Significance of proprioceptive mechanisms in the regulation of stance.

Compensatory electromyographic (EMG) responses and several biomechanical parameters were studied following impulsive disturbance of the limbs during stance of human volunteers on a treadmill. Treadmill acceleration impulses were backwards or forwards directed, or their initial direction was reversed after 30 ms. Backwards directed impulses were followed by gastrocnemius, forwards directed ones by tibialis anterior EMG responses (latency 65 to 75 ms) whose durations depended on impulse duration. When the direction of the impulse was reversed, the respective antagonistic leg muscles were activated again with a delay of 68 to 75 ms after onset of stretch of these muscles. The behaviour of the EMG responses could best be correlated to the displacement at the ankle joint and may be described in terms of a stretch reflex response. The results indicate that these stretch reflex responses help control of the body's centre of gravity thereby preventing falling. Head movements induced by the impulses showed little correlation with the appearance of the EMG responses, suggesting that the vestibular system is unlikely to be directly involved in the generation of these responses. Vestibular signals may, however, significantly contribute to slow body sway stabilization.

The contribution of vestibular input to the stabilization of human posture: a new experimental approach.

An experiment was designed to evaluate the vestibular contribution to the stabilization of upright stance in normals and in two patients with loss of vestibular function. A forward or backward displacement of a load (2 kg) by a torque motor attached to the subject induced opposing movements in the head and trunk. The small linear acceleration of the head in space of about 0.1 g was followed, with a latency of 50-65 ms, by EMG responses in the tibialis anterior and rectus femoris (backward acceleration) or gastrocnemius muscles (forward acceleration). These responses were absent in patients with a vestibular deficit. It is suggested that the observed EMG responses are due to fast acting vestibulospinal reflexes involved in the regulation of upright stance. For comparable head accelerations the integrated EMG responses induced by the vestibulospinal mechanism are about ten times smaller than those induced by spinal stretch reflexes during displacement of the feet. Vestibulospinal reflexes would appear, therefore, to play only a minor role in the compensation of stumbling.

Interlimb coordination of stance in children: divergent modulation of spinal reflex responses and cerebral evoked potentials in terms of age.

EMG responses in the gastrocnemius (GM) and tibialis anterior muscles (TA) of both legs together with cerebral evoked potentials (CP), were recorded following perturbations of stance on a treadmill with split belts, in two age groups of children. Unilateral displacements were followed by ipsilateral short latency and bilateral long latency EMG responses. The CP was similar in both tasks. When displacements were simultaneously induced in opposite directions, a significant reduction in the long latency components of EMG responses occurred, while the amplitude of the CP was maximal in this condition. In the older children the CP and long latency EMG responses were larger and the short latency reflex potentials smaller in all conditions compared to the younger children. It is concluded that (1) CP and EMG responses reflect a divergent modulation of a given somatosensory input; (2) developmental changes are reflected in alterations in the amplitude of CP and EMG responses; (3) there is no evidence of transcortically mediated muscle responses.

Compensation of human stance perturbations: selection of the appropriate electromyographic pattern.

Perturbations of stance evoke purposive EMG patterns which are directed to hold the body's centre of gravity over the feet. Dorsiflexing rotation of the feet is followed by a monosynaptic stretch reflex response in the gastrocnemius muscle, succeeded by a late compensatory tibialis anterior activation. Backward translation of the feet elicits only a compensatory polysynaptic EMG response in the gastrocnemius muscle, while an early gastrocnemius response is absent. The amplitude modulation of the gastrocnemius H-reflex has been investigated during the early part of the two modes of perturbation. Only during translational perturbation a progressive decrease in gastrocnemius H-reflex amplitude started within 5 ms after onset of displacement. The degree of the reduction in amplitude in the former perturbation was dependent on the displacement velocity. Only the contact forces (torques) differed between the two modes of perturbations within the first 10 ms after onset of perturbations. It is suggested that signals from pressure receptors within the body are responsible for the early change in H-reflex amplitude during translational perturbations and it is concluded that the simplest spinal reflex is under very rapid and powerful moment-to-moment control by changes in peripheral feedback. In view of a strong reciprocal modulation of monosynaptic and polysynaptic reflex responses, the later purposive EMG responses may be determined by early changes in presynaptic inhibition of group I afferents.

Compensation of translational and rotational perturbations in human posture: stabilization of the centre of gravity.

