[Application of image-guided injection for cervical and lumbar syndromes]. / Anwendung Bildwandler-gestützter Injektionen bei Zervikal- und Lumbalsyndromen.

The X­ray image-guided injection methods are an important tool for the treatment of cervical and lumbar pain syndromes. For the application of these methods it is necessary to have a differentiated consideration of cervical and lumbar pain syndromes. This leads to a decoding of complaints to assignable pain generators, which enables a targeted injection method. Depending on the origin of pain, injections are placed at the nerve root or the joints. Thus, the vicious cycle of pain can be stopped. A correct technical procedure is of enormous importance. Particular attention must be paid to the pharmacological effects and special complications. A monitoring and precautionary measures are mandatory.

[The application of different injection methods for cervical and lumbar syndromes]. / Anwendung unterschiedlicher Injektionstherapien bei Zervikal- und Lumbalsyndromen.

The differentiated consideration of cervical and lumbar pain syndromes leads to a decoding of complaints to assignable pain generators which enables a targeted injection method. Depending on the origin of pain injections are placed at the nerve root or the joints. Thus, the vicious cycle can be stopped. A correct technical procedure is of enormous importance. Because pharmacological effects and special complications are possible, monitoring and precautions are mandatory.

[Injection therapy for cervical and lumbar syndromes]. / Injektionstherapie bei Zervikal- und Lumbalsyndromen.

In cervical and lumbar pain syndromes special injections are key for effective pain therapy. Depending on the origin of pain injections are placed at the nerve root or the joints. Thus, the vicious cycle can be stopped. A correct technical procedure is of enormous importance. Because pharmacological effects and special complications are possible, monitoring and precautions are mandatory.

Prospective medium-term results of multimodal pain management in patients with lumbar radiculopathy.

Lumbar radiculopathy is one of the most common diseases of modern civilisation. Multimodal pain management (MPM) represents a central approach to avoiding surgery. Only few medium-term results have been published in the literature so far. This study compared subjective and objective as well as anamnestic and clinical parameters of 60 patients who had undergone inpatient MPM because of lumbar radiculopathy before and 1 year ±2 weeks after treatment. The majority of patients were very satisfied (35%) or satisfied (52%) with the treatment outcome. Merely 8 patients commented neutrally and none negatively. The finger-floor distance had decreased significantly (p < 0.01), and 30 patients (50%) had shown improved mobility of the spine after therapy. The need for painkillers had also been significantly reduced after 1 year. The arithmetical average of pain on a visual analogue scale was 7.21 before treatment, which had significantly decreased to 3.58 at follow-up (p < 0.01). MPM is an effective approach for treating lumbar radiculopathy by mechanical nerve root irritation. Therefore, in the absence of an absolute indication for surgery or an absolute contradiction for MPM, patients should first be treated with this minimally invasive therapy.

[Surgical treatment of scoliosis in childhood and adolescence: Age group and etiology-related indications and choice of instrumentation]. / Operative Behandlung der Skoliose im Kindes- und Jugendalter: Differenzialindikation und Verfahrenswahl bei verschiedenen Altersgruppen und in Abhängigkeit der Ätiologie.

The indications for a corrective surgical procedure for the complex 3-dimensional deformations of the spine collectively known under the term scoliosis, essentially depend on knowledge of the underlying etiology, the time of initial diagnosis in relation to the growth curve of the child and on considerations about the general operability of the patient. An early onset of scoliosis in childhood under defined diagnostic criteria is usually associated with a fast progression of spinal curvature and requires early surgical intervention during the growth period, while scoliosis in adolescence often allows a delayed surgical intervention until all conservative means have been taken into consideration. Corrective measures in the growing spine require procedures and adjustable hardware which can be adapted to vertebral and thoracic growth and thus anticipate the threat of pulmonary insufficiency due to postural and spinal collapse. Towards the end of puberty when spinal growth slowly comes to an end, corrective spinal fusion procedures are considered in those cases of early and late onset scoliosis, where curvature progression is likely to occur.

[Injection therapy of cervical spine syndromes]. / Injektionstherapie beim Zervikalsyndrom.

In cervical spine syndromes, specific injections can reach the pain focus or diminish the nerve root irritation, thus overcoming the vicious circle. Indications, contra-indications, complications, the exact procedure of placing the needle, and the combined use with conservative treatment must be taken into consideration.

