Juristischer Notfallkoffer beim Einsatz wegen zivil-, strafrechtlicher oder sonstiger Ansprüche gegen einen Mediziner

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Spontaneous spondylodiscitis and endocarditis: interdisciplinary experience from a tertiary institutional case series and proposal of a treatment algorithm

Previously, the simultaneous presence of endocarditis (IE) has been reported in 3–30% of spondylodiscitis cases. The specific implications on therapy and outcome of a simultaneous presence of both diseases are not yet fully evaluated. Therefore, the aim of this study was to investigate the influence of a simultaneously present endocarditis on the course of therapy and outcome of spondylodiscitis. A prospective database analysis of 328 patients diagnosed with spontaneous spondylodiscitis (S) using statistical analysis with propensity score matching was conducted. Thirty-six patients (11.0%) were diagnosed with concurrent endocarditis (SIE) by means of transoesophageal echocardiography. In our cohort, the average age was 65.82?±?4.12 years and 64.9% of patients were male. The incidence of prior cardiac or renal disease was significantly higher in the SIE group (coronary heart disease SIE n?=?13/36 vs. S n?=?57/292, p?<?0.05 and chronic heart failure n?=?11/36 vs. S n?=?41/292, p?<?0.05, chronic renal failure SIE n?=?14/36 vs. S n?=?55/292, p?<?0.05). Complex interdisciplinary coordination and diagnostics lead to a significant delay in surgical intervention (S?=?4.5?±?4.5 days vs. SIE?=?8.9?±?9.5 days, p?<?0.05). Mortality did not show statistically significant differences: S (13.4%) and SIE (19.1%). Time to diagnosis and treatment is a key to efficient treatment and patient safety. In order to counteract delayed therapy, we developed a novel therapy algorithm based on the analysis of treatment processes of the SIE group. We propose a clear therapy pathway to avoid frequently observed pitfalls and delays in diagnosis to improve patient care and outcome.

     

Effect of drugs used for neuropathic pain management on tetrodotoxin-resistant Na(+) currents in rat sensory neurons

BACKGROUND: Tetrodotoxin-resistant Na(+) channels play an important role in generation and conduction of nociceptive discharges in peripheral endings of small-diameter axons of the peripheral nervous system. Pathophysiologically, these channels may produce ectopic discharges in damaged nociceptive fibers, leading to neuropathic pain syndromes. Systemically applied Na(+) channel--blocking drugs can alleviate pain, the mechanism of which is rather unresolved. The authors investigated the effects of some commonly used drugs, i.e., lidocaine, mexiletine, carbamazepine, amitriptyline, memantine, and gabapentin, on tetrodotoxin-resistant Na+ channels in rat dorsal root ganglia. METHODS: Tetrodotoxin-resistant Na(+) currents were recorded in the whole-cell configuration of the patch-clamp method in enzymatically dissociated dorsal root ganglion neurons of adult rats. Half-maximal blocking concentrations were derived from concentration-inhibition curves at different holding potentials (-90, -70, and -60 mV). RESULTS: Lidocaine, mexiletine, and amitriptyline reversibly blocked tetrodotoxin-resistant Na(+) currents in a concentration- and use-dependent manner. Block by carbamazepine and memantine was not use-dependent at 2 Hz. Gabapentin had no effect at concentrations of up to 3 mm. Depolarizing the membrane potential from -90 mV to -60 mV reduced the available Na(+) current only by 23% but increased the sensitivity of the channels to the use-dependent blockers approximately fivefold. The availability curve of the current was shifted by 5.3 mV to the left in 300 microm lidocaine. CONCLUSIONS: Less negative membrane potential and repetitive firing have little effect on tetrodotoxin-resistant Na(+) current amplitude but increase their sensitivity to lidocaine, mexiletine, and amitriptyline so that concentrations after intravenous administration of these drugs can impair channel function. This may explain alleviation from pain by reducing firing frequency in ectopic sites without depressing central nervous or cardiac excitability.     

Surgical treatment of spinal metastases from renal cell carcinoma—effects of preoperative embolization on intraoperative blood loss

The objective of this paper is analyzing the effects of preoperative embolization on intraoperative blood loss in spinal surgery for renal cell carcinoma (RCC) metastasis and identifying factors contributing to an increased blood loss in the surgical procedure. A retrospective analysis was performed in patients who were treated in for spinal metastasis from RCC between 2011 and 2016. Factors analyzed were reduction of tumor blush, timing of embolization, selective vs. superselective approach, surgical factors, and tumor volume and localization. Parameters were statistically correlated with intraoperative blood loss (hemoglobin (Hg) decrease, blood loss in milliliters, number of transfused blood bags). Twenty-five patients with 34 surgical interventions were included. Seventeen cases were treated superselectively and 11 treated selectively. Mean perioperative blood loss was 2248?±?1833 ml. Higher blood loss was detected for vertebra replacement compared to percutaneous procedures (Hg decrease 4.22 vs. 2.62, p?<?0.05). Blood loss increased with increasing tumor volumes (0–50 ccm/50–100 ccm/>?100 ccm) for Hg loss (3.29/3.64/4.24 mg/dl, NS), blood loss in milliliters (1291/2620/4971 ml, p?<?0.001), and number of transfusions (1.2/3.4/7.0, p?<?0.001). Stratifying by the grade of embolization, no significant differences were found between the groups (>?90%/90–75%/75–50%) for Hg loss, blood loss, or number of transfusions. Endovascular embolization for RCC metastasis of the spine is a safe procedure; however, in this cohort, patients undergoing embolization did not show a reduced blood loss in comparison to the non-embolized cohort. Additional factors contributing to an increased blood loss were tumor size and mode of surgery.     

Combined modified en bloc corpectomy with replacement of the aorta in curative interdisciplinary treatment of a large osteosarcoma infiltrating the aorta

Purpose

We report a case of a large three-level spinal osteosarcoma infiltrating the adjacent aorta. This is the first case in which a combined modified three-level en bloc corpectomy with resection and replacement of the adjacent aorta was successful as a part of interdisciplinary curative treatment.

Methods

Case report.

Results

The surgical procedure was performed as a two-step treatment. A heart lung machine (HLM) was not used, in order to avoid cerebral and spinal ischemia and to decrease the risk of hematogenous tumor metastases. Instead, a bypass from the left subclavian artery the distal descending aorta was used. We modified the en bloc corpectomy procedure, leaving a dorsal segment of the vertebral bodies to enable rapid surgery. The procedure was successful and the en bloc resection of the vertebral body with aortal resection could be achieved. Except for pallhypesthesia in the left dermatomes Th7–Th10, the patient does not have any postoperative neurologic deficits.

Conclusion

Combined corpectomy with aortic replacement should be considered as a reasonable option in the curative treatment of osteosarcoma with consideration of the immense surgical risks. The use of an HLM is not necessary, especially considering the inherent risk of hematogenous tumor metastases. Modified corpectomy leaving a dorsal vertebral body segment was considered a reasonable variation since tumor-free margins could still be expected.

     

Posterior vertebral column resection with 360-degree osteosynthesis in osteoporotic kyphotic deformity and spinal cord compression

Neurosurgical Review - Osteoporotic fractures with severe kyphosis and neurologic deficits often require decompression and stabilisation. To reduce the risk of procedure-related complications,...