EMG responses in the leg muscles, head acceleration and joint movements induced by dorsiflexing rotation of the ankle have been analysed. Perturbations were induced while subjects were standing on a platform with the ankle joints co-linear with the axis of rotation or while standing above the axis (between 5 and 25 cm), which introduced an additional translational component to the displacement. The former condition was followed by a monosynaptic gastrocnemius reflex potential and a late tibialis anterior activation (latency about 100 ms); in the latter condition the monosynaptic reflex response became smaller and a longer latency gastrocnemius response (latency about 70 ms) appeared, the strength and duration of which increased in parallel with the translational component, while the amplitude of the tibialis anterior activity decreased. Neither vestibulospinal nor muscle proprioceptive mechanisms can solely account for this effect as the biomechanical parameters were little changed in the different conditions. It is suggested that the controlled variable in the investigated task is to hold the bodies' centre of gravity over the feet which makes the change in the pattern meaningful: pure dorsiflexion of the feet is followed by a backwards sway of the body, thus a tibialis anterior activation is functionally essential to hold the centre of gravity over the feet. A backwards translation of the feet withdraws the supporting surface, thus a gastrocnemius activation is needed to restore the centre of gravity over the feet. The inhibition of the monosynaptic reflex with increasing translation is suggested to arise from a reciprocal modulation of mono- and polysynaptic gastrocnemius reflex responses.

Human postural reflexes and gravity--an under water simulation.

This study represents the first attempt to investigate the influence of gravity on postural adjustments. Subjects were displaced while standing under water on a movable platform, while the buoyancy of the body was adjusted by using a variety of lead vests. Under water, an approximately linear relationship was found between body weight and impulse directed electromyographic response amplitudes in the leg and thigh muscles. Loading of the subjects out of water resulted in a saturation of the response amplitude. The biomechanical signals recorded during the displacements indicated that neither vestibulospinal nor muscle proprioceptive reflex mechanisms can account for the effect observed under water. It is suggested that the EMG responses are mediated by reflexes which are activated by pressure receptors within the body in order to hold the centre of gravity over the feet.

Ranging accuracy test of the sonic microstereometric system.

We have recently introduced a new type of ultrasonic-based, three-dimensional ranging system for the localization of small handheld surgical tools to be used during operation in open stereotactic brain surgery. This targeting system has now been extensively laboratory tested during thousands of measuring cycles with a CNC-based measuring table. The typical accuracy found in a single direction was 0.4 mm and better. The accuracy vector in space was 0.897 mm (n = 2312). The test-retest accuracy was typically 0.4 mm. With the given accuracy, the system is suitable for all ranging tasks in open stereotactically guided microsurgery.

Sonic stereometry in microsurgical procedures for deep-seated brain tumors and vascular malformations.

A frameless computerized navigating system was successfully employed in 20 cases of open microsurgical operations on deep-seated brain tumors and vascular malformations. Localization in space was made by measuring the traveling time of sonic waves (24 kHz) in air. This allowed the construction of mechanically simple, lightweight freehand targeting instruments. The tips can be localized with a measuring accuracy of +/- 1 mm intracranially on the basis of computed tomographic scans. This thoroughly redesigned sonic stereometrical device is being optimized for everyday use; magnetic resonance imaging, digital substraction angiography, and other diagnostic modalities will be implemented. Some perspectives on "computer-aided (neuro)surgery" are discussed.

First clinical experience with the automatic positioning system and Leksell gamma knife Model C. Technical note.

In May of 1999, the first Leksell Model C gamma knife was installed at the Gamma Knife Zentrum in Krefeld, Germany. The authors recount their experience with this latest technical gamma knife development. Until the end of 1999, extensive physical and technical tests were performed and the system's hardware and software were continuously improved and adapted to the user's needs. By the end of 1999, 163 GKSs had been performed using the new functionality of the Model C in manual or "trunnion" mode. The trunnions, the two parts of the system that fix the patient headframe to the gamma knife when the isocenter positions, are checked manually. During the same period the new automatic positioning system (APS) was extensively tested and refined so that the first APS treatment could be performed in January 2000. Fifty GKSs have been performed with the APS capability of the Model C. It was possible to use APS alone in 74% of surgeries whereas in 14% some shots were given with APS and some with trunnions. In 12%, GKS was scheduled and planned for APS, but due to unexpected technical (6%) or mechanical (6%) reasons the treatment had to be performed manually. At present there are some spatial restrictions with Model C in APS mode when compared with the Model B. The most significant restriction is the narrow space for the patient's shoulders, especially when deep-seated lesions are treated. Through mechanical changes of the APS motor housing and some modifications of and to the motor driven couch adjustment, these limitations will be reduced in the future. The APS treatment runs smoothly and fast. In no case did any relevant safety error occur during GKS. The more stringent mechanical limitations of the APS compared with the Model B means that frame placement on the head is more critical than before.

