Early sacral neuromodulation prevents urinary incontinence after complete spinal cord injury.

BACKGROUND: The study aim was to investigate potential influences on human nerves and pelvic organs through early implantation of bilateral sacral nerve modulators (SNMs) in complete spinal cord injury (SCI) patients during the acute bladder-areflexia phase. METHODS: Ten patients with neurologically-confirmed complete spinal cord lesions (SCLs) were provided with bilateral SNMs during the phase of atonic-detrusor muscle. Modulation was achieved by two electrodes implanted into each S(3)-foramen. Six patients declined and served as controls. The mean follow-up was 26.2 months. RESULTS: Videourodynamics (VU) confirmed detrusor acontractility, resulting in urinary continence as well as significant reductions in urinary tract infections (UTIs). Bowel movements did not require oral laxatives; additional preprogrammed parameters achieved erections for intercourse. INTERPRETATION: Early SNM implantation in SCI patients may revolutionize neurogenic lower urinary tract (LUT) dysfunction management; it prevented detrusor overactivity and urinary incontinence, ensured normal bladder capacity, reduced UTI rates, and improved bowel and erectile functionality without nerve damage. CONCLUSION: Future SCI investigations will be conducted to evaluate the potential benefits of even earlier SNM placement to progressively enhance pelvic organ functionality. This new approach may provide important clues required for assessing whether neuronal information is passed through the sympathetic trunk ganglion to the brain after complete SCI. Further investigations are needed to determine if functional magnetic resonance imaging (fMRI) might be helpful for analyzing changes in brain function in patients with SNMs and those taking antimuscarinics.

Immune depression syndrome following human spinal cord injury (SCI): a pilot study.

Experimental spinal cord injury (SCI) has been identified to trigger a systemic, neurogenic immune depression syndrome. Here, we have analyzed fluctuations of immune cell populations following human SCI by FACS analysis. In humans, a rapid and drastic decrease of CD14+ monocytes (<50% of control level), CD3+ T-lymphocytes (<20%, P<0.0001) and CD19+ B-lymphocytes (<30%, P=0.0009) and MHC class II (HLA-DR)+ cells (<30%, P<0.0001) is evident within 24 h after spinal cord injury reaching minimum levels within the first week. CD15+ granulocytes were the only leukocyte subpopulation not decreasing after SCI. A contributing, worsening effect of high dose methylprednisolone cannot be excluded with this pilot study. We demonstrate that spinal cord injury is associated with an early onset of immune suppression and secondary immune deficiency syndrome (SCI-IDS). Identification of patients suffering spinal cord injury as immune compromised is a clinically relevant, yet widely underappreciated finding.

A multicenter, double-blind, randomized, parallel group study comparing polyvinyl chloride and polyvinyl chloride-free catheter materials.

PURPOSE: In this study we compared a polyvinyl chloride catheter with a new polyvinyl chloride-free catheter with the same hydrophilic coating, and determined whether patient perception of ease and comfort of clean intermittent catheterization was independent of the catheter material. MATERIALS AND METHODS: This investigation was designed as a randomized, double-blind, parallel group, multicenter study. Eligible patients were experienced users of clean intermittent catheterization with a polyvinyl chloride catheter for a minimum of 1 month before randomization. They were randomized to continue to use the polyvinyl chloride catheter or switch to a polyvinyl chloride-free catheter for 4 weeks. Both catheters had a similar appearance. Patient perception of ease and comfort of clean intermittent catheterization was scored with questionnaires, and adverse events were documented. RESULTS: A total of 195 patients were recruited from 6 countries and 13 centers for the intent to treat analysis, and 179 were used for the per protocol analysis. Before randomization 94% to 98% of the patients rated the polyvinyl chloride catheter as easy or manageable to handle during different phases of clean intermittent catheterization and overall 92% of patients were satisfied. Of the eligible patients satisfaction was reported by 89% randomized to continue using the polyvinyl chloride catheter and by 78% randomized to switch to the polyvinyl chloride-free catheter (not significant). The rate of adverse events was low and comparable between the 2 groups. CONCLUSIONS: The study confirms that clean intermittent catheterization is easy and safe. Conversion from a polyvinyl chloride to a polyvinyl chloride-free core catheter material does not alter patient perception of catheterization.

[Value of scintigraphy with 111In-acetylacetone-labelled auto-leukocytes in the diagnosis of infected total endoprostheses]. / Zur Wertigkeit der Szintigraphie mit 111In-Acetylaceton-Eigenleukozyten in der Diagnostik infizierter Totalendoprothesen.

