The spinal cord injury-induced immune deficiency syndrome: results of the SCIentinel study.

Infections are prevalent after spinal cord injury (SCI), constitute the main cause of death and are a rehabilitation confounder associated with impaired recovery. We hypothesize that SCI causes an acquired lesion-dependent (neurogenic) immune suppression as an underlying mechanism to facilitate infections. The international prospective multicentre cohort study (SCIentinel; protocol registration DRKS00000122; n = 111 patients) was designed to distinguish neurogenic from general trauma-related effects on the immune system. Therefore, SCI patient groups differing by neurological level, i.e. high SCI [thoracic (Th)4 or higher]; low SCI (Th5 or lower) and severity (complete SCI; incomplete SCI), were compared with a reference group of vertebral fracture (VF) patients without SCI. The primary outcome was quantitative monocytic Human Leukocyte Antigen-DR expression (mHLA-DR, synonym MHC II), a validated marker for immune suppression in critically ill patients associated with infection susceptibility. mHLA-DR was assessed from Day 1 to 10 weeks after injury by applying standardized flow cytometry procedures. Secondary outcomes were leucocyte subpopulation counts, serum immunoglobulin levels and clinically defined infections. Linear mixed models with multiple imputation were applied to evaluate group differences of logarithmic-transformed parameters. Mean quantitative mHLA-DR [ln (antibodies/cell)] levels at the primary end point 84 h after injury indicated an immune suppressive state below the normative values of 9.62 in all groups, which further differed in its dimension by neurological level: high SCI [8.95 (98.3% confidence interval, CI: 8.63; 9.26), n = 41], low SCI [9.05 (98.3% CI: 8.73; 9.36), n = 29], and VF without SCI [9.25 (98.3% CI: 8.97; 9.53), n = 41, P = 0.003]. Post hoc analysis accounting for SCI severity revealed the strongest mHLA-DR decrease [8.79 (95% CI: 8.50; 9.08)] in the complete, high SCI group, further demonstrating delayed mHLA-DR recovery [9.08 (95% CI: 8.82; 9.38)] and showing a difference from the VF controls of -0.43 (95% CI: -0.66; -0.20) at 14 days. Complete, high SCI patients also revealed constantly lower serum immunoglobulin G [-0.27 (95% CI: -0.45; -0.10)] and immunoglobulin A [-0.25 (95% CI: -0.49; -0.01)] levels [ln (g/l × 1000)] up to 10 weeks after injury. Low mHLA-DR levels in the range of borderline immunoparalysis (below 9.21) were positively associated with the occurrence and earlier onset of infections, which is consistent with results from studies on stroke or major surgery. Spinal cord injured patients can acquire a secondary, neurogenic immune deficiency syndrome characterized by reduced mHLA-DR expression and relative hypogammaglobulinaemia (combined cellular and humoral immune deficiency). mHLA-DR expression provides a basis to stratify infection-risk in patients with SCI.

Biomechanical evaluation of temporary epiphysiodesis at the femoral epiphysis using established devices from clinical practice.

The aim of this study is to compare biomechanical features of different devices used in clinical routine for temporary epiphysiodesis (eight-Plate® and FlexTackTM). The tested implants were divided into four different groups (eight-Plate® vs. FlexTackTM for lateral and anterior implantation) á 10 samples for testing implanted eight-Plate® vs. FlexTackTM in fresh frozen pig femora for maximum load forces (Fmax) and axial physis distance until implant failure (lmax). A servo hydraulic testing machine (858 Mini Bionix 2) was used to exert and measure reproducible forces. Statistical analyses tested for normal distribution and significant (p < 0.05) differences in primary outcome parameters. There were no significant differences between the eight-Plate® lateral group and the FlexTackTM lateral group for neither Fmax (p = 0.46) nor lmax (p = 0.65). There was a significant higher Fmax (p < 0.001) and lmax (p = 0.001) measured in the eight-Plate® group compared to the FlexTackTM group when implanted anteriorly. In anterior temporary ephiphysiodesis, eight-Plate® demonstrated superior biomechanical stability. At this stage of research, there is no clear advantage of either implant and the choice remains within the individual preference of the surgeon.