Surgery and radiotherapy compared with gamma knife radiosurgery in the treatment of solitary cerebral metastases of small diameter.

OBJECT: The aim of this retrospective study was to compare treatment results of surgery plus whole-brain radiation therapy (WBRT) with gamma knife radiosurgery alone as the primary treatment for solitary cerebral metastases suitable for radiosurgical treatment. METHODS: Patients who had a single circumscribed tumor that was 3.5 cm or smaller in diameter were included. Treatment results were compared between microsurgery plus WBRT (52 patients, median tumor dose 50 Gy) and radiosurgery alone (56 patients, median prescribed tumor dose 22 Gy). In case of local/distant tumor recurrence in the radiosurgery group, additional radiosurgical treatment was administered in patients with stable systemic disease. Survival time was analyzed using the Kaplan-Meier method, and prognostic factors were obtained from the Cox model. The patient groups did not differ in terms of age, gender, pretreatment Karnofsky Performance Scale (KPS) score, duration of symptoms, tumor location, histological findings, status of the primary tumor, time to metastasis, and cause of death. Patients who suffered from larger lesions underwent surgery (p < 0.01). The 1-year survival rate (median survival) was 53% (68 weeks) in the surgical group and 43% (35 weeks) in the radiosurgical group (p = 0.19). The 1-year local tumor control rates after surgery and radiosurgery were 75% and 83%, respectively (p = 0.49), and the 1-year neurological death rates in these groups were 37% and 39% (p = 0.8). Shorter overall survival time in the radiosurgery group was related to higher systemic death rates. A pretreatment KPS score of less than 70 was a predictor of unfavorable survival. Perioperative morbidity and mortality rates were 7.7% and 1.6% in the resection group, and 8.9% and 1.2% in the radiosurgery group, respectively. Four patients presented with transient radiogenic complications after radiosurgery. CONCLUSIONS: Radiosurgery alone can result in local tumor control rates as good as those for surgery plus WBRT in selected patients. Radiosurgery should not be routinely combined with radiotherapy.

Perturbations of human posture: influence of impulse modality on EMG responses and cerebral evoked potentials.

Leg muscle EMG responses and cerebral evoked potentials (CP), elicited by perturbations of stance while on a treadmill with split belts, were analyzed in order to study the relationship between compensatory leg muscle responses and afferent input to supraspinal centers. Various conditions of perturbation were used to establish the extent to which compensatory EMG responses and CPs show congruent behavior. Four different treadmill acceleration rates were applied in three different conditions (unilateral perturbation, directed forward or backward; bilateral perturbation, directed forward or backward; and opposing bilateral perturbation). EMG responses and CPs showed parallel increases in amplitude with increasing displacement velocity. The EMG responses showed distinct differences, predominantly in the response amplitude, between the different perturbation conditions, whereas the CPs were affected only to a minor degree. Tibialis anterior EMG responses were more closely related to the CP following forward perturbation than the corresponding gastrocnemius responses were to the CP following backward perturbation. We conclude that the EMG responses are more closely related than the CPs to displacement parameters and suggest that this is due to the further spinal processing of the afferent input needed to generate an appropriate EMG response. The closer relationship between the tibialis anterior response and CP may reflect a predominant central representation and control of tibialis anterior activation in the regulation of posture. The functional implications of these findings are discussed.

Body sway stabilization in human posture.

Electromyographic (emg) responses and joint movements of the leg were analysed in subjects standing with eyes closed on a sinusoidally moving treadmill (0.16 Hz or 0.33 Hz, amplitude 33 cm). Activity in antagonistic leg muscles was reciprocally modulated, with a predominant gastrocnemius activation during deceleration of forward movement and tibialis anterior activation during deceleration of backward movement of the treadmill. In these phases, it was necessary to compensate for sway induced by body inertia. The match between treadmill movement and emg activity was better for the gastrocnemius than for the tibialis anterior muscle. The characteristic pattern of leg muscle emg activity is suggested to be modulated predominantly by vestibulo-spinal reflexes partly because treadmill movements did not evoke muscle strength, and partly because patients with loss of vestibular function showed basic alterations in the emg pattern and could only compensate for the slow sinus while standing unsupported.

