[Minimally invasive posterior and anterior stabilization of the thoracolumbar spine after traumatic injuries]. / Minimal-invasive dorsale und ventrale Stabilisierung der thorakolumbalen Wirbelsäule bei traumatischen Verletzungen.

Injuries of the thoracolumbar junction are the most common fractures of the spine due to their anatomical position and load. Common classification systems differentiate between stable and unstable injuries and thus also between operative and conservative therapy. The majority of injuries can be treated conservatively; however, unstable injuries require surgical treatment for a variety of reasons. In the grey area between stable and unstable injuries, a clinical decision based on clinical experience is necessary in order to select the best treatment. A wide variety of parameters must be included and a change in strategy from conservative to operative may also be necessary. Posterior instrumentation is the most common procedure; purely anterior stabilization is rarely used. The length of the instrumentation/spondylodesis depends on bone quality, age of the patient, and fracture. The decision as to whether anterior operative treatment should be performed depends on fracture morphology, success of reduction, and the resulting stability. The open surgical procedure is increasingly being replaced by minimally invasive procedures in posterior and anterior techniques but can be an advantage in complex injuries (B and C injuries according to AO). Hybrid procedures are also possible. This also applies to the treatment of osteoporotic fractures, since a clear assignment between traumatic and osteoporotic cause is not always easy and possible. This article describes the principles, the possible indications, and limitations of minimally invasive posterior and anterior stabilization.

Rescue Nuss procedure for inferior vena cava compression syndrome following posterior scoliosis surgery in Marfan syndrome.

PURPOSE: Scoliosis surgery in Marfan syndrome is common, even in the presence of a funnel chest. However, to date, no case has been reported with acute intra-/postoperative decompensation caused by vena cava compression following posterior spinal derotation and fusion. METHODS: A 15-year-old male patient with Marfan syndrome, a funnel chest and severe scoliosis was treated with surgery for the spinal deformity. Intraoperatively, the patient developed a clinically relevant compression of the inferior vena cava with severe circular depression. Postoperatively, a cava compression syndrome with severe pleural effusion, ascites and enormous swelling of the lower limbs was developed. A conservative treatment of the symptoms, consisting of thoracic drainage and negative fluid balance, failed. Subsequently, the patient was transferred to pediatric intensive care unit for further treatment. Echocardiography and a CT scan demonstrated cava compression syndrome. A rescue Nuss procedure of the funnel chest deformity was performed since conservative treatment failed. The clinical course proceeded without complications and with a decrease in clinical symptoms of inferior inflow congestion. The patient was discharged after almost 3 weeks. CONCLUSION: The problem of congenital stenosis of the inferior vena cava in Marfan syndrome has not yet been investigated. In the case of simultaneously existing funnel chest and scoliosis in Marfan syndrome, an interdisciplinary discussion is required to decide whether a repair of the funnel chest should be performed first in order to prevent a clinically relevant compression syndrome. For the detection of a preoperatively relevant stenosis of the inferior vena cava, an MRI or thoracic/abdominal CT should be used preoperatively.

[Surgical treatment of posterior shoulder dislocation: importance of arthroscopy]. / Operative Versorgung der posterioren Schulterluxation: Stellenwert der Arthroskopie.

OBJECTIVE: Posterior dislocations of the shoulder represent a rare injury with frequently occurring soft tissue and/or bony concomitant lesions such as the reverse Hill-Sachs lesion and the dorsal labrum tear. For the combination of these injuries, no evidence-based therapeutic recommendations exist. AIM OF STUDY: Reflecting on two clinical cases and the current literature data, options for the treatment of combined osseous and soft tissue injuries due to posterior dislocation of the shoulder are presented. METHODS: We report two cases of fresh traumatic first-time posterior dislocations that were each explored arthroscopically and subsequently operated using an open technique. In the first case, we performed refixation of the labrum, followed by open osteosynthesis with bone substitution. Treatment of the second case included diagnostic arthroscopy and - after a frustrating attempt to elevate the defect in an arthroscopically assisted retrograde technique - open reconstruction of the humeral head with an allograft. RESULTS: In both cases good clinical outcomes with Constant scores of 79 and 86 points at the 16- and 12-month follow-ups, respectively, were achieved. Radiologically complete integration of the used materials was found. CONCLUSION: These cases show that for the operative treatment of fresh, traumatic posterior shoulder dislocation, it is useful to explore the joint arthroscopically to identify concomitant injuries of the labrum and if necessary treat them. The bony pathology of the humeral head can subsequently be addressed in an open technique, whereby the appropriate treatment should be chosen based on the size of the defect.

