Thermocoagulation of the Medial Branch of the Dorsal Branch of the Lumbal Spinal Nerve: Flouroscopy Versus CT.

Objective: For radiofrequency neurotomy of the medial branch of the lumbar dorsal rami, physicians use techniques guided either by fluoroscopy or computerized tomography (CT), and advocate for their respective techniques. Crucial to the choice of technique is how well each can capture the target nerve. The present study was, therefore, undertaken to assess in cadavers the accuracy of fluoroscopic-guided and CT-guided techniques. Design: In10 cadavers preserved with Thiel's method, electrodes with 10mm active tips were placed in supine position on the right using a fluoroscopic-guided technique, and on the left using a CT-guided technique. Using a special dissection approach, the relationship between the target nerve and the tip of the electrode was revealed. The displacement between electrode and the nerve, and the extent to which the electrode was parallel to the nerve, were measured with callipers. Results: Under fluoroscopy guidance, electrodes were placed accurately beside the nerve, and were parallel to it for 9 ±1.9 mm. In only two cases did the electrode pass too deeply. Under CT guidance, electrodes often failed to reach the nerve, but when they did they were parallel to it for only 3.2 ± 3.2 mm. In seven cases, the electrode passed too deeply beyond the target nerve. Conclusion: The fluoroscopy-guided technique can be relied upon to achieve optimal placement of electrodes on the lumbar medial branches. The CT-guided technique fails to do so, and should not be used in practice until a modified version has been developed and validated.

Serial clinical and MRI examinations after arthroscopic rotator cuff reconstruction using double-row technique.

PURPOSE: Rotator cuff reconstruction using arthroscopic double-row technique enables a better repair of the anatomical footprint at the tendon insertion. Objective of this serial study was to illustrate structural and functional results during recovery following double-row reconstruction. METHODS: Forty-five patients with mid-sized ruptures of the supraspinatus tendon were assessed prospectively and underwent arthroscopic surgery using the double-row technique. Rupture localization, size, form, and extent of retraction were recorded intraoperatively. Clinical and MRI follow-up examinations were carried out for all patients after 6, 12, 26, and 52 weeks. A A standard protocol was used during the follow-up examinations to determine tendon integration, signal changes in the tendon, extent of bone marrow edema near the enclosed absorbable suture anchors, muscle changes. The clinical results were correlated with the MRI appearance. RESULTS: After 26 weeks, the Constant score (CS) showed a highly significant increase for the first time with a value of 78 (p < 0.001). Tendon integration according to Sugaya showed a left shift over time, with higher CS-values for lower Sugaya classifications. Significant improvements in strength were first measured between the 26-week and 52-week follow-ups (9->19/p < 0.001). Highly significant improvement (p < 0.001) of the tendon signal and the fatty infiltration was found in the same time interval. The hypotrophy showed slight improvement, while a highly significant reduction of the bone marrow edema was found between weeks 12 and 26 (p < 0.001). There were no re-ruptures after week 26. CONCLUSIONS: The present serial study showed that it took 26 weeks to reach a significant clinical improvement concerning CS. With regard to tendon healing, no further deterioration of the structural results occurred between week 26 and week 52 postoperative. There were slightly but not significant better clinical results according to the the Sugaya classification. However, parameter "strength" was significantly increased between weeks 26 and 52. This was consistent with a significant decrease in the signal intensity at the repaired tendon site, an additional improvement in the fatty infiltration, and the atrophy according to Thomazeau in the same time interval. LEVEL OF EVIDENCE: I.

[Epidural spinal cord stimulation for therapy of chronic pain. Summary of the S3 guidelines]. / Epidurale Rückenmarkstimulation zur Therapie chronischer Schmerzen. Zusammenfassung der S3-Leitlinie.

