Neurosurgical management of thoracic and lumbar vertebral osteomyelitis and discitis in adults: a review of 43 consecutive surgically treated patients.

We report 43 consecutive surgically treated patients with pyogenic (37 patients) and tuberculous (6 patients) osteomyelitis of the thoracic and lumbar spine encountered within an 8-year period, including 1 with late recurrence after 15 months. There were 24 men and 18 women, ranging in age from 21 to 83 years. Twenty-six patients were in poor general condition because of associated illnesses, especially diabetes mellitus. Disease occurred at the thoracic level in 19 patients and on the lumbar spine in 24. After diagnosis, five patients were merely treated by posterior decompression; three of them, however, required further surgery for recurrent infection, spinal instability, and secondary neurological impairment. They are included in the 40 patients who underwent combined posterior débridement and internal fixation with transpedicular screw-rod systems. Autologous interbody bone grafting was performed simultaneously in 18 patients and in a second stage operation in 21 patients. One of them (tuberculous) experienced early recurrence and required anterior fusion. In two patients, methylmethacrylate packing was used for spine reconstruction; one of them had a late recurrence. Of the 26 patients with preoperative marked or severe neurological deficit (Frankel Grades A, 2 patients; B, 1 patient; C, 17 patients; and D, 6 patients), 23 (88%) had significant improvement of one grade (15 patients) or more (8 patients). There were no permanent complications. However, intensive care treatment was necessary in 20 of the 26 patients in reduced general condition (mean age, 72 yr). Two patients required further surgery because of postoperative epidural hematoma and pedicle screw malpositioning. In conclusion, most patients with thoracic and lumbar osteomyelitis can be successfully treated by combined débridement and internal fixation using only a posterior approach. Autogenous interbody bone grafting can be simultaneously performed and allows early mobilization of the patient.

Antibiotic prophylaxis with two doses of cephalosporin in patients managed with internal fixation for a fracture of the hip.

A prospective, randomized, double-blind study was performed to evaluate the effects of antibiotic prophylaxis on the development of a wound infection in 239 patients who had immediate stabilization of a fracture of the proximal part of the femur with a dynamic hip screw. The effects of two perioperative doses of cefotiam, given twelve hours apart, were compared with those of two doses of a placebo. Sixteen perioperative risk factors were evaluated to determine whether it was possible to identify patients who were at risk for a wound infection. All patients were followed for a minimum of six weeks. Antibiotic prophylaxis significantly reduced the prevalence of wound infection (p < 0.05): the rate of major wound infection decreased from 5 to 1 per cent and the rate of minor wound infection, from 11 to 4 per cent. The most powerful predictors of major wound infection were the duration of the operation, the interval between the accident and admission to the hospital, and the duration of postoperative urinary catheterization. The preoperative level of serum albumin and the absolute lymphocyte count were significant predictors (p < 0.05) of minor wound infection and systemic infection, respectively.

Intercondylar fractures of the humerus. An operative approach.

In this paper we review a series of thirty-four intercondylar fractures of the distal end of the humerus that were treated by open reduction over a ten-year period. The fracture patterns were classified according to the system of Müller et al. and a strict rating scale incorporating subjective data, objective motion, and the functional status of the involved elbow was used for the results. At a mean follow-up of 5.8 years, thirteen results were rated as excellent; fourteen, as good; four, as fair; and three, as poor. Complications included postoperative neuritis in five patients; three non-unions; and refracture, heterotopic bone, and deep sepsis in one patient each.

Operative treatment of distal humeral fractures in the elderly.

We treated 49 patients at an average age of 80 years (75 to 90) with distal mostly intraarticular humeral fractures by open reduction. There were 8 class A, 13 class B and 28 class C fractures on Müller's classification. The patients were reviewed at a postoperative average of 18 months. The patients' assessment of the result was very good in 31%, good in 49%, fair in 15% and poor in 5%. The flexion-extension range was very good in 41%, good in 44% and fair in 15%. The incidence of implant failure, pseudarthrosis of the olecranon osteotomy and ulnar nerve lesion was no higher in these elderly patients than in younger patients. Old age is not a contraindication to open reduction and internal fixation; it is important to restore full function.