Scintigraphy with 111In-acetylacetone-leucocytes is valuable in detecting infectious processes in alloarthroplasties of the hip and knee. The sensitivity of 95% is high whereas the specificity of 74% is low due to the high incidence of falsely positive results. These are seen mainly in aggressive granulomas of the hip caused by alloarthroplasties using metal sockets and polyethylene heads. Since those alloarthroplasties are no longer used the incidence of falsely positive scans will decrease and the specificity of the method is likely to increase.

[Indium-111 scintigraphy in acute and chronic osteomyelitis in animal model. An experimental study]. / Die Leukozytenszintigraphie mit 111-Indium bei akuter und chronischer Osteomyelitis im Tiermodell--Ein experimentelle Studie.

Studies on 28 New Zealand white rabbits with experimentally induced osteomyelitis show that 111In-leukocyte scans turn negative when inflammation changes from the acute stage (histologically represented mainly by granulocytes and only small development of collagenous fibres) into the chronic stage (histologically showing marked lymphoplasmacytic infiltration and increased development of connective tissue). Falsely negative scans (i.e. cold lesions) are due to marked medullar necroses accompanied by diminished development of an abscess wall and reduced concentration of granulocytes within the necroses. Truly negative scans (i.e. cold lesions) are seen in chronic osteomyelitis with extended medullar fibrosis accompanied by reduced blood flow in comparison to the normal medullar bone of the contralateral side. The histological course of experimental osteomyelitis in rabbits is in some respect comparable with the stages of osteomyelitis in man and allows to predict the result of the leukocyte scan.

[Radius head resection as a reconstructive measure of the elbow joint]. / Die Radiusköpfchenresektion als wiederherstellende Massnahme am Ellenbogengelenk.

The authors followed up 55 patients to check on the clinical manifestations prevailing ten years after resection of the head of the radius with particular reference to the pattern presented in the radiocarpal joint. Particular attention was paid to functional and roentgenological changes in the regions of the elbow and wrist. Overall results were unsatisfactory, although a clear improvement in function could be seen in old fractures of the head of the radius, although the function did not improve beyond that achieved by primary resection of the head. No convincing improvement was obtained in old dislocations of the radial head (most of them being accompanied by additional injuries) by a resection of the head of the radius. With the progress of time after the operation, the overall result deteriorated, depending on the likewise slowly progressing proximal dislocation of the radius and hence negative influence exercised on the biomechanics in the distal radioulnar or wrist joint. On the basis of these results it is recommended to attempt radial head preserving treatment as the initial measure in fractures of the head of the radius, i.e. to promote osteosynthesis as far as ever possible.

[Fatigue fractures in the area of the hip joint in joggers]. / Ermüdungsfrakturen im Hüftgelenksbereich bei Joggern.

An increased incidence of fatigue fractures of the lower extremities has been observed as a result of the jogging craze. The authors describe a fatigue fracture of the neck of the femur and a fracture dislocation (not described to date) of the hip joint with fracture of the posterior acetabular margin and avulsion of a femoral head fragment.

[Pharyngo-vertebral fistula with transspinous course to the neck skin due to a cervical spondylodesis - case report and review of the literature]. / Pharyngovertebrale Fistel mit transspinalem Verlauf zur Nackenhaut bei zervikaler Spondylodese - Falldarstellung und Literaturübersicht.

BACKGROUND: Pharyngo-vertebral fistulas - especially with delayed diagnosis - are a rare but grave reported complication in cervical spine surgery. PATIENTS AND METHODS: We present a patient, sent postoperatively from Italy after cervical spine surgery to our department. The patient has developed a pharyngo-vertebral fistula with transspinous course to the dorsal neck skin due to infected spondylodesis. CASE REPORT: In the presented patient, the successful closure of the pharyngo-vertebral fistula with transspinous course was made after diverse revisions at the anterior side with a platysma flap, at the posterior one with a drain. REVIEW OF THE LITERATURE: Aetiology, diagnostic work-up and treatment opinions are discussed in a detailed literature review. CONCLUSION: To the best of the authors' knowledge the presented pharyngo-vertebral fistula with transspinous course to the dorsal neck skin as a complication after anterior cervical spine surgery has not been reported in the literature before.

Cortical processing of residual ano-rectal sensation in patients with spinal cord injury: an fMRI study.