Epidural spinal cord stimulation (SCS) is a reversible but invasive procedure which should be used for neuropathic pain, e.g. complex regional pain syndrome I (CRPS) and for mostly chronic radiculopathy in connection with failed back surgery syndrome following unsuccessful conservative therapy. Epidural SCS can also successfully be used after exclusion of curative procedures and conservative therapy attempts for vascular-linked pain, such as in peripheral arterial occlusive disease stages II and III according to Fontaine and refractory angina pectoris. Clinical practice has shown which clinical symptoms cannot be successfully treated by epidural SCS, e.g. pain in complete paraplegia syndrome or atrophy/injury of the sensory pathways of the spinal cord or cancer pain. A decisive factor is a critical patient selection as well as the diagnosis. Epidural SCS should always be used within an interdisciplinary multimodal therapy concept. Implementation should only be carried out in experienced therapy centers which are in a position to deal with potential complications.

[Arthroscopic reconstruction of the rotor cuff]. / Die arthroskopische Rotatorenmanschettenrekonstruktion.

Over the last years treatment of rotator cuff tears is evolving gradually from open to complete arthroscopic repair. There had been fast developments in arthroscopic techniques and instruments and there is a better understanding of biomechanical backgrounds. For a good clinical outcome it is not necessary to obtain a watertight closure in all cases but to balance the force couples in the coronal and transverse plane. There is recent discussion regarding the optimum techniques and stitches for cuff reconstruction and resulting developments in this field. To determine the individual reconstruction technique it is crucial to recognize the different tear categories. Based on these findings we are now able to treat nearly every cuff tear arthroscopically, even a retracted massive lesion.

[Lumbar discogenic pain]. / Diskogene lumbale Rückenschmerzen -- Pathomechanismus, Diagnostik und Klinik.

Lumbar discogenic pain in the sense of an internal disc disruption (IDD) represents a nociceptive pain syndrome with the source of pain in the innervated outer third of the annulus. Such discs anatomically appear with almost normal contours. Neither clinical nor technical assessments have any diagnostic value, with the exception of MRI which has been shown, if present in symptomatic patients, to have a positive predictive value of up to 89 % to indicate a strong correlation to a painful grade 3 or 4 fissure. However, only the stimulation of a disc (controlled provocation discography) with a subsequent CT scan is of exclusive diagnostic value. As an underlying pathomechanism, a compression fracture of the superior subchondral endplate like a fatigue fracture is discussed. In this way, a deterioration of the homogeneous intradiscal stress distribution could occur with consecutive damage to the internal disc environment and the expression of a radial fissure. The clinical picture of discogenic pain is non-specific. It does not correlate with degenerative changes. It does not differ from any other back pain. Thus, it has to be differentiated from zygapophysial joint pain as well as from sacroiliac joint pain and muscular-ligamentous pain sources. In a single study of American workers, the prevalence of IDD was 39 %, rendering it one of the most important causes for patients with a specified source of back pain.

[The effect of continuous thoracic peridural anesthesia on the pulmonary function of patients undergoing colon surgery. Results of a randomized study of 116 patients]. / Einfluss der kontinuierlichen thorakalen Periduralanaesthesie auf die Lungenfunktion kolonchirurgischer Patienten. Ergebnisse einer randomisierten Untersuchung an 116 Patienten.