Unicondylar fractures of the distal humerus: an operative approach.

This paper retrospectively reviews a series of 22 unicondylar fractures of the distal end of the humerus that were treated by open reduction and internal fixation over a 10 year period. The fracture patterns were classified according to the system of Müller et al. A strict rating scale was developed that incorporated subjective data, objective elbow motion, and the functional status of the involved elbow. At an average follow-up of 5.9 years (range 2.3 to 12.3 years), 12 elbows were rated as excellent, 6 as good, and 4 as fair. Complications included extensive posttraumatic arthritis in four patients, a nonunion in one, and a transient radial nerve palsy in one.

[Laparoscopic closure of a Bochdalek hernia in the adult]. / Laparoskopischer Verschluss einer Bochdalek-Hernie beim Erwachsenen.

We report the case of a 27-year-old female patient with a symptomatic Bochdalek hernia operated on laparoscopically. We discuss the diagnostic strategy and options in therapy.

[Diagnostic significance of clinical symptoms versus ultrasonography in appendicitis. A prospective study]. / Diagnostischer Stellenwert von Klinik versus Sonographie bei Appendizitis. Eine prospektive Studie.

The aim of the presented study was to find what importance ultrasonography has in the diagnosis of acute appendicitis compared to clinical findings and on the surgeon's decision regarding to laparotomy. 111 patients entering the emergency station with suspected appendicitis were evaluated in a prospective clinical study. Surgeon and radiologist had to commit themselves to the diagnosis, afterwards signs were discussed. Clinical accuracy over all was 89%. Pain migration and peritonitis signs corresponded significantly with appendicitis (p less than 0.0001). The appendix was well seen in sonographic examination in 32% (accuracy 80%), in 27% was doubtful (accuracy 70%), and in 41% the appendix could not be demonstrated. Diameter of a normal appendix was 8 mm compared to 12 mm for an inflamed appendix (p less than 0.05). Rates negative laparotomies decreased from 16% to 12.7%. The surgeon was not influenced by sonography in 75%. In 12% ultrasonography decided for laparotomy and in 4.5% sonography prevented operation. We conclude from our results, that sonography reduces the negative laparotomy rate. Ultrasonography is especially useful in doubtful clinical pictures. Clinical findings and experience remain of major importance in appendicitis-diagnosis.

Remote monitoring of nuclear power plants in Baden-Wuerttemberg.

As part of its responsibilities as nuclear supervisory authority, the Ministry of the Environment, Climate Protection and the Energy Sector Baden-Wuerttemberg (UM) operates a computer-based system for remote monitoring of nuclear power plants (NPPs) (KFUe, Kernreaktor-Fernüberwachung). In addition to the Baden-Wuerttemberg NPPs located at Philippsburg, Neckarwestheim and the disused Obrigheim, those in foreign locations close to the border area, i.e. Fessenheim in France, and Leibstadt and Beznau in Switzerland, are monitored. The KFUe system provides several methods to evaluate and present the measured data as well as to ensure compliance of threshold limits and safety objectives. For the UM, it serves as an instrument of the nuclear supervision. In case of a radioactive release, the authorities responsible for civil protection can use dispersion calculations in order to identify potentially affected areas and to initiate protective measures for the population. Beyond the data collected at the plant sites, various international radiation and meteorological measuring networks are integrated in the KFUe. The State Institute for Environment, Measurements and Nature Protection (LUBW), the technical operator of the KFUe, runs its own special monitoring network for ambient gamma dose rate and nuclide specific activity concentration measurements in the vicinity of each NPP. This article gives an overview of the solution to combine data of different sources on a single screen: dose rate networks, dose rate traces measured by car, airborne gamma spectra of helicopters, mobile dose rate probes, grid data of weather forecasts, dispersion calculations, etc.

[Does sonography help in the diagnosis of appendicitis?]. / Hilft die Sonographie in der Diagnostik der Appendizitis?