[Odontoid fracture after high impact trauma : Assess instability correctly]. / Densfraktur nach Hochrasanztrauma : Instabilität richtig einschätzen.

Odontoid process fractures are frequent injuries of the cervical spine and usually occur at an advanced age and often due to minor trauma. In younger patients they are mainly observed in the context of high impact trauma. Odontoid fractures are classified according to Anderson and D'Alonzo. In rare cases the fracture results in cervical myelopathy, which can be life-threatening.In this article, two cases of patients with odontoid fractures and traumatic myelopathy are presented. The first case concerns a type III fracture, the second a type II fracture. In both cases the instability present was incorrectly assessed on the basis of the anatomical position in the initial computed tomography (CT). In the further course both cases showed considerable instability, which led to fatal spinal cord injuries.The purpose of this case report is to draw attention to the possible presence of spinal cord injuries in supposedly trivial odontoid fractures when high speed trauma has occurred. In particular, spinal cord compression should be considered in patients requiring resuscitation without having an internal medical cause. If the patient with a bone injury on CT, e.g. cannot be adequately assessed clinically by intubation, the indications for magnetic resonance imaging must be generously considered. This is the only way to ensure early detection of a myelopathy and timely treatment.

Implementation of a multidisciplinary infections conference improves the treatment of spondylodiscitis.

Establishing a multidisciplinary approach regarding the treatment of spondylodiscitis and analyzing its effect compared to a single discipline approach. 361 patients diagnosed with spondylodiscitis were included in this retrospective pre-post intervention study. The treatment strategy was either established by a single discipline approach (n = 149, year 2003-2011) or by a weekly multidisciplinary infections conference (n = 212, year 2013-2018) consisting of at least an orthopedic surgeon, medical microbiologist, infectious disease specialist and pathologist. Recorded data included the surgical and antibiotic strategy, complications leading to operative revision, recovered microorganisms, as well as the total length of hospital and intensive care unit stay. Compared to a single discipline approach, performing the multidisciplinary infections conference led to significant changes in anti-infective and surgical treatment strategies. Patients discussed in the conference showed significantly reduced days of total antibiotic treatment (66 ± 31 vs 104 ± 31, p < 0.001). Moreover, one stage procedures and open transpedicular screw placement were more frequently performed following multidisciplinary discussions, while there were less involved spinal segments in terms of internal fixation as well as an increased use of intervertebral cages instead of autologous bone graft (p < 0.001). Staphylococcus aureus and Staphylococcus epidermidis were the most frequently recovered organisms in both patient groups. No significant difference was found comparing inpatient complications between the two groups or the total in-hospital stay. Implementation of a weekly infections conference is an effective approach to introduce multidisciplinarity into spondylodiscitis management. These conferences significantly altered the treatment plan compared to a single discipline approach. Therefore, we highly recommend the implementation to optimize treatment modalities for patients.

Gestational diabetes mellitus (GDM). Comparative evaluation of two treatment regimens, diet versus insulin and diet.

Two-hundred and two pregnant women with impaired glucose tolerance were randomized to treatment with diet or diet and insulin by stratified selection. Self-monitoring of blood glucose was performed six times a day, 3 days/wk. Dietary treatment was considered inappropriate if fasting and postprandial blood glucose values exceeded 7 and 9 mmol/L, respectively, in which case insulin therapy was instituted. Insulin doses were adjusted according to blood glucose values, aiming at fasting and postprandial values below 5 and 6.5 mmol/L, respectively. There were no perinatal deaths. The two treatment regimens disclosed no differences regarding achieved degree of maternal blood glucose control, hemoglobin A1c at delivery, obstetric or neonatal complications, infant's size at birth including skin-fold thickness, or C-peptide concentration in cord serum. Routine treatment of pregnant women with mild carbohydrate intolerance with insulin seems unnecessary. However, 15 patients (14%) in the diet group needed insulin to achieve acceptable blood glucose control, underlining the importance of monitoring blood glucose to detect those who are at risk of developing overt diabetes.

Profiles of intermediary metabolites in insulin-dependent pregnant diabetic women with or without endogenous insulin production.

The levels of glucose, free fatty acids (FFA), glycerol, 3-hydroxybutyrate (3-HB), cyclic AMP, and C-peptide immunoreactivity (CPR) were determined in venous plasma samples taken every half hour during an 8-h period under standardized conditions in 10 insulin-dependent pregnant women. The metabolic profiles were determined in each trimester of pregnancy. The women were divided into two groups, one with (group I: 3B, 1C, and 1D according to White's classification) and one without (group II: 1B, 3C, and 1D) measurable plasma CPR levels. Plasma glucose values were significantly higher (P less than 0.01) with greater variability in group II than in group I in the first and second trimesters, while no such difference was found in the third trimester of pregnancy. FFA, glycerol, 3-HB, and cyclic AMP levels were not different between the groups in any trimester of pregnancy. Amniotic fluid CPR was higher and skinfold thickness of the newborn greater in group II than in group I. Neonatal complications occurred only in infants of group II mothers. It is concluded that determination of plasma CPR in diabetic women in early pregnancy could give additional prognostic information to that obtained by the White classification.