Clinical decision-making on spinal cord injury-associated pneumonia: a nationwide survey in Germany.

STUDY DESIGN: Survey study. OBJECTIVES: Spinal cord injury (SCI)-associated pneumonia (SCI-AP) is associated with poor functional recovery and a major cause of death after SCI. Better tackling SCI-AP requires a common understanding on how SCI-AP is defined. This survey examines clinical algorithms relevant for diagnosis and treatment of SCI-AP. SETTING: All departments for SCI-care in Germany. METHODS: The clinical decision-making on SCI-AP and the utility of the Centers for Disease Control and Prevention (CDC) criteria for diagnosis of 'clinically defined pneumonia' were assessed by means of a standardized questionnaire including eight case vignettes of suspected SCI-AP. The diagnostic decisions based on the case information were analysed using classification and regression trees (CART). RESULTS: The majority of responding departments were aware of the CDC-criteria (88%). In the clinical vignettes, 38-81% of the departments diagnosed SCI-AP in accordance with the CDC-criteria and 7-41% diagnosed SCI-AP in deviation from the CDC-criteria. The diagnostic agreement was not associated with the availability of standard operating procedures for SCI-AP management in the departments. CART analysis identified radiological findings, fever, and worsened gas exchange as most important for the decision on SCI-AP. Frequently requested supplementary diagnostics were microbiological analyses, C-reactive protein, and procalcitonin. For empirical antibiotic therapy, the departments used (acyl-)aminopenicillins/ß-lactamase inhibitors, cephalosporins, or combinations of (acyl-)aminopenicillins/ß-lactamase inhibitors with fluoroquinolones or carbapenems. CONCLUSIONS: This survey reveals a diagnostic ambiguity regarding SCI-AP despite the awareness of CDC-criteria and established SOPs. Heterogeneous clinical practice is encouraging the development of disease-specific guidelines for diagnosis and management of SCI-AP.

Natural Killer (NK) Cell Functionality after human Spinal Cord Injury (SCI): protocol of a prospective, longitudinal study.

BACKGROUND: Natural killer (NK) cells comprise the main components of lymphocyte-mediated nonspecific immunity. Through their effector function they play a crucial role combating bacterial and viral challenges. They are also thought to be key contributors to the systemic spinal cord injury-induced immune-deficiency syndrome (SCI-IDS). SCI-IDS increases susceptibility to infection and extends to the post-acute and chronic phases after SCI. METHODS AND DESIGN: The prospective study of NK cell function after traumatic SCI was carried out in two centers in Berlin, Germany. SCI patients and control patients with neurologically silent vertebral fracture also undergoing surgical stabilization were enrolled. Furthermore healthy controls were included to provide reference data. The NK cell function was assessed at 7 (5-9) days, 14 days (11-28) days, and 10 (8-12) weeks post-trauma. Clinical documentation included the American Spinal Injury Association (ASIA) impairment scale (AIS), neurological level of injury, infection status, concomitant injury, and medications. The primary endpoint of the study is CD107a expression by NK cells (cytotoxicity marker) 8-12 weeks following SCI. Secondary endpoints are the NK cell's TNF-α and IFN-γ production by the NK cells 8-12 weeks following SCI. DISCUSSION: The protocol of this study was developed to investigate the hypotheses whether i) SCI impairs NK cell function throughout the post-acute and sub-acute phases after SCI and ii) the degree of impairment relates to lesion height and severity. A deeper understanding of the SCI-IDS is crucial to enable strategies for prevention of infections, which are associated with poor neurological outcome and elevated mortality. TRIAL REGISTRATION: DRKS00009855 .

Quantitative in vivo fusion assessment by (18)F-fluoride PET/CT following en bloc spondylectomy.