Eleven paraplegic patients with complete traumatic spinal cord injuries (SCI) [according to American Spinal Injury Association (ASIA) criteria] at different levels (Th3-L3) were investigated during non-painful stimulation of the distal rectum and anal canal, using event related functional magnetic resonance imaging. Although a complete lesion was clinically diagnosed in all, four of them experienced reproducible sensations during anal and/or rectal stimulation. In six patients, individual data analysis revealed significant activation in the right secondary somatosensory cortex SII, the posterior cingular gyrus, the prefrontal cortex, and the left posterior cerebellar lobe during either anal or rectal stimulation or both. A Region of interest analysis using a data mask from healthy controls confirmed that SCI patients demonstrate cortical activation in areas similar to those activated in healthy volunteers, but to a less extensive degree. This supports the notion that the diagnosis of complete spinal cord transsection by ASIA criteria alone may be insufficient for assessment of 'completeness' of cord lesions, and that visceral sensitivity testing may be required in addition.

[CT-based assessment score after ventral spondylodesis for thoracolumbar spine fracture]. / CT-basierter Auswertungsscore nach ventraler Spondylodese bei thorakolumbalen Wirbelfrakturen.

BACKGROUND: Dorsoventral stabilization is a common procedure to treat thoracolumbar spine fractures. Especially in respect of the evaluation of alternative procedures to autogenous bone graft, a standardized evaluation score for ventral spondylodesis is necessary. PATIENTS AND METHODS: In a group of 44 patients a follow-up CT scan was evaluated with a standardized scoring system by four different independent evaluators (a trauma surgeon, an orthopedic surgeon, and two radiologists). The score is based on the morphologic classification of the region between graft and vertebral body. It allows a classification of the spondylodesis as sufficient, partial, and not sufficient. RESULTS: The statistical evaluation of the classification of the different evaluators shows very good interobserver agreement in monosegmental fusion and good agreement in bisegmental fusion. CONCLUSION: The demonstrated score is easy to handle, does not need special equipment for CT scans, and shows good interobserver agreement in the classification of spinal fusion after ventral spondylodesis for thoracolumbar spine fracture.

[Development of the spine after traumatic spinal cord injury in children and adolescents]. / Die Entwicklung der Wirbelsäule bei traumatischer Querschnittlähmung im Kindes- und Adoleszentenalter.

In the 1970s, there was growing concern about the risk of secondary deformations of the spine as these seemed to endanger the otherwise improving prognosis for the life of paraplegic subjects, especially of paralyzed children and adolescents. According to the literature, the level and extent of the spinal cord injury and the age at the time of injury are determinants of the development of scoliosis, hyperlordosis or global kyphosis. Correction of the deformity by brace orthosis is not indicated except for children. The indications for surgical intervention in terms of the extent of the scoliosis and technical performance corresponds to the well known situation for idiopathic scoliosis except for the length of fusion. A special form of scoliosis, the so called "collapsing spine", allows good surgical correction because it is usually not rigid. Early, substantial degenerative processes such as segmental intervertebral instability at the level of the paraplegia, as well as distinct uncarthrosis proximally distant from the innervated zones with secondary radicular damage, are observed. By means of modern surgical procedures, the appearance of the patient's body, as well as the quality of life, can be favorably influenced.

[Grice's method of subtalar arthrodesis--long term results of 63 operations]. / Subtalare Arthrodese nach Grice--Langzeitergebnisse von 63 Operationen.

Deformities of the back foot should be operated after failed conservative treatment. In this article long time results of 36 patients are demonstrated, which are operated on with extraarticular blocking (Grice-OP) of the lower ankle. Most patients are suffering of cerebral palsy. Walking could be improved after surgery but we could not reduce orthopaedic devices. In relation to Spina bifida patients CP-patients showed worse correlation of the back foot valgus. We got better results using k-wires for stabilisation of the back foot. Grice-OP is able to prevent severe deformities but it is often followed by a subtalar arthrodesis after growth arrest.

[Satisfaction following automated percutaneous lumbar discectomy as a function of clinical parameters]. / Zufriedenheit nach automatisierter perkutaner lumbaler Diskektomie in Abhängigkeit von klinischen Parametern.

182 patients assessed their condition after automated percutaneous lumbar discectomy (APLD). The analysis of descriptive data parameters++ provides new guidelines for the indication of this minimally invasive procedure: persistent leg pain despite conservative treatment, lumbar disc prolapse in one segment, minimal monological pathology, This ideal constellation implies a restriction of the common guidelines. Under these premises 50% of the patients will be satisfied. So the indication for APLD seems to be justified under more unfavorable patient profiles if the natural course of sciatica was poor.