The aim of the presented study was to find whether improvement has ultrasonography in the diagnosis of acute appendicitis and on surgeon's decision referring to laparotomy. 111 patients entering into the emergency station with suspected appendicitis were evaluated in a prospective clinical study. Surgeon and radiologist had to commit themselves to the diagnosis, afterwards signs were discussed. In 32% the appendix was well seen (accuracy 80%), in 27% sonographic examination was doubtful (accuracy 70%) and in 41% the appendix could not be demonstrated. Diameter of normal appendix was 8 mm compared to inflamed appendix with 12 mm (p less than 0.05). The negative laparotomy decreased from 16% to 12.7%. Surgeon was not influenced by sonography in 75%. In 12% ultrasonography decided for laparotomy and in 4.5% sonography prevented operation. We conclude from our results, that sonography reduces negative laparotomy rate. Especially ultrasonography is useful in doubtful clinical pictures.

[Intra-articular unicondylar humerus fractures. Late results following stable osteosynthesis]. / Intraartikuläre unikondyläre Humerusfrakturen. Spätresultate nach stabiler Osteosynthese.

The authors report the late results in a series of 45 unicondylar intra-articular fractures of the distal humerus treated by internal fixation. The fractures were classified according the AO system. The average follow-up time was 4.25 years. A rating scale was used that was based on patient interviews. Based on the late results, internal fixation is concluded to be the treatment of choice for all unicondylar intra-articular fractures of the humerus.

Appendicitis diagnosis today: clinical and ultrasonic deductions.

A total of 111 patients referred with a diagnosis of suspected "appendicitis" were entered into a prospective study. The surgeon and radiologist in charge of ultrasonography made separate diagnoses, and their findings were then combined and discussed as indications for surgery. Clinically, a history of pain migration proved to be reliable (p < 0.0001) as a diagnostic indicator, in contrast to nausea and initial irregularity of bowels. The duration of symptoms was significantly shorter in patients with proved appendicitis than among patients with negative findings (median 24 hours compared with 41 hours, p < 0.04). Among patients with perforated appendicitis, the symptomatic history was prolonged (not significantly) by 3 hours. Peritoneal signs such as pain on percussion, rebound tenderness, guarding, and a leukocytosis of more than 13,000/mm3 were indicative of appendicitis (p = 0.0001 for each sign). Lively bowel sounds excluded the possibility of appendicitis (p = 0.001). Scanty bowel sounds, rectal tenderness, axillorectal temperature difference, and a left shift in leukocytes were of no diagnostic significance. The doctor's "clinical experience" is significant at the level of p < 0.03. On ultrasonography, the following signs were indicative of appendicitis: periappendicular infiltration (p = 0.0003), a visible "cockade," and an appendix larger than 12 mm in diameter (p = 0.04). For 75% of the patients the surgeon was sure of his own clinical diagnosis and did not allow himself to be influenced by the sonographic findings. In 12% of doubtful cases ultrasonographic results decisively favored operation, and in 4.5% (n = 5) it prevented an unnecessary laparotomy in the presence of positive clinical symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

[Dangerous hypoprothrombinemic hemorrhage in antibiotic therapy]. / Gefährliche hypoprothrombinämische Blutungen unter Antibiotikatherapie.

Antibiotics can be associated with hypoprothrombinaemic haemorrhages in risk patients. Risk factors are: poor nutrition, impaired liver- or renal function, coagulation depleting medical therapy or illness. Pathogenetically there is a vitamin K deficiency with reduction of vitamin K dependent clotting factors; mainly by decreased vitamin K synthesis in intestinal bacterias. In consequence every risk patient under antibiotics should receive vitamin K prophylactically and in a parenteral way, because of unreliable resorption in gastrointestinal tract. Prothrombin-time-monitoring is essential to recognize the hypoprothrombinemia in every risk patient under antibiotics.

[Intestinal foreign body with sigmoid perforation in an area of carcinomatous stenosis: incidental finding or etiology?]. / Intestinaler Fremdkörper mit Sigmaperforation in karzinomatösem Stenosebereich: Zufallsbefund oder Ursache?