PURPOSE: The purpose of this retrospective analyses was to evaluate the bone viability in the ventral column of the spine following large segmental defect reconstructions. Osseous integration of implants following spinal fusion procedures is an essential precondition to provide adequate mechanical strength to any applied forces and subsequently satisfying patient outcomes. Although CT scan is the non-invasive gold standard for fusion assessment, it lacks the ability to visualize bone viability and, therefore, discrepancy remains about sensitivity and specificity of CT as evaluation tool of spinal fusion. METHODS: A novel modality, (18)F Fluoride PET/CT, specifically allows quantitative in vivo evaluation of metabolic activity of the osseous integration. Bone viability following large segmental reconstructions in patients after mono- and multi-level en bloc spondylectomies (EBS) was analyzed. Spinal fusion was assessed on plain radiographs and CT scans according to the FDA fusion criteria as well as (18)F PET/CT. RESULTS: A total of eight patients underwent (18)F PET/CT were included (one 4-level-, one 3-level, two 2-level and four 1-level EBS). The average follow-up between EBS and radiographic studies was 24.8 months. On plain radiographs and CT scans, successful fusion was confirmed in all patients. However, (18)F PET/CT showed non-union in all cases. The metabolic bone activity within the cage was fourfold decreased compared to the reference vertebra, whereas the metabolic activity of the adjacent endplates was 1.6-fold increased compared to the reference vertebra. CONCLUSION: This study suggests a discrepancy between fusion rates assessed by plain radiographs and CT scan compared to (18)F PET/CT.

Avoiding drainage after major hip surgery in children is a viable option: results from a retrospective comparative study.

PURPOSE: The use of closed-suction drainage systems to evacuate haematomas after surgical procedures is still common practice in many orthopaedic departments. However, no evidence to support the routine use of closed-suction drains in orthopaedic surgery exists. Post-operative handling and removal of the drain is particularly complicated in children. We hypothesised that the use of surgical drains in major hip procedures in children does not reduce the complication rate. METHODS: The records of 63 children undergoing 97 major hip procedures managed with closed-suction drains (centre A), and 75 children undergoing 130 major hip procedures without application of wound drains (centre B) were retrospectively reviewed in this dual-centre study. Demographic data, pre-existing conditions, surgical indications and procedures, duration of hospitalisation and complication rates were analysed. RESULTS: Children (mean age, 8.3 ± 4 years) in both groups presented similar demographics, medical histories, surgical indications and procedures. No intra-operative complications occurred in either group. In the undrained group a significant shorter hospitalisation time was observed. Overall, there were 31 complications (31.9 %) in the drained group and 26 complications (20 %) in undrained group (p = 0.05). Applying the Clavien-Dindo grading system, both groups had mainly minor grade I and grade II complications. No differences regarding the rate of wound-related complications were observed between the two groups. CONCLUSIONS: The use of wound drains in our study cohorts has been shown to have no positive impact on complications rates after corrective osteotomies around the hip joint in children. In the light of our results and of the poor evidence of drainage use in adults, we do not recommend the routine use of drains in children undergoing orthopaedic hip procedures.

Transposition of the vertebral artery after a unilateral c1 lateral mass fracture: a case report and review of the literature.

In any cervical spine trauma involving dislocation of the facet joints or transverse foramen, a concomitant injury of the vertebral arteries must be excluded. Early diagnosis of an arterial occlusion is important because therapeutic intervention can prevent further complications, such as irreversible vertebrobasilar ischemia. Conservative and surgical treatment strategies are chosen depending on patient symptoms, fracture morphology, and grade of vascular injury. The benefit of anticoagulant medication after blunt injuries of the vertebral arteries in preventing thromboembolic events remains a matter of debate in the current literature. We present a case report of a professional biathlete with a unilateral vertebral artery injury. Adequate interpretation of both initial clinical and radiological findings is essential to detect this injury and to determine appropriate therapeutic intervention to optimize clinical outcome.

The SCIentinel study--prospective multicenter study to define the spinal cord injury-induced immune depression syndrome (SCI-IDS)--study protocol and interim feasibility data.