[Surgical therapy of osteoporotic vertebral body fractures]. / Operative Behandlung osteoporotischer Wirbelkörperfrakturen.

Osteoporosis is an age-related systemic disease leading to increased bone fragility. The vertebral bodies of the transitional area between the thoracic and lumbar spine are often involved. A large number of unreported or late-diagnosed fractures have to be assumed. If risk factors such as advanced age or comorbidities are present in the case of new-onset back pain, an osteoporotic vertebral body fracture as a possible cause has to be considered. This sets the diagnostic workup in motion, consisting of clinical and radiological examinations. In addition to conservative treatment, minimal invasive cement augmentation of the fracture via vertebroplasty or kyphoplasty is an option. Open surgical procedures, feared by older patients and their physicians, are rarely necessary. Of utmost importance after dealing with the fracture is the subsequent treatment of the underlying osteoporotic disease to prevent the occurrence of further fractures.

[Clinical pathway - conservative back pain treatment]. / Klinischer Behandlungspfad - konservative Wirbelsäulenbehandlung.

Back pain is a very common clinical picture. The causes are often not only somatic, which generally has led to a biopsychosocial understanding of this disease. Therefore, it is necessary to employ a multimodal treatment approach to achieve effective and longer-lasting relief. Such a concept requires the cooperation of multiple disciplines in a sophisticated and strongly organized manner. In our clinic we have developed a clinical pathway for conservative back pain treatment that avoids the use of too much time by careful coordination of the therapy elements. It has proven to be a successful tool for the efficient treatment of patients with primarily somatically caused back pain. The following article describes this clinical pathway.

[Orthotic methods for osteoporosis and osteoporotic vertebral fracture]. / Orthesenversorgung bei Osteoporose und osteoporotischen Wirbelkörperfrakturen.

Even in times of kyphoplasty and vertebroplasty, braces remain an efficient option in the treatment of osteoporotic hyperkyphosis due to imminent or manifest vertebral wedging with the obligatory pain and fracture risk of adjacent vertebraes. In the same fashion, acute osteoporotic fractures with considerable backpain can be treated with an adequate orthosis besides analgetics and osteological drugs. Essential is the careful selection of the right brace for a given type of osteoporotic fracture: Overall brace-frames (Stagnara type) should be used only in highly unstable or multiple osteoporotic fractures with impact onto the spinal canal where surgery is not possible. These brace frames should be administered only for the shortest possible period (8-12 weeks) to reduce muscle atrophy and immobilization. However, in the typical stable osteoporotic wedge fracture, light weight constructions like the Jewett or Bähler-Vogt brace or - in less severe cases - dynamic braces (e.g. TorsoStretch brace or SpinoMedActive brace) should be used to minimize muscle atrophy and demineralisation. Brace treatment at its best though, can be only one step in the cascade of measures to fight demineralisation and the clinical consequences: General physiotherapy, analgetics and specific osteological drugs and minerals add essentially to the treatment.

[Current state of doing minimal invasive total hip replacement in Germany, the use of new implants and navigation--results of a nation-wide survey]. / Aktueller Stand der minimalinvasiven Hüftendoprothetik in Deutschland, neue Implantate und Navigation--Ergebnisse einer bundesweiten Umfrage.