Serum levels of somatomedins and somatomedin-binding protein in pregnant women with type I or gestational diabetes and their infants.

The serum levels of the low mol wt form of somatomedin-binding protein (SMBP) were 5-fold higher in both diabetic (n = 44) and nondiabetic pregnant women (n = 14) than in nonpregnant women. No difference was found between women with type 1 diabetes and those with gestational diabetes. There was a negative correlation between maternal levels of SMBP during the last trimester and the birth weight percentile of the infants (r = -0.51). There was a 2- to 3-fold elevation of maternal insulin-like growth factor (IGF-I) levels during pregnancy in both diabetic and nondiabetic women. A positive correlation (r = 0.49) was found between maternal IGF-I levels and the birth weight percentiles of their infants. The correlation between the ratio of IGF-I to SMBP, which may reflect the IGF-I available to the placenta, to birth weight percentile was higher (r = 0.57), and the SE of estimate of weight percentile was 23%. The ratio between IGF-I and SMBP in cord blood was correlated with birth weight, although cord blood IGF-I and SMBP values were not. The IGF-II levels in cord serum were 50% higher in the infants of diabetic than in those of nondiabetic mothers. These findings raise the questions of whether maternal SMBP levels influence the amount of IGF-I available for the fetal-placental unit and whether IGF-II participates in glucose homeostasis in the fetus.

Mucopolysaccharidosis VII as cause of fetal hydrops in early pregnancy.

We report on fetal hydrops presenting at 18 weeks of gestation and diagnosed as beta-glucuronidase deficiency. The parents were first cousins and there were 2 previous similar fetal deaths. beta-Glucuronidase was absent in cultured fetal fibroblasts and lymphoblasts but was normal in the tested relatives. The activities of other lysosomal enzymes were normal.

Cytokines in fetal blood and amniotic fluid in Rh-immunized pregnancies.

OBJECTIVE: To determine fetal serum and amniotic fluid (AF) levels of interleukin (IL)-3, IL-6, granulocyte-macrophage colony-stimulating factor, stem cell factor, and erythropoietin, and to explore the relationship between cytokines and hemoglobin concentration, white blood cell count (WBC), and platelet count in fetuses affected by Rh immunization. METHODS: Thirty-four consecutive Rh-immunized patients in gestational weeks 19-33 were included. All patients were investigated by funipuncture and 13 by amniocentesis. The levels of IL-3, IL-6, granulocyte-macrophage colony-stimulating factor, stem cell factor, and erythropoietin were estimated using commercially available immunoassays. RESULTS: There was a significant correlation between erythropoietin concentrations in fetal serum and AF (r = 0.54, P < .05), whereas none of the other cytokines showed a positive correlation between these two compartments. Fetal serum contained higher concentrations of IL-3, granulocyte-macrophage colony-stimulating factor, stem cell factor, and erythropoietin compared with AF. In contrast, the IL-6 level was significantly higher in AF compared with fetal serum (P = .002). Erythropoietin and IL-3 levels were both negatively correlated with fetal hemoglobin concentrations (r = -0.75, P = .02, and r = -0.67, P = .045). The fetal WBC correlated significantly with the fetal serum concentration of granulocyte-macrophage colony-stimulating factor (r = 0.38, P = .04). CONCLUSION: Human fetuses with anemia due to erythrocyte immunization exhibit an increased production of erythropoietin and IL-3. Other studied cytokines (such as stem cell factor, granulocyte-macrophage colony-stimulating factor, and IL-6) did not correlate with the degree of fetal anemia. Among the studied cytokines, only erythropoietin showed a positive correlation between fetal serum and AF.

Nerve conduction in diabetic pregnancy. A prospective study.

Repeated neurographic examinations were performed during and after the pregnancies of 32 diabetic women who had no signs of neuropathy before pregnancy or at the initial examination during the first trimester. The motor conduction velocity, the sensory conduction velocity and the peak amplitude of the compound action potential of the investigated peripheral nerves were not affected by pregnancy. It is concluded that pregnancy does not impair nerve conduction or induce neuropathy in most diabetic women.

Is fetal insulin secretion affected by fetal hypoxia?