[Arthrolysis and arthroplasty of the elbow joint. A comparison of surgical results between children and adults]. / Die Arthrolyse und Arthroplastik des Ellenbogengelenkes. Ein Vergleich der operativen Ergebnisse zwischen Kindern und Erwachsenen.

Because of stiffness of the elbow joint until 1988 146 operations have been done in 132 patients on the Department of Orthopaedic Surgery in Heidelberg. 55 procedures have been done in children and adolescents younger than 16 years, 91 times in adults. In both groups posttraumatic stiffness and stiffness of other origin have been treated. Procedures have been mobilisation in anesthesia, simple or enlarged arthrolysis as well as arthroplasties. Results have been evaluated by the method of Cauchoix and Deburge (relative gain of range of movement). In nontraumatic stiffness of the elbow younger patients under the age of 16 years showed better results than the adults, in posttraumatics the results seemed to be better in the adults. Mere mobilisation in anesthesia showed disappointing results in both groups generally.

[Anticoagulant activity of triiodinated x-ray opaque media (author's transl)]. / Gerinnungshemmende Wirkungen trijodierter Röntgenkontrastmittel

The anticoagulant activity of the triiodinated X-ray opaque media iodipamide, iothalamate and diatrizoate on standardized normal human pool plasma was investigated in vitro. We found a dose dependent lengthening of the thrombin time, the reptilase time and the partial thromboplastin time together with a dose dependent drop of the calcium thromboplastin and factor V activity. Iodipamide proved to exert the most pronounced anticoagulant activity of the 3 contrast media tested. The results are interpreted as latent disseminated intravascular coagulation with hyperfibrinolysis following the direct interaction of contrast media with the coagulation enzymes.

[Symphysis injury--clinical and ultrasound follow-up]. / Symphysensprengung--klinische und sonographische Verlaufskontrolle.

We report about the sonography as a non-invasive method for diagnosis and control of a postpartal injury of the symphysis.

[Ultrasound follow-up of bone lengthening osteotomy]. / Sonographische Verlaufskontrollen von Verlängerungsosteotomien.

We report about the possibilities of sonography with regard to postoperative control of limb-lengthening. During the phase of distraction we can show the amount of lengthening with a 5 or 3.5 MHZ linear transducer. We can measure the lengthening or the axial deviation with a sonography as exactly as with an x-ray. X-rays can be saved and the x-ray doses can be reduced.

[Complication rate following trochanteric osteotomy in total hip endoprosthesis. A retrospective study with failure analysis]. / Die Komplikationsrate nach Trochanterosteotomie bei Hüfttotalendoprothesen. Eine retrospektive Studie und Fehleranalyse.

In total hip arthroplasty extended approach, simplified luxation and improved exposure are the major advantages of trochanteric osteotomy. The main complication of the iatrogenic fracture is the nonunion which has occurred in about 20% of our patients (61 operations, 80% revision procedures). The rate of nonunion decreases using an optimized technique of reattachment, in particular; sufficient thickness of wires and placing of K-wires in the trochanter minor region. However, the bony nonunion has not necessarily an influence of the clinical outcome. Fibrous union provides in most cases satisfactory stability and function. In 3 patients revision surgery was necessary caused by the trochanter osteotomy: 2 suffered from a painful bursitis. In the 3rd case a strong abductor impairment occurred as the result of the trochanteric osteotomy. Refixation of the dislocated trochanter became necessary. Considering the risk of complications trochanteric osteotomy should be for exceptional cases only.

[Postoperative infections and wound healing disorders in patients with infantile cerebral palsy]. / Postoperative Infektionen und Wundheilungsstörungen bei Patienten mit infantiler Cerebralparese.

As part of a retrospective study including 569 patients with ICP and a group of 405 controls, the risk of postoperative wound healing disorders and wound infections was investigated in surgically treated children with cerebral palsy. The higher rate of wound healing disorders in ICP patients could not be attributed to factors such as excessively long duration of operation, secondary interventions, or a high number of interventions per operation. Rather, the causes of the increased risk of infection have to be seen in connection with the symptoms of ICP itself, such as immunological weakness, increased tendency to sweat, reduced circulation in the affected extremity and disturbances of sensitivity and perception. A direct link between these parameters and increased risk of postoperative infection can only be established by prospective studies.