AIM: Total hip replacement has been developed to a very successful surgical procedure over 3 decades. In the last years many new helpful implants were introduced to the market, minimally invasive procedures were presented together with the technique of navigation. There is no scientific proof of the benefit of these procedures. The objective of this study was to collect data about the preferences of the surgeons for procedures and implants. METHODS: In a countrywide anonymous survey, staff of 240 German trauma surgery and orthopaedic surgery departments were asked about their MIS procedures and their treatment strategies (August 2006). RESULTS: 184 of the questionnaires have been returned representing 64,569 THRs, 65% with cementless fixation, 12.6% with bone conserving implants and 4.1% with resurfacing. We found that 77% of the respondents were doing minimally invasive THR. 34% of all THR are minimally invasive (MIS) procedures, while 23% of the patients ask for MIS. Most of the surgeons (54%) define "minimally invasive" as the preservation of muscle, tendons and soft tissue, and 33% as the length of skin incision to be less than 10 cm. 78% are convinced that long-term survival is achievable even with less invasive methods. The most common MIS approach is the anterior/anterolateral (42%), for the standard procedure (not MIS) the dorsal approach is the most used (42%), and for revision surgery the lateral approach (44%). 77% of the respondents never use navigation and 54% are convinced that there is no sense in it. 75% of MIS surgeons use special MIS instruments: 97% use redon drainage, 48% the cell-saver, 71% of the operations are performed by senior/head surgeons. The assistant quota was largest in high-volume centres. CONCLUSION: Innovative implants are used with care, more than one-third of all implants are still fixed with cement. MIS is performed in one-third of the THRs and it is not driven by sensationalised reports in the media. Even the surgeons' philosophy is oriented by long-term survival, most of them are defining MIS by preventing soft tissue damage and not by the length of skin incision. The transgluteal approach is still widespread, the drawbacks are hardly detectable, the soft tissue damage irreversible. Still lacking an adequate definition of the term "MIS", it is unclear whether the soft tissue is spared or the damage to it is the same under a smaller skin incision. Computer-aided surgery in THR is not used by most of the surgeons, for the majority it is not favourable.

[Minimally invasive injection therapy for patients with radicular lumbar spine syndrome. First results of an minimally invasive treatment for patients with lumbar radiculopathy]. / Minimalinvasive Injektionstherapie beim radikulären Lumbalsyndrom. Erste Ergebnisse bei Patienten mit lumbaler Radikulopathie.

BACKGROUND: There are few studies on minimally invasive injection therapy (MIT) combined with multimodal conservative therapeutic options. Here, we evaluate the results of MIT in a clinical study. METHODS: A total of 61 patients with radicular lumbar symptoms treated with MIT were examined before and 14.5 months after treatment. Subjective, objective, clinical and anamnestic parameters were considered. RESULTS: In most cases, protrusions and prolapses were seen. Radicular pain, sensible and motoric deficits and also functionality of the spine could be rectified after MIT. No major complications were seen during treatment. CONCLUSION: MIT is an effective approach with few complications for the treatment of patients with radicular syndromes.

[Neuromuscular imbalances of the lower back in tennis players--the effects of a back exercise program]. / Neuromuskuläre Dysbalancen der Rückenmuskulatur im Tennissport und ihre Therapie mit einem funktionsgymnastischen Trainingsprogramm.

SUMMARY BACKGROUND DATA: Tennis players asymmetrically load the trunk while playing. Neuromuscular imbalances are risk factors for low back injuries. The association between neuromuscular activity patterns of the lower back and back exercise has not been researched yet. METHODS: Simultaneous maximum isometric trunk extension test and surface-electromyographic recordings from lumbar erector spinae in 82 amateur tennis players in a specially built apparatus before and after a seven-week back exercise home program. RESULTS: Left-right neuromuscular imbalances of lumbar erector spinae were present amongst 48 (58.5 %) out of 82 tennis athletes, statistically closely related to handedness. Within the training group (n = 70), neuromuscular imbalances of erector spinae were significantly evened out without a significant increase of maximum trunk extension strength. No such effects were detected within the control group (n = 12). CONCLUSION: Tennis specific biomechanics seems to predispose to lumbar neuromuscular imbalances. A back exercise program for tennis player can significantly even out those imbalances.

[Minimal-invasive injection therapy for cervical syndromes]. / Minimal-invasive Therapie bei Zervikalsyndromen.

The specific minimal-invasive injection therapy is a key-procedure for cervical spine syndromes when performing a multimodal pain-therapy. Due to the exactly placed injections pain can be overcome. Indication is given in cases of continuing spine pain and is an alternative to operative procedure, as for as no absolute indication for operation is given. The complex injection technique affords knowledge and expertise. The exact application and the specific complications are presented in detail.

[Minimally invasive injection therapy in lumbar syndromes]. / Minimal-invasive Injektionstherapie beim Lumbalsyndrom.

Minimally invasive injection therapy is an effective approach for the treatment of sciatica with less complications. This therapy is a sufficient option in cases without absolute indications for operation.The paper describes in detail the different injection techniques like spinal nerve analgesia, epidural dorsal/perineural injections, vertebral joint infiltrations, and radiculographies.