BACKGROUND: Infections are the leading cause of death in the acute phase following spinal cord injury and qualify as independent risk factor for poor neurological outcome ("disease modifying factor"). The enhanced susceptibility for infections is not stringently explained by the increased risk of aspiration in tetraplegic patients, neurogenic bladder dysfunction, or by high-dose methylprednisolone treatment. Experimental and clinical pilot data suggest that spinal cord injury disrupts the balanced interplay between the central nervous system and the immune system. The primary hypothesis is that the Spinal Cord Injury-induced Immune Depression Syndrome (SCI-IDS) is 'neurogenic' including deactivation of adaptive and innate immunity with decreased HLA-DR expression on monocytes as a key surrogate parameter. Secondary hypotheses are that the Immune Depression Syndrome is i) injury level- and ii) severity-dependent, iii) triggers transient lymphopenia, and iv) causes qualitative functional leukocyte deficits, which may endure the post-acute phase after spinal cord injury. METHODS/DESIGN: SCIentinel is a prospective, international, multicenter study aiming to recruit about 118 patients with acute spinal cord injury or control patients with acute vertebral fracture without neurological deficits scheduled for spinal surgery. The assessment points are: i) <31 hours, ii) 31-55 hours, iii) 7 days, iv) 14 days, and v) 10 weeks post-trauma. Assessment includes infections, concomitant injury, medication and neurological classification using American Spinal Injury Association impairment scale (AIS) and neurological level. Laboratory analyses comprise haematological profiling, immunophenotyping, including HLA-DR expression on monocytes, cytokines and gene expression of immune modulators. We provide an administrative interim analysis of the recruitment schedule of the trial. DISCUSSION: The objectives are to characterize the dysfunction of the innate and adaptive immune system after spinal cord injury and to explore its proposed 'neurogenic' origin by analyzing its correlation with lesion height and severity. The trial protocol considers difficulties of enrolment in an acute setting, and loss to follow up. The administrative interim analysis confirmed the feasibility of the protocol. Better understanding of the SCI-IDS is crucial to reduce co-morbidities and thereby to attenuate the impact of disease modifying factors to protect neurological "outcome at risk". This putatively results in improved spinal cord injury medical care. TRIAL REGISTRATION DRKS-ID: DRKS00000122 (German Clinical Trials Registry).

Necrotizing fasciitis: is the bacterial spectrum changing?

PURPOSE: Necrotizing fasciitis (NF) is a rare, but potentially fatal pathology. The aim of the present study was to identify the population characteristics of the NF patients, the responsible bacteria, and the differences between survivors and nonsurvivors. METHODS: In this retrospective case-control study, all patients with NF from January 1, 2005, to December 31, 2010, treated in an academic level 1 trauma center, were identified, and their medical records were reviewed. RESULTS: The mortality rate of the 24 identified patients was 20.8 %. The majority of the infections (54.2 %) (13/24) were monomicrobial. Hemolytic Streptococcus of group A (25 %) and methicillin-resistant Staphylococcus aureus (20.8 %) were the commonest germs. The mean number of comorbidities was 3.62 (standard deviation (SD) 3.58). Diabetes mellitus, cardiovascular disease, and immunosuppression were the commonest. Mean number of operations was 8.1 (SD 4.7). Five patients (20.8 %) developed a disseminated intravascular coagulation (DIC); all of them died. Nonsurvivors, who presented with deteriorated coagulation factors, developed a DIC (p < 0.001) and received more often antibiotic monotherapy (ampicillin/sulbactam) as initial empirical therapy (p < 0.001). CONCLUSIONS: The present study suggests a shift of the bacterial spectrum towards monomicrobial infections with multiresistant bacteria. The early recognition of high-risk patients and the aggressive surgical treatment with at least double-schema antibiotic therapy are of outmost importance.

Development of rice bodies in 2 children younger than 3 years.

Rice bodies are synovial fluid nodules macroscopically resembling shiny white rice beans. They have been seen in synovial fluid from several types of inflammatory arthritis including tuberculosis, pyogenic arthritis, and juvenile idiopathic arthritis and adult rheumatoid arthritis. Microscopically, they consist of amorphous material, fibrin, and collagen. We report the rare cases of 2 children younger than 3 years with multiple rice body formations in the knee joints.