Ingestion of a foreign body is a common incident. In most cases it rarely produces symptoms, but sometimes may cause severe complications such as abscess formation, obstruction or perforation. A definite diagnosis can be difficult to obtain for the following reasons: 1. the past history doesn't give any clue; 2. the symptoms are veiled by another intestinal disease; 3. radio opaquity of the foreign body is absent; 4. complications can mimic different symptoms inspite of their unique etiology. The following case reports a patient with an intestinal perforation, where a foreign body and a stenosis, caused by a sigma neoplasm, were simultaneously present. Histological findings showed that the foreign body, not the neoplasm, was causing the perforation, whereas for the underlying disease it only was an incidental finding.

[Spontaneous rupture of the spleen during anticoagulant therapy]. / Spontane Milzruptur unter Antikoagulantientherapie.

Three cases of spontaneous rupture of the spleen in patients which were on long-term anticoagulant therapy are reported. In patients with the trias faulty coagulation, signs of hemorrhagic shock and of peritonitis in the upper abdominal part the possibility of a spontaneous rupture of the spleen must be considered. The diagnosis can then be confirmed by a positive peritoneal lavage. Once the diagnosis is made, the therapy is splenectomy.

[Choledochus carcinoma in choledochal cyst--a rarity. Presentation of the disease with a case report]. / Choledochuskarzinom in Choledochuszyste--eine Rarität. Präsentation des Krankheitsbildes anhand eines Fallbeispieles.

Around 1800 choledochal cysts are described in the literature, of which around 6% have turned malignant. The incidence of malignant degeneration increases with age and amounts to as much as 28%. As the prognosis for malignant choledochal cysts is poor, the only therapy is an early cystectomy before the appearance of malignant changes. The diagnosis of the cyst is made using sonography, ERCP and abdominal CT. Histology alone provides conclusive diagnosis of malignant degeneration. The case of a 29-year-old-woman who entered our clinic with non-specific right-side abdominal pains is presented. A choledochal cyst was diagnosed by means of sonography, ERCP and abdominal CT. Intraoperatively, a choledochal carcinoma was found in the choledochal cyst (type Ia according to Todani), with infiltration to the surrounding area as well as liver metastasis. A cystectomy and Roux-Y-hepatico-jejunostomy were performed. The patient died 8 months after the diagnosis.

[Value of subtotal stomach resection in stomach cancer]. / Stellenwert der subtotalen Magenresektion beim Magencarcinom.

The controversy about the extent of resection of gastric cancer has been lasting for decennies. The extreme viewpoints may have become less divergent recently although controlled data are still lacking. As gastrectomy has generally become safer, a somewhat broader indication for it is justified. Subtotal resection is still justified for cancer of the antrum of the intestinal type (Laurén-classification) without evidently involved distant nodes and as long as a clear margin can be expected, furthermore in some advanced disease situations and finally in high risk patients, especially with severe cardiopulmonary handicaps.

[Successful treatment of a cheilothorax in lymphangiomatosis of the ribs (Gorham-Stout syndrome)]. / Erfolgreiche Behandlung eines Chylothorax bei Lymphhämangiomatose der Rippen (Gorham-Stout-Syndrom).

In 1955 Gorham and Stout described the syndrome of lymphangiomatosis of the bone resulting in widespread monofocal osteolysis in the skeletal system. The results of therapy are difficult to evaluate as the disease may come to a sudden stand-still. If angiomatosis arises near the thorax, pleural effusion occurs due to simultaneous involution of the thoracic duct. This complication has a fatal outcome and effective treatment is required. A case is reported in a 61-year-old male in whom radiotherapy of the lower ribs on the right thorax reduced the lymphangiomatous swelling and healed the chylothorax.

[Subcapital humerus fracture with lesion of the axillary artery. 2 case reports and review of the literature]. / Subkapitale Humerusfraktur mit Läsion der A. axillaris: Zwei Fallberichte und Literaturübersicht.

Two cases of fractures of the humeral neck in association with an axillary artery injury are reported. Even now, there are still only 14 well-documented cases in the literature. Trauma, pattern of injuries and treatment are analyzed. The treatment is focused on preservation of hand function, which is more important than shoulder motion. Neurovascular damage causes an impairment of hand function. The priorities of treatment (reperfusion versus osteosynthesis) are dictated by the degree of ischemia. Long-term disability is determined by brachial plexus injury.