapie der peripartalen Hämorrhagie

Background

In order to ensure evidence-based haemostatic management of postpartum haemorrhage (PPH, blood loss >500?ml) consistent with guidelines appropriate structural conditions must be fulfilled regardless of different levels (1–3) in perinatal care. The aim of the survey was to identify differences in haemostatic management in PPH under consideration of the different levels of perinatal care in Germany.

Materials and methods

An electronic questionnaire assessing the structural and therapeutic preconditions for haemostatic management was sent to 533 anaesthesiology departments serving obstetric units.

Results

A total of 156 (29?%) questionnaires returned from hospitals of all levels were analysed. PPH occur in all and increase with higher level hospitals (level 1 <5 PPH/year vs. 3 >30 PPH/year). The percentage of PPH requiring red blood cell (RBC) transfusion amounts to <25?% (all levels). A bleeding history (35?%, all levels), laboratory coagulation tests (29?%, all levels) as well as viscoelastic point-of-care coagulation tests (42?%, mainly level 3) are limited in their availability. Blood loss is usually estimated (99?%, all levels), not measured. Tranexamic acid (>80?%, all levels), fibrinogen (>60?%, all levels) and fresh frozen plasma (FFP) (30?%, level 2a) are first line therapeutics. In level 2b and 3 FFP is a second line therapeutic. RBC transfusion is indicated at haemoglobin <5–7?g/dl (57–69?%, all levels), while 15–29?% in level 3 did not base their decision to transfuse RBC on haemoglobin only.

Conclusions

Guideline-consistent haemostatic management of PPH is provided in almost all hospitals independent of the perinatal care level. Deviances from guidelines (measuring blood loss, bleeding history of the patient) affect all levels of perinatal care in Germany.

     

Surgical treatment for posttraumatic shoulder stiffness

Objective

The aim of this systematic review is to show the feasibility and efficacy of operatively treated posttraumatic shoulder stiffness and to report on the implementation of a standardized treatment algorithm.

Materials and methods

In January 2016, a systematic literature search of Medline (www.pubmed.com) was performed to identify studies with cohorts of patients with operatively treated posttraumatic shoulder stiffness. Studies were included according to predefined inclusion and exclusion criteria.

Results

In total, nine studies with 191 patients were included. After a mean of 7 months (range: 3.7–12) of conservative treatment with pain medication and physiotherapy, surgery was performed. The mean follow-up was 24 months (range: 6–46). All studies showed an improvement in clinical scores or range of motion (ROM) on follow-up.

Conclusion

To our knowledge, no previous systematic review of operatively treated posttraumatic shoulder stiffness has been published. Based on this systematic review, arthroscopic-guided or arthroscopic release of posttraumatic shoulder stiffness is an effective method to relieve pain and gain ROM. A clearly defined time until surgery does not exist and must be determined individually.

     

Two cycles of MOPP and radiotherapy for stage III1A and stage III1B Hodgkin's disease

One hundred two adult patients with stage III1A (76 patients) and stage III1B (26 patients) Hodgkin's disease were treated with two cycles of mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) and radiotherapy (XRT) between 1970 and 1984. Sixty-four of the patients were treated between 1970 and 1978 with two cycles of MOPP and XRT to the mantle, upper abdomen, and pelvis. The remaining 38 patients were treated from 1978 to 1984 with a modification of the protocol in which pelvic XRT was omitted and low-dose whole-lung XRT was administered to patients with unfavorable mediastinal disease. The 10-year actuarial freedom-from-progression (FFP) and determinate survival rates at a mean follow-up of 93 months were 84% and 86% for stage III1 disease, 86% and 84% for stage III1A disease, and 78% and 91% for stage III1B disease. Three patients died of treatment-related toxicities without evidence of Hodgkin's disease, two died of complications of myelosuppression and one of acute nonlymphocytic leukemia (ANLL). Neither FFP nor determinate survival rates were significantly influenced by B symptoms, unfavorable mediastinal disease, histologic subtype, extent of abdominal disease, the omission of pelvic XRT, the use of whole-lung XRT, or the number of splenic nodules. Patients 40 years of age or older had a 73% determinate survival rate at 10 years compared with 88% for patients younger than 40 years (P = .01). This survival difference was due to treatment-related toxicity in the older group. This study indicates that two cycles of MOPP and XRT to the mantle and upper abdomen is as effective as more intensive treatment for all patients with stage III1 Hodgkin's disease. This treatment program can preserve fertility and has had only a 1% actuarial incidence of ANLL at 15 years.     

Synovial cytokine expression in ankle osteoarthritis depends on age and stage

Purpose

Aim of the study was the analysis of cytokine expression in ankle osteoarthritis (OA) hypothesizing age-dependent regulation patterns.

Methods

Forty-nine patients undergoing an arthroscopy of the ankle with different stages of chronic OA were prospectively included in a clinical trial comparing the group <18 years (n = 9, Ø15.1 ± 2.0 years) with the older patients (≥18 years, n = 40, Ø36.5 ± 11.9). Lavage fluids were analysed by ELISA for levels of aggrecan, BMP-2/7, IGF-1/R, bFGF, CD105, MMP-13, and IL-1β. Additionally, clinical parameters and scores (FFI, CFSS, AOFAS) were evaluated and supplemented by radiographic scores [Kellgren–Lawrence Score (KLS) for conventional X-rays, Ankle Osteoarthritis Scoring System (AOSS) for MRI].

Results

In contrast to distribution of gender and BMI (p < 0.005), parameters characterizing the cartilage defect as ICRS grading, size, and duration of symptoms were not dependent on age. The incidence of osteochondritis dissecans (OCD) was higher in the group <18 years (p < 0.006), but the average degree of OCD grading was not different. KLS and AOSS were significantly higher in the group ≥18 years (p < 0.02). Correlating with the higher degree of OA in the elderly, clinical function measured by FFI and AOFAS was statistically significantly worse (p < 0.05). Intra-articular concentrations of aggrecan (3.1-fold), bFGF (8.7-fold), BMP-7 (2.7-fold), and CD105 (1.5-fold) were statistically significantly higher in the group ≥18 years (p < 0.03).

Conclusions

Confirming the hypothesis, increased synovial levels of aggrecan, bFGF, BMP-7, and CD105 were found in patients over 18 years. This correlated with a higher stage of OA determined by radiographic changes or deteriorated function and may offer starting points for new diagnostics and interventional strategies.

Level of evidence

II.