Comparative evaluation of a novel measurement tool to assess lumbar spine posture and range of motion.

PURPOSE: The diagnosis of low back pain pathology is generally based upon invasive image-based assessment of structural pathology, but is limited in methods to evaluate function. The accurate and robust measurement of dynamic function may assist in the diagnosis and monitoring of therapy success. Epionics SPINE is an advanced strain-gauge measurement technology, based on the two sensor strips SpineDMS system, which allows the non-invasive assessment of lumbar and thoraco-lumbar motion for periods of up to 24 h. The aim of this study was to examine the reliability of Epionics SPINE and to collect and compare normative data for the characterisation of spinal motion in healthy subjects. Furthermore, the identification of parameters that influence lumbar range of motion (RoM) was targeted. METHODS: Spinal shape was measured using Epionics SPINE in 30 asymptomatic volunteers during upright standing, as well as maximum flexion and extension, to check intra-rater reliability. Furthermore, back shape was assessed throughout repeated maximum flexion and extension movements in 429 asymptomatic volunteers in order to collect normative data of the lordosis angle and RoM in different gender and age classes. RESULTS: The lordosis angle during standing in the healthy collective measured with Epionics SPINE was 32.4° ± 9.7°. Relative to this standing position, the average maximum flexion angle was 50.8° ± 10.9° and the average extension angle 25.0° ± 11.5°. Comparisons with X-ray and Spinal Mouse data demonstrated good agreement in static positions. Age played a larger role than gender in influencing lumbar posture and RoM. CONCLUSIONS: The Epionics SPINE system allows the practical and reliable dynamic assessment of lumbar spine shape and RoM, and may therefore provide a clinical solution for the evaluation of lower back pain as well as therapy monitoring.

Surgical management of recurrent thoracolumbar spinal sarcoma with 4-level total en bloc spondylectomy: description of technique and report of two cases.

INTRODUCTION: The descriptions of total spondylectomy and further development of the technique for the treatment of vertebral sarcomas offered for the first time the opportunity to achieve oncologically sufficient resection margins, thereby improving local tumor control and overall survival. Today, single level en bloc spondylectomies are routinely performed and discussed in the literature while only few data are available for multi-level resections. However, due to the topographic vicinity of the spinal cord and large vessels, the multisegmental resections are technically demanding, represent major surgery and only few case reports are available. Surgical options are even more limited in cases of revision surgery and local recurrences when en bloc spondylectomy was considered to be not feasible due to high risk of vital complications in expanding resection margins. Deranged anatomy, implants in situ and extensive intra-/paraspinal scar tissue formation resulting from previously performed approaches and/or radiation are considered the principal complicating factors that usually hold back spine surgeons to perform revision for resection leaving the patient to palliative treatment. METHODS: We present two patient cases with previously performed piecemeal vertebrectomy in the thoracic spine due to a solitary high-grade spinal sarcoma. After extensive re-staging, both patients underwent a multi (4)-level en bloc spondylectomy in our department (one patient with combined en bloc lung resection). Except a local wound disturbance, there was no severe intra- or postoperative complication. RESULTS: After multilevel en bloc spondylectomy both patients showed a good functional outcome without neurological deficits, except those resulting from oncologically scheduled resection of thoracic nerve roots. After a median follow-up of 13 months, there was no local recurrence or distant metastasis. The reconstruction using a posterior screw rod system that is interconnected to an anterior vertebral body replacement with a carbon composite cage showed no implant failure or loosening. In summary, the approach of a multilevel en bloc surgery for revision and oncologically sufficient resection in cases of spinal sarcoma recurrences seems possible. However, interdisciplinary decision making in a tumor board, realistic evaluation of surgical resectability to attain tumor free margins, advanced experiences in spinal reconstructions and involvement of vascular, visceral and thoracic surgical expertise are essential preconditions for acceptable oncological and functional outcome.

Traumatic spinal cord injury.

