[Follow-up of spondylodiscitis following intervertebral disk operation--on the etiology, therapy and prevention]. / Die Verlaufsformen der Spondylodiszitis nach Bandscheibenoperation--zur Genese, Therapie und Prophylaxe.

Operations on lumbar disc prolapses are the most frequent operations in German neurosurgery divisions. After such operations, spondylodiscitis is a dreaded complication which is sometimes difficult to diagnose. Treatment of spondylodiscitis is always protracted and a burden for doctors and patients. Hence, it appears worthwhile to present a further report on discitis and spondylodiscitis, infections of the intervertebral space and the surrounding tissues after disk operations. Various clinical pictures are described: septic progress forms with neurological disorders and the necessity of open wound treatment as well as clinical pictures without septic signs with good recovery after immobilisation and antibiotic treatment. In two cases, CT-guided puncture of purulent suppuration with identification of the causative organisms and specific antibiotic treatment was possible. All patients had a relatively good result: pareses and/or bladder/rectal disorders disappeared completely in every case. The causes of discitis are discussed. The condition arises when nosocomial microorganisms, or very frequently even harmless skin bacteria, enter the wound. A large number of operations are carried out under pressure of time and under hectic conditions, as well as in a confined space in operation theatres which are too warm; these factors increase the susceptibility to infection. However, the resistance of the patient to infection is also weakened after longterm prior antiinflammatory treatment and a stay in hospital before the operation. Besides appropria to treatment of the infection (immobilisation, wound treatment, antibiotic therapy), psychological management of the patient is an important component of therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of MRT for therapy of para-sellar tumors]. / Die Bedeutung der MRT für die Therapie sellanaher Geschwülste.

When planning treatment of tumours in the sella region it is of the utmost importance to obtain precise information about the localization, spread, and (if possible) the type of alteration. Aside from the classic radiographic methods of native diagnosis, angiography, and CT, MRI has been available for some years now. This is a method whereby images can be gained from the various stages of an energetic reaction in the biological substrate: tomograms are possible for any desired plane--those routinely needed for cerebral diagnosis from the horizontal, coronary, and sagittal planes and, given a further improvement of this technology, from special oblique planes which can be matched to the direction of a probable surgical approach. A number of examples demonstrate the significance of this new method, which is a valuable addition to the procedures used up to now: indeed, in some cases it is superior to them. It has been shown that most of the neighbouring structures which border on or have been pushed aside by the tumour in the sella region (blood vessels, brain, optic chiasma, subarachnoid spaces, and occasionally even bone structures) can be identified better than with the procedures used up to now. MRI has thus proved to be valuable, and occasionally indispensable, for the correct choice when considering the many therapeutic methods available for tumours in the sella region.

[New aspects in the diagnosis of intervertebral disk displacement of the upper lumbar spine with special reference to magnetic resonance tomography]. / Neue Aspekte zur Diagnostik des Bandscheibenvorfalls der oberen Lendenwirbelsäule unter besonderer Berücksichtigung der MRT.

A report is presented on two patients who received surgery on a disc prolapse between the lumbar vertebrae 4 and 5 as treatment for compression of the fifth lumbar root, but in whom the clinically relevant disc prolapse was located higher (lumbar vertebrae 1/2 or thoracic vertebra 12/lumbar vertebra 1). Magnetic resonance tomography made a major contribution to the later diagnosis of the high disc prolapses. Besides precise localization of the lesion, MRT made it easier to understand why such a high disc prolapse can cause a compression syndrome of the fifth lumbar root.

The centralized prenatal genetics screening program of New York City III: The first 7,000 cases.