Micro-stereometry: a frameless computerized navigating system for open microsurgery.

We are introducing a new type of ultrasonic-based three dimensional (3D) ranging system for the localization of small hand-held surgical tools to be used during operation in open and stereotactic brain surgery. The new device has been extensively tested in the laboratory and showed a linear localization accuracy of +/- .4 mm. The calibration of the system is automatically done by an active calibration frame as well as by pointing to fiducial markers. The position of the tool is sent to a visualization unit and overlaid in realtime on preoperatively scanned computed tomography (CT) and magnetic resonance imaging (MRI) pictures. First clinical tests showed the improved accuracy, handling, and versatility of the new stereometric navigation system, which will soon become the backbone of a computer-aided surgery (CAS) system with a variety of locatable tools.

[Endoscopic resection of malignant melanomas of the uvea after preoperative stereotactic single dose convergence irradiation with the Leksell gamma knife]. / Endoresektion maligner Melanome der Uvea nach präoperativer stereotaktischer Einzeldosis-Konvergenzbestrahlung mit dem Leksell-Gamma-knife.

In cases of large volume and highly prominent melanomas of the uvea, it is rare for conventional methods of radiation therapy to enable salvage of the globe or even residual functionality of the affected eye. Complications due to the massive amount of accumulated necrotic tissue often necessitate subsequent enucleation of the blinded eye. Tumor-destroying, single-dose convergence irradiation (radiosurgery) of such tumors applied shortly before endoresection can represent a possible therapeutic alternative in these types of cases.

[Stereotactic radiosurgery using the Gamma Knife for large uveal melanomas]. / Stereotaktische Konvergenzbestrahlung grosser uvealer Melanome mit dem Gamma-Knife. Vorläufige Ergebnisse bei 100 Patienten.

BACKGROUND: We report the results over 3 years with stereotactic radiosurgery using the Gamma Knife for large and unsuitably located uveal melanomas. PATIENTS AND METHODS: A total of 100 patients (51 male, 49 female) have been treated since 1997 following a standardised treatment protocol (outpatient single-shot treatment, maximum dose 50 Gy, tumour margin dose min.25 Gy, retrobulbar anaesthesia alone for globe fixation). The localisation and/or dimension of the tumours did not allow radiation brachytherapy with Ru106 plaques. Of the tumours 18 were located in the ciliary body, 61 were located at the posterior pole, and 21 were located in the mid-periphery. All patients were followed and tested ophthalmologically and neuroradiologically at regular intervals. The 1-year follow-up data were available for 73 patients, 2-year follow-up data for 33 patients and 3-year follow-up-data for 17 patients. RESULTS: Before therapy the maximum apical tumour height (MAH) was median 7.8 mm (95% CI 2.9-12.5 mm): 1 year after treatment (73 patients) the MAH was median 5.7 mm (95% KI 2.4-10.2 mm),2 years after treatment (33 patients) the MAH was median 4.3 mm (95% KI 2.2-8.8 mm),and 3 years after treatment (17 patients) the MAH was median 4.6 mm (95% KI 2.4-8.5 mm). All differences to the MAH of the corresponding patients before treatment were statistically significant (paired t-test). Within the first year after treatment seven patients were enucleated due to a painful secondary glaucoma,within the second year after radiation two patients (one tumour recurrence, and one secondary glaucoma) and within the third year one more patient (tumour recurrence) was enucleated. CONCLUSIONS: Our 3-year results demonstrate that radiosurgery using the Gamma Knife is beneficial in achieving a local tumour control in 98% of eyes with large and unsuitably located uveal melanomas. The risk for a secondary enucleation is highest in the first year after treatment with a favourable overall rate of 10%. Due to the excellent local tumour control rate we decreased the maximum dose to 40 Gy (min.tumour margin dose 20 Gy) in the subsequently treated patients.

Malignant brain oedema after radiosurgery of a medium-sized vestibular schwannoma.