Traumatic spinal cord injury (SCI) has devastating consequences for the physical, social and vocational well-being of patients. The demographic of SCIs is shifting such that an increasing proportion of older individuals are being affected. Pathophysiologically, the initial mechanical trauma (the primary injury) permeabilizes neurons and glia and initiates a secondary injury cascade that leads to progressive cell death and spinal cord damage over the subsequent weeks. Over time, the lesion remodels and is composed of cystic cavitations and a glial scar, both of which potently inhibit regeneration. Several animal models and complementary behavioural tests of SCI have been developed to mimic this pathological process and form the basis for the development of preclinical and translational neuroprotective and neuroregenerative strategies. Diagnosis requires a thorough patient history, standardized neurological physical examination and radiographic imaging of the spinal cord. Following diagnosis, several interventions need to be rapidly applied, including haemodynamic monitoring in the intensive care unit, early surgical decompression, blood pressure augmentation and, potentially, the administration of methylprednisolone. Managing the complications of SCI, such as bowel and bladder dysfunction, the formation of pressure sores and infections, is key to address all facets of the patient's injury experience.

Unilateral Extraforaminal Lumbar Interbody Fusion (ELIF): Surgical Technique and Clinical Outcome in 107 Patients.

STUDY DESIGN: Description of the technique and retrospective study of patients treated with unilateral extraforaminal lumbar interbody fusion (ELIF) for degenerative lumbar spinal disorders. OBJECTIVE: To investigate clinical and radiologic outcome of patients treated with unilateral ELIF. SUMMARY OF BACKGROUND DATA: Lumbar interbody fusion is the classic treatment for higher grades of degenerative disk disease or lumbar segment instability and is performed by posterior (PLIF), posterolateral, or anterior (ALIF) approaches. Those techniques are well established with known limitations and complications. Today, minimally invasive procedures generate more interest especially in terms of muscle damage to achieve better functional outcome. We introduce a unilateral extraforaminal fusion technique which respects neural as well as muscle structures aiming to preserve function. METHODS: Intraoperative and perioperative data, neurological status, Oswestry Disability Index, the Visual Analogue Scale for leg and back pain, and patient satisfaction were investigated preoperatively and at latest follow-up. Fusion status was controlled by x-ray and CT scans at a 6 months' follow-up investigation. RESULTS: A total of 107 patients [female/male: 67/40; average age, 52.8 (± 13.8) y] were included at a maximum of 31(± 9.4) months. Complications occurred in 4% of patients. Transient radicular pain was investigated in 16 patients. The Oswestry Disability Index and the Visual Analogue Scale for back and leg pain improved significantly. Patients showed a short hospital stay and high percentage of return to work ratio (70%). Fusion was achieved in 97% of patients. CONCLUSIONS: The unilateral ELIF fusion technique demonstrates encouraging clinical and radiologic midterm outcome that for some indications is comparable with established fusion techniques.

Three-dimensional fluoroscopy-navigated percutaneous screw fixation of acetabular fractures.

OBJECTIVE: Anatomic reduction and articular restoration after acetabular fractures occur (Ac-Fxs) are accepted predictors for good function and slow progression of posttraumatic osteoarthritis of the hip. The aim of this study was to retrospectively analyze Ac-Fxs, which were treated with closed reduction and percutaneous (three-dimensional) fluoroscopy-based navigated screw fixation. DESIGN: Level 4, retrospective clinical and radiographic assessment. SETTING: Level 1 trauma center. PATIENTS: Twelve patients (male/female: 9/3; mean age: 60 years; range: 16-80 years) with moderately displaced Ac-Fxs were included. INTERVENTION: In enrolled patients, the treatment involved percutaneous three-dimensional fluoroscopy-based navigated lag screw positioning. Closed reduction was achieved by lag screws, or reduction was aided by the insertion of percutaneous Schanz pins. MAIN OUTCOME MEASUREMENTS: The quality of the reduction and screw positions were assessed using intraoperative and postoperative computed tomography scans. Functional outcome was assessed using the Harris hip score, the visual analog scale for pain, and the Tegener activity scale. RESULTS: A total of 22 periacetabular screws were placed (mean: 1.8 ± 1.1 screws/patient, range: 1-5). The mean follow-up was done for 30 (16-72) months. The postoperative reduction was anatomical in all patients, and the mean fracture displacement was significantly reduced (gap: 4.1 ± 1.8 mm to 0.4 ± 0.7 mm/step: 1.4 ± 0.6 mm to 0.2 ± 0.4 mm). No secondary dislocations or malunions/nonunions were found. All screws correctly addressed the fracture morphology and corresponded to preoperative planning. The Harris hip score, the visual analog scale (motion), and Tegener activity scale showed excellent to very good results (92.4 ± 6.8, 1.9 ± 1.3, and 3.8 ± 1.6, respectively). CONCLUSIONS: The navigated, percutaneous screw fixation of selected Ac-Fxs is a promising method that allows for closed reduction and fixation while obtaining a very good radiographic and functional outcome. LEVEL OF EVIDENCE: Therapeutic level 4.