[Postoperative autologous retransfusion of collected shed blood after total knee arthroplasty with the cell saver]. / Postoperative Drainageblutretransfusion mit dem Cellsaver bei endoprothetischem Kniegelenkersatz.

AIM: The purpose of this study was to examine if it is possible to reduce transfusion of blood units by collecting shed blood with the Cell Saver for autologous retransfusion in total knee arthroplasty (TKA). METHOD: In 186 patients drainage blood was collected over a 6-h period after total knee arthroplasty with a Cell Saver system in order to make retransfusions if necessary. A tourniquet was used routinely throughout the operation. No preoperative blood donation was performed. In 19 patients preoperative haemoglobin levels were below 12 g/dL (group A, anaemic patients). In the other 167 patients (group B) the preoperative haemoglobin levels were higher. RESULTS: 4 patients (21 %) in group A received a homologous blood transfusion. Only 1 patient (0.6 %) in group B received one unit of erythrocyte concentrate (difference statistically significant, P < 0.001). In group A 8 patients (42 %) received 284 ml (145-621 ml) Cell-Saver concentrate on average, 38 patients (23 %) in group B received 358 mL (147-776 ml) Cell-Saver concentrate on average. CONCLUSION: With a risk lower than 1 % for patients without anaemia to get a homologous blood transfusion one can do without the more expensive preoperative blood donation in total knee arthroplasty if a tourniquet is used for the operation and a Cell Saver is used for facultative retransfusion of drainage blood.

Molecular evidence for local denervation of paraspinal muscles in failed-back surgery/postdiscotomy syndrome.

A study was performed to analyze whether local denervation of the medial branch of the dorsal ramus of the lumbar spinal nerve occurs in a patient with postoperative failed-back surgery syndrome/postdiscotomy syndrome (FBSS/PDS). We investigated the effect of the loss of innervation of the multifidus muscle on neuronal nitrite oxide synthetase (n-NOS) and endothelial nitrite oxide synthetase (e-NOS) applying realtime RT-PCR and immunohistochemistry. Our study demonstrates a substantial reduction of n-NOS expression, supporting the view that local denervation of the multifidus is involved in the pathology of FBSS. No regulation of e-NOS was detectable. Interestingly, this change is region-specific and does not occur throughout the entire multifidus segment. This result supports the hypothesis that local denervation of the multifidus muscle is involved in the pathology of FBSS/ PDS.

[A prospective double blind study of cervical nerve infiltration with isotonic saline and local anaesthetic]. / Isotone Kochsalzlösung gegen Lokalanästhetika. Prospektiv randomisierte Doppelblindstudie bei zervikalen Spinalnervenanalgesie.

PURPOSE OF THE STUDY: Aim of this investigation was the examination of the therapeutic effect of cervical nerve infiltration with mepivacaine in comparison to local applications of isotonic sodium chlorid solution in a prospective randomised double blind study. METHODS: 57 patients with cervicocephalgia or cervicobrachialgia were injected daily with mepivacaine ( n=28) or physiological sodium chlorid solution ( n=29). The success was judged through the blinded patients and blinded therapists first after three days of treatment. If no improvement occurred a single injection of mepivacaine and triamcinolonacetonid was given. This injection could be repeated if required. At the end of the inpatient treatment, after a mean of 14 days, the patients assessed the treatment according to a scale of 1-4 (painfree - no improvement). RESULTS: The average therapeutic effect, in the subjective appraisal of 1-4 by the patients, was 2.15 in the mepivacaine-group and 2.54 in the sodium chlorid - group. In the mepivacaine-group no pain (note 1) was achieved two times and 21 times a clear improvement (note 2), while in the sodium chlorid - group 18 times a clear improvement was achieved and never freedom of pain ( p<0,038). In the mepivacaine-group twice a steroidinjection was required, while in the sodium chlorid - group this was necessary in 16 cases ( p<0,01). CONCLUSION: Cervical injections with mepivacaine improve the subjective pain perception in cervicocephalgia and cervicobrachialgia significantly better than isotonic sodium chlorid - solution in short term results and can therefore be prefered. After an inpatient treatment good and excellent subjective results could be achieved in a high percentage.