In a prospective randomized clinical investigation, we examined the influence of continuous thoracic epidural analgesia (TEA) on pulmonary function and pathologic chest X-ray findings. METHODS. One hundred sixteen patients having resection and/or anastomosis of the colon participated in this study; 57 were randomly assigned to the epidural group, whereas 59 were given systemic analgesia. Both groups were comparable with regard to ASA classification and pre-existing disease, as well as operative procedures and surgeons. Bupivacaine 0.75% was given to the TEA patients pre- and intraoperatively (epidural catheter T8/9), and postoperatively they received bupivacaine 0.25% continuously by motor pump for 3 days. We aimed to reach an analgesic spread from T5 to L2. In order to maintain sufficient analgesia, we had to increase the dosage from 19.2 mg/h on the evening of the operative day to 22.2 mg on the 3rd postoperative day. However, under these conditions the number of blocked segments decreased from 9.3 postoperatively to 6.6 on the 3rd postoperative day. Balanced anesthesia (isoflurane plus fentanyl) was given to the control group. Postoperatively, these patients received systemic analgesia on request (piritramide i.m., tramadol, or a simple analgesic). Vital capacity and pain score (10-point nominal analog score) were evaluated at 1, 8, 24, 36, 48, 60 and 72 h postoperatively. Blood gas analyses were taken at 1, 8, 24, 48 and 72 h, and chest X-rays were performed on the 1st, 3rd, and 8th postoperative days. Statistically significant results are indicated by "*" (P less than 0.05) and "*" (P less than 0.005) and "***" (P less than 0.001). The standard deviations were shown in cases of statistical significance. RESULTS. There were significantly lower pain scores by 1.0-2.2 points at 1, 8, 24 and 36 h postoperatively in the TEA group. Fourteen patients in group I required adjustments of the postoperative pain treatment regime: 6 had a unilateral epidural block; in 4 the catheter was withdrawn involuntarily. Up to the 2nd postoperative day, patients in the control group received systemic analgesics significantly more often. The vital capacity (percentage of preoperative value) was significantly higher in the TEA group than in the control group after 1 h (58.5% vs 51.7%) and 8 h (63.9% vs 56.7%). From the 1st postoperative day on there was no difference between both groups with regard to arterial blood gases, there was no difference in pCO2 between both groups 1 h postoperatively; it was, however, significantly lower in patients receiving bupivacaine at 8, 24, 48 and 72 h. There was no difference in pO2 at any time. The number of pathologic chest X-ray findings showed no difference between both groups. Looking especially for infiltrates, dystelectasis, atelectasis, and congestion, we also could not demonstrate any difference between the groups. (ABSTRACT TRUNCATED AT 400 WORDS)

Epidural analgesia in colonic surgery: results of a randomized prospective study.

Colonic surgery patients were studied to measure: the influence of continuous thoracic epidural analgesia (TEA) on a postoperative pain score, the time till onset of defaecation, blood loss, postoperative temperature elevations, rate of bacterial contamination of wounds and urine, and general surgical complications. Group I patients (n = 57) received general anaesthesia and TEA for the operation, followed by continuous TEA (0.25 per cent bupivacaine) for 72 h. Group II patients (n = 59) received general anaesthesia for the operation, followed by systemic analgesia on request. Significant beneficial effects of TEA in group I were demonstrated by lower pain scores in the first 24 h after surgery and earlier defaecation. However, there were fewer temperature elevations in group II. There was no significant difference between the groups in terms of positive bacteriological cultures, blood loss, need for postoperative mechanical ventilation and complications. However, there was a trend toward a higher rate of rectal anastomotic breakdown, increased blood replacement and intensive care therapy, and longer hospitalization in group I. These results do not suggest any significant beneficial therapeutic effect of continuous TEA in colonic surgery compared with a conventional systemic analgesic regimen. In selected patients (i.e. those with severe pain or those prone to develop postoperative ileus) continuous TEA may be beneficial.

[Standardization of invasive neuromodulatory procedures]. / Standardisierung invasiver neuromodulativer Verfahren. Leitlinie der Stufe I der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF-Expertenempfehlung).

The Working Group on Neuromodulation of the German Association for the Study of Pain, composed of representatives from various scientific specialty societies, met on December 9, 2000, March 24, 2001, October 5, 2001, and December 8, 2001. As a result of these discussions grounded in current knowledge, the following guidelines were formulated for the standardization of invasive techniques of neuromodulation intended to serve as a systematic aid in decision-making and to provide recommendations for practice-oriented methods. The guidelines were based on both the clinical and practical experience of the group participants (see information box on the next page) as well as on the current scientific literature and guidance from the consensus report of the European Federation of IASP Chapters (EFIC) [23]. The guidelines serve the purpose of orientation and have no effect on either assumption of liability or discharge from liability. The guidelines were conceived for use by physicians in private practice,doctors in hospitals,and nonmedical personnel concerned with the care of chronic pain patients. The Working Group consists of unsalaried volunteers. The participants received no honorarium and were only reimbursed for normal travel expenses in accordance with customary directives. The guidelines will be revised should new scientific results become available, at the latest in 2 years. The plan exists to further develop the guidelines to stages II and III (AWMF). The Steering Committee of the DGSS appraised the guidelines and authorized the guidelines before publication.