Age-related loss of lumbar spinal lordosis and mobility--a study of 323 asymptomatic volunteers.

BACKGROUND: The understanding of the individual shape and mobility of the lumbar spine are key factors for the prevention and treatment of low back pain. The influence of age and sex on the total lumbar lordosis and the range of motion as well as on different lumbar sub-regions (lower, middle and upper lordosis) in asymptomatic subjects still merits discussion, since it is essential for patient-specific treatment and evidence-based distinction between painful degenerative pathologies and asymptomatic aging. METHODS AND FINDINGS: A novel non-invasive measuring system was used to assess the total and local lumbar shape and its mobility of 323 asymptomatic volunteers (age: 20-75 yrs; BMI <26.0 kg/m2; males/females: 139/184). The lumbar lordosis for standing and the range of motion for maximal upper body flexion (RoF) and extension (RoE) were determined. The total lordosis was significantly reduced by approximately 20%, the RoF by 12% and the RoE by 31% in the oldest (>50 yrs) compared to the youngest age cohort (20-29 yrs). Locally, these decreases mostly occurred in the middle part of the lordosis and less towards the lumbo-sacral and thoraco-lumbar transitions. The sex only affected the RoE. CONCLUSIONS: During aging, the lower lumbar spine retains its lordosis and mobility, whereas the middle part flattens and becomes less mobile. These findings lay the ground for a better understanding of the incidence of level- and age-dependent spinal disorders, and may have important implications for the clinical long-term success of different surgical interventions.

Current practice of methylprednisolone administration for acute spinal cord injury in Germany: a national survey.

STUDY DESIGN: Written mail-out survey. OBJECTIVE: To determine current practice in high-dose methylprednisolone succinate (MPSS) administration for treatment of acute spinal cord injury (SCI) in Germany. SUMMARY OF BACKGROUND DATA: Reanalysis of the National Acute Spinal Cord Injury Studies (NASCIS) resulted in criticism of the use of high-dose MPSS for treatment of acute SCI. Subsequently, SCI treatment guidelines were revised leading to a reduction in MPSS use across North America. The impact of these revisions on SCI treatment in Germany is not known. METHODS: A questionnaire was sent to all trauma, orthopedic and neurosurgical departments of German university centers, affiliated teaching hospitals, and specialized SCI care centers. Survey included 6 questions about the administration of MPSS after acute SCI. RESULTS: Three hundred seventy-two respondents completed the survey (response rate: 51% overall, 76% university hospitals, 85% specialized SCI care centers). Overall, 55% of departments that treat SCI prescribe MPSS. Among them, 73% are "frequent" users administering MPSS to more than 50% of their patients. Ten percent prescribe according to NASCIS I, 43% NASCIS II, 33% NASCIS III, and 13% "generic protocols." As justification for MPSS treatment, "effectiveness" ranked before "common practice" and "medicolegal reasons." "Specialized" SCI care centers differ in that (1) MPSS is administered less frequently, (2) NASCIS I doses are not used, and (3) during the past several years, practice patterns are more likely to have shifted away from the treatment of SCI with MPSS. CONCLUSION: About one-half of the institutions continue to prescribe MPSS in the setting of acute SCI. A need for further education in almost one-fourth of German departments treating acute SCI is demonstrated through responses indicating use of the outdated NASCIS I protocol, a "legal need" or "unchanged MPSS application during the last years." "Specialized" SCI centers are more likely to change their practice in accordance with evolving literature. LEVEL OF EVIDENCE: 3.