CASE REPORT: We present a patient with an unusual malignant brain oedema occurring after gamma knife radiosurgery of a medium-sized vestibular schwannoma. CLINICAL PRESENTATION: A 62-year-old female with a large vestibular schwannoma underwent partial microsurgical resection; 6 months later she underwent a second intervention with gamma knife radiosurgery for a medium-sized tumour remnant. With a latency period of 6 months after radiosurgery, she presented with progressive neurological deterioration. Serial magnetic resonance imaging revealed progression of the tumour and of the perifocal oedema which finally extended up to the ipsilateral internal capsule. The patient became comatose. INTERVENTION: The tumour was nearly completely removed via a standard retrosigmoid craniotomy. Histopathological examination demonstrated increased mitotic activity compared to the initial histology. The patient became conscious 10 days after surgery and recovered slowly. Surprisingly, the brain oedema resolved rapidly. The CT scan obtained 11 days after surgery showed almost complete disappearance of the oedema. CONCLUSION: Although rare, radiosurgery of medium-sized vestibular schwannomas causing brainstem compression may lead to life-threatening tumour progression and malignant brain oedema. Therefore, microsurgical gross total resection should be the preferred treatment option in vestibular schwannomas causing significant brainstem compression.

[Endoresection of large uveal melanomas after pretreatment by single-dose stereotactic convergence irradiation with the leksell gamma knife--first experience on 46 cases]. / Endoresektion grosser Melanome der Uvea nach stereotaktischer Single-dose-Vorbestrahlung mit dem Leksell Gamma-Knife -- Erste Erfahrungen an 46 Fällen.

BACKGROUND: The aim of this non-comparative, consecutive case series is to evaluate the short-term results after endoresection of large uveal melanomas in combination with pretreatment with stereotactic gamma knife radiosurgery. METHODS: Between March 2000 and November 2002, forty-six patients with large uveal melanomas underwent stereotactic radiosurgery followed by endoresection of the tumour via a standard three-port vitrectomy including laser photocoagulation and silicone oil tamponade. The average tumour height was 9.5 mm. The minimum dose delivered to the tumour volume was 25 Gy. RESULTS: The median follow-up time was 410 days. In 40 cases (87 %), the eye was retained with a VA of 20/200 or better in 30 cases (65.2 %) and 20/63 or better in ten cases (21.7 %). In 12 eyes with a follow-up of >/= 0.5 years, the median VA was 20/80 after silicone oil removal and cataract surgery had been performed. Six eyes (13 %) were enucleated due to serious complications caused by the radiosurgery (3 cases) or endoresection (3 cases). In 13 patients (28.2 %), additional major surgery was required. Seven patients developed liver metastases during follow-up and six patients died. No local tumour recurrences were observed. CONCLUSIONS: Eyes with large uveal melanomas can be salvaged by stereotactic radiotherapy followed by endoresection.

A basic posture control mechanism: the stabilization of the centre of gravity.

Holding the body's centre of gravity steady represents the crucial variable for the stabilization of posture in upright stance in man. The visual, vestibular and muscle proprioceptive systems have all been shown to contribute to sway stabilization. Nevertheless, earlier work has suggested that an additional receptor system is needed to signal the position of the body's centre of gravity relative to the support surface, i.e., the feet. This proposed receptor system should be 'gravity' dependent. To evaluate the properties of this receptor system, an experiment was designed under simulated 'microgravity', in water immersion. An approximately linear relationship was found between contact force and impulse directed EMG response amplitudes in the leg muscles. Out of water loading of the subjects resulted in no further increase of the response amplitude. A gain control mechanism for postural reflexes which is dependent on body weight was demonstrated. In a further experiment it could be shown that the receptors for this mechanism are distributed along the vertical axis of the body: it is suggested that these force-dependent receptors are pressure receptors within the joints and the vertebral column.

Reproducibility and adaptation of the EMG responses of the lower leg following perturbations of upright stance.

The electromyographic (EMG) response of gastrocnemius, soleus and anterior tibialis muscles to a backwardly directed perturbation of stance was recorded in 12 normal subjects using surface electrodes and studied with regard to its reproducibility (test-retest reliability coefficients, variability coefficients) and to adaptational effects. (1) Reproducibility was shown to be uniformly high and can be interpreted as an index for the high intraindividual constancy of the results. (2) Adaptational effects have been found and should be circumvented, either by pre-adapting the subjects to the motor task, or by restriction of the period of measurement. (3) Variation of the position of the electrodes produced only small effects. The impedance of the surface electrodes was not critical if kept below 5 k omega. EMG investigations with surface electrodes during stance and perturbations of stance provide highly reliable results with respect to intraindividual changes but interindividual variability of the results clearly marks the limits of this method. The interindividual variability observed with surface electrodes is of the same order as that reported in the literature for inserted needle recording.