The Prenatal Diagnosis Laboratory of New York City (PDL) is a regional program for the prevention of genetic diseases. The administrative aspects of the establishment of the laboratory were described in papers I [Hsu, 1981] and II [Hsu and Benn, 1981] in this series. We now report our experience of the first 7,000 referrals to the laboratory. The laboratory achieved a success rate of 99.5% in obtaining a diagnosis. The frequency with which a repeat amniocentesis was required was 1.9%, usually attributable to inadequate initial amniotic fluid volume or condition. Cases were completed in an average time of 20.82 days. A total of 149 (2.13%) cytogenetic abnormalities were detected. There were 59 nonmosaic autosomal trisomies and 29 sex chromosome abnormalities. The incidence of unbalanced structural abnormalities (0.186%) was much higher than that reported in surveys of newborn infants largely because of the prenatal detection of cases with supernumerary chromosomes. The incidence of balanced structural abnormalities was also considerably higher than that found in surveys of the newborn population, in part because of the detection of subtle familial pericentric inversions of common chromosome regions (inv(Y)(p11q11), inv(2) (p11q13), and inv(1)(p11q13)). The incidence of cases with multiple independent chromosome abnormalities was no higher than expected by chance. A high incidence of mosaicism, pseudomosaicism, and maternal cell contamination was found. Screening for neural tube defects accounted for the detection of a further 16 abnormalities. Nearly all women with severely abnormal fetuses (trisomy 13, 18, 21) elected to terminate their pregnancy whereas only 62% of patients with a prenatally diagnosed sex chromosome abnormality elected to terminate their pregnancies. Full details of follow-up and confirmatory studies for unusual diagnoses are reported. Utilization of prenatal diagnosis in the New York City area has increased sharply since PDL became operational. The laboratory's success illustrates the role of a prenatal diagnosis laboratory that provides a service independent of the patient's financial status. The experience further shows the high degree of acceptance of prenatal diagnosis by individuals at high risk for a child with a genetic disorder.

Osteopenia in rheumatology practice: pathogenesis and therapy.

Postmenopausal osteoporosis has a multifactorial pathogenesis related to decreases in bone mass, calcium intake, and circulating estrogen levels. Therapy with supplemental calcium, estrogen, fluoride, anabolic steroids, and calcitonin is discussed. Corticosteroid-induced osteopenia is in part related to a decrease in intestinal calcium absorption and therapy with supplemental vitamin D and calcium may favorably alter the outcome. The osteopenia of rheumatoid arthritis appears to be a diffuse process, with increased metabolic bone activity at sites that are remote from the areas of active synovitis.

Wegener's granulomatosis. Clinical features and outcome in 13 patients.

Thirteen patients with Wegener's granulomatosis were seen over 10.5 years. The clinical features resembled those in previously reported series, except for the increased frequency of inflammatory arthritis, which was a prominent early feature in ten patients (77%). Four (31%) of the 13 had fulminant vasculitis and died before receiving an adequate course of cytotoxic drug therapy. Two of these four had a pulmonary-renal syndrome that mimicked Goodpasture's syndrome. All of the remaining nine patients (69%) achieved an initial remission with cytotoxic agents (azathioprine or cyclophosphamide), but four died in less than one year with no evidence of vasculitis at autopsy. The 56% survival rate to one year in these nine patients contrasts with an 86% to 100% survival in other series. Chronic renal failure was a prominent sequela in those who survived one year.

Stress exertion on adjacent segments after ventral cervical fusion.

Special investigations of the adjacent segments are performed in patients with cervical fusion operations caused by different indications: Only a few of alteration was seen after operations caused by infectious disease, tumor or trauma. A different situation arises with degenerative lesions, where often progressive changes were seen in the adjacent segments. This phenomena may be dependent at first of the kind of lesion (degeneration) and only at second of the kind of operation.

Generalized skeletal response to 99mtechnetium methylene diphosphonate in rheumatoid arthritis.

The total body retention (TBR) and the 5- and 24-h lumbar spine to soft tissue (LS/ST) ratios of 99mtechnetium methylene diphosphonate was studied in 19 patients with rheumatoid arthritis (RA), 16 patients with metastatic tumors that did not involve the lumbar spine, 10 patients with chronic renal failure and 17 controls. The TBR was significantly higher in all groups compared to the controls. The 5-h LS/ST did not differ between any of the groups although the 24-h LS/ST ratios were significantly elevated in RA and those with chronic renal failure. The 24-h LS/ST in RA was correlated only with disease duration. The results are consistent with a generalized increase in bone turnover in RA and may explain the recognized lack of sensitivity of quantitative scintigraphic techniques in this disorder.

Hepatic abnormalities in adult onset Still's disease.

Five patients with adult onset Still's disease are reported. Three had abnormal liver function tests (LFT) prior to receiving salicylates. Liver biopsy in 1 of these 3 and in another with normal LFT was abnormal. The elevated LFT returned to normal with high dose salicylate therapy coincident with remission of disease activity. It is proposed that hepatic abnormalities in Still's disease frequently reflect the underlying disease and not salicylate hepatotoxicity (SH).

Hairy-cell leukaemia with polyarteritis nodosa.