Fifty-five pregnant Rhesus isoimmunized women were subjected to fetal blood sampling or fetal blood transfusion on 135 occasions. Glucose and C-peptide concentrations were measured in fetal blood, in addition to the routine investigations for complete blood count, blood gases and lactate concentration, in order to investigate whether fetal insulin secretion was affected by hypoxia from fetal anemia. We found a strong relation between the concentration of C-peptide and gestational age at sampling (r = 0.53, P less than or equal to 0.000001). Multiple regression analysis also demonstrated that glucose (P less than or equal to 0.0051) and lactate (P less than or equal to 0.0003) also affected the concentration of C-peptide. We were unable to find any relation between C-peptide concentrations and blood gas variables. We conclude that fetal insulin secretion, measured as C-peptide concentration in fetal blood, is not affected by hypoxia from anemia as long as hemoglobin concentration remains within the range 2.1-14.8 g/dl).

Nonimmune hydrops fetalis: case reports and brief review.

We report two cases of nonimmune hydrops fetalis diagnosed prenatally. One fetus died in utero, and the second fetus survived and the infant was discharged from the intensive care nursery at 4 weeks of age. A brief review of the literature and the difficulties in arriving at a diagnosis and the management are described, along with certain prognostic factors determining the outcome.

Fetal intracardiac transfusions in patients with severe rhesus isoimmunisation.

Six patients with pregnancies of 19-31 weeks' duration showing evidence of erythroblastosis fetalis were treated with 25 fetal intracardiac blood transfusions. Complications related to the procedure occurred on five occasions in three patients. In two of the six patients the fetus died, but it was unlikely that death was related to the intracardiac transfusions. Fetal intracardiac blood transfusion may result in potentially severe complications but offers an alternative when transfusion cannot be performed into the umbilical cord.

Feto-placental blood volume in severely anemic erythroblastotic fetuses.

The feto-placental blood volume was studied using a hemoglobin hemodilution technique in 15 erythroblastotic fetuses at 43 intravascular transfusions. Four severely anemic fetuses (Hb 30 g/l) had significantly larger blood volumes than 11 moderately anemic fetuses (Hb 30-79 g/l), 169 +/- 37 versus 105 +/- 32 ml/kg fetal body weight (p less than 0.001). We speculate that hypovolemia might be an adaptive change to maintain an adequate hemoglobin concentration. An escape of fluid from the intra- to the extra-vascular space will probably compensate for the reduction in total red cell mass and thus slightly increase the hemoglobin concentration. Theoretically, interstitial fluid accumulation will continue until the hydrostatic pressure of the extravascular tissue balances that of the capillary. This compensatory mechanism seems to function until the hemoglobin concentration drops below, 30 g/l, at which point the blood volume will increase, suggesting a change from a hypo- to a hyper-volemic state.

Fetal growth and fetal glucose and C-peptide levels in relation to the degree of anemia in fetuses affected by rhesus iso-immunization.

Fetal growth rate was determined by measuring the fetal biparietal diameter at 63 two-week time points during the second trimester in 14 patients with severe Rhesus isoimmunization. Growth rate was found to be related to the fetal hemoglobin concentration which was determined at the end of each 2-week period. Fetuses with a hemoglobin concentration of less than 30% of the normal value had a significantly decreased growth rate (p less than 0.01). These fetuses had also reduced C-peptide (p less than 0.05) and increased glucose levels (p less than 0.1) compared with less anemic fetuses. The physiological background to impaired fetal growth in cases of severe fetal anamia at Rhesus iso-immunization is discussed.

Random capillary blood glucose and conventional selection criteria for glucose tolerance testing during pregnancy.

The normal variation of random capillary blood glucose values and the usefulness of elevated (greater than or equal to 6.5 mmol/l) blood glucose values as a selection criterion for oral glucose tolerance testing (OGTT) during pregnancy were investigated. A consecutive series of 1,500 pregnant women without signs or symptoms of diabetes and 81 pregnant women with conventional selection criteria for OGTT were studied. The mean blood glucose value was 4.66 mmol/l and the 95% tolerance interval of all blood glucose values was 2.93-6.38 mmol/l. Blood glucose levels were not influenced by time of day or trimester of pregnancy. A blood glucose value of 6.5 mmol/l or higher was found in 174 women, 10 of whom had an abnormal OGTT. Four of thirty women with glycosuria or signs of accelerated fetal growth and 7 of 81 women with conventional selection criteria had abnormal OGTT's. The incidence of carbohydrate intolerance during pregnancy was 1.3%. The results of this study suggest that an elevated (greater than or equal to 6.5 mmol/l) random capillary blood glucose value may be a good selection criterion for OGTT in addition to conventional selection criteria when screening for carbohydrate intolerance during pregnancy.