Off label use of botulinum toxin in children under two years of age: a systematic review.

The treatment of children with cerebral palsy with Botulinum Toxin is considered safe and effective, but is only approved for children older than two years of age. The effect of BoNT-A injection on juvenile skeletal muscle especially on neuromuscular junction density, distribution and morphology is poorly delineated and concerns of irreversible damage to the motor endplates especially in young children exist. In contrast, earlier treatment could be appropriate to improve the attainment of motor milestones and general motor development. This review systematically analyzes the evidence regarding this hypothesis. A database search, including PubMed and Medline databases, was performed and all randomized controlled trials (RCTs) comparing the efficacy of Botulinum Toxin in children younger than two years were identified. Two authors independently extracted the data and the methods of all identified trials were assessed. Three RCTs met the inclusion criteria. The results of the analysis revealed an improvement in spasticity of the upper and lower extremities as well as in the range of motion in the joints of the lower limbs. However, evidence of an improvement of general motor development could not be found, as the assessment of this area was not completely specified for this patient group. Based on available evidence it can not be concluded that Botulinum Toxin treatment in children younger than two years improves the achievement of motor milestones. However, there is evidence for the reduction of spasticity, avoiding contractures and delaying surgery. Due to some limitations, the results of this review should be cautiously interpreted. More studies, long-term follow up independent high-quality RCTs with effectiveness analyses are needed.

MRI evaluation of hip containment and congruency after closed reduction in congenital hip dislocation.

BACKGROUND: Developmental dysplasia of the hip is the most common congenital skeletal disease. In its most severe form--dislocation--the treatment is directed at reducing the hip and establishing normal congruency between the femoral head and the acetabulum. Closed reduction with casting is a common primary treatment, where reduction is confirmed by magnetic resonance imaging (MRI). OBJECTIVE: This study analyses anatomical aspects depicted on MRI after closed reduction to identify disparities in the growth behaviour of dislocated hips. MATERIALS AND METHODS: In 38 patients MRI after closed reduction was available for analysis. After exclusion of children with underlying diseases or syndromes, MRIs of 28 children were evaluated with respect to head coverage index, acetabular head index and sphericity. The results were compared to the stable opposite sides. RESULTS: Twenty-two stable and 27 initially unstable hips were available for further analysis. The head coverage index as well as the acetabular head index of the unstable hips was significantly smaller than that of the stable hips. The sphericity score of the dislocated femoral heads was significantly lower than that of the stable ones. CONCLUSION: Dislocated hips showed significantly lower values for all of the evaluated parameters concerning congruency and containment. MRI is not only useful to confirm successful reduction but may also help to predict outcome by evaluating following dislocation.

Velocity of lordosis angle during spinal flexion and extension.

The importance of functional parameters for evaluating the severity of low back pain is gaining clinical recognition, with evidence suggesting that the angular velocity of lordosis is critical for identification of musculoskeletal deficits. However, there is a lack of data regarding the range of functional kinematics (RoKs), particularly which include the changing shape and curvature of the spine. We address this deficit by characterising the angular velocity of lordosis throughout the thoracolumbar spine according to age and gender. The velocity of lumbar back shape changes was measured using Epionics SPINE during maximum flexion and extension activities in 429 asymptomatic volunteers. The difference between maximum positive and negative velocities represented the RoKs. The mean RoKs for flexion decreased with age; 114°/s (20-35 years), 100°/s (36-50 years) and 83°/s (51-75 years). For extension, the corresponding mean RoKs were 73°/s, 57°/s and 47°/s. ANCOVA analyses revealed that age and gender had the largest influence on the RoKs (p<0.05). The Epionics SPINE system allows the rapid assessment of functional kinematics in the lumbar spine. The results of this study now serve as normative data for comparison to patients with spinal pathology or after surgical treatment.