In four patients a systemic vasculitis similar to polyarteritis nodosa developed within 2 years of the onset of hairy-cell leukaemia. Arteriographic studies in two patients revealed microaneurysms, and biopsy specimens in three patients revealed a vasculitis affecting medium-sized vessels. Blood neutrophilia and neutrophilic vascular infiltrate were absent. One patient had circulating immune complexes. Two patients responded to corticosteroids alone, one required cyclophosphamide as well as steroids, and one improved without chemotherapy. The association of vasculitis with hairy-cell leukaemia may provide insight into the pathogenesis of arteritis.

Hepatic toxicity associated with gold therapy.

Three patients with rheumatoid arthritis developed jaundice after initiation of chrysotherapy. Gold sodium thiomalate had been administered in dosages of 37.5, 60, and 110 mg in these patients before the onset of jaundice. Liver function studies indicated a cholestatic jaundice in all subjects. One patient underwent exploratory laparotomy because of progressive jaundice. Liver biopsy was done in two patients. In one patient significant bile stasis and thrombi were seen in the biliary tree. In another patient liver biopsy showed ballooning of hepatocytes with minimal cholestasis. All patients recovered spontaneously. Awareness of this rare complication may prevent unnecessary diagnostic and surgical procedures in patients with rheumatoid arthritis who may develop jaundice while receiving chrysotherapy.

Immunologic abnormalities in patients with malignant lymphoproliferative diseases.

The B- and T-lymphocyte distribution was studied in 45 patients with malignant lymphoproliferative diseases. Eight patients with untreated Hodgkin's disease had normal mean percentages of complement receptor lymphocyte (CRL) cells and T-cells; however, the mean absolute number of T-cells was decreased. T-lymphocytes were also decreased in 3 patients with Hodgkin's disease treated 7-24 months previously. The number of T-lymphocytes increased markedly in all patients after treatment. Lymphocyte surface markers in non-Hodgkin's lymphoma showed distinctive patterns. Patients with leukemic reticuloendotheliosis or "hairy cell leukemia" characteristically had low percentages of CRL but normal or increased percentages of surface immunoglobulin-positive lymphocytes. The mean percentage and number of T-lymphocytes in this group were normal. Eight patients with nodular lymphocytic lymphoma and 2 patients with nodular lymphocytic-histiocytic lymphoma had normal mean numbers of CRL but decreased numbers of T-lymphocytes. Of 6 patients with diffuse lymphocytic lymphoma, 4 had elevated percentages and numbers of CRL. Despite low percentages, normal numbers of T-lymphocytes were found in 3 of these patients.

Immunological identification of subpopulations of mononuclear cells in sarcoid granulomas.

The quantity of both circulating B and T lymphocytes in patients with sarcoidosis is diminished, although the relative percentage of each cell type appears normal. Immunocompetent cells comprising B and T lymphocytes, plasma cells, and histiocytes have been recognized in the sarcoid granuloma and the implications of these findings have been discussed.

Immunologic characterization of the mononuclear cell infiltrates in rheumatoid synovia, in rheumatoid nodules, and in lip biopsies from patients with Sjögren's syndrome.

Two subcutaneous rheumatoid nodules and 8 rheumatoid synovia from patients with rheumatoid arthritis (RA); and 2 parotid glands, 1 "pseudolymphoma," and 6 lip biopsies from patients with Sjogren's syndrome (SS) were studied to identify mononuclear cells. The palisading mononuclear cells in subcutaneous nodules had a surface membrane receptor for complement. B lymphocytes surrounded by larger numbers of non-B lymphocytes were found in RA synovium and between salivary ducts of SS lip biopsies. A "pseudolymphoma" obtained from a patient with SS consisted primarily of B lymphocytes. The predominant mononuclear cell in rheumatoid synovia and salivary glands in patients with RA and SS do not have surface membrane receptors from complement and are thus probably T lymphocytes or null cells.

Association of polyarthritis, subcutaneous nodules, and pancreatic disease.

A patient with nodular liquefying panniculitis, polyarthritis and an occult pancreatic neoplasm is described. The skin lesion was initially mistaken for erythema nodosum. Subcutaneous and synovial fluids demonstrated similar negatively birefringent, rectangular particles, lying in between fat globules. Serum lipase,although continuously elevated, did not fluctuate with disease activity. Biochemical evidence of lipolysis in either the synovial fluid or serum was not demonstrable. Immunologic mechanisms appeared not to be involved in the pathogensis of the panniculitis or the arthritis.

Diagnosis of sarcoidosis by lip biopsy of minor salivary glands.

In two patients with bilateral parotid gland swelling of unknown etiology the diagnosis of sarcoidosis was established by lip biopsy of the minor salivary glands. This simple, innocuous biopsy procedure may prove useful in tissue documentation of sarcoidosis.