[Manual medicine and osteopathic methods on the growing spine]. / Manuelle Medizin und osteopathische Verfahren an der wachsenden Wirbelsäule.

The application of various techniques in manual medicine on infants, toddlers and adolescents enjoys widespread acknowledgement not only in the musculoskeletal field but also beyond that. For a long time, the seminars of the DGMM have been trying to structure the advanced training of doctors and the vocational training of physiotherapists and to adjust it according to the latest clinical and scientific findings (in this subject matter). Considering the controversial debates, this seems particularly necessary and meaningful. This article aims to identify the current state of discussion and the consensus between medical associations but it also means to provide assistance in daily routine.

An fMRI study of emotional face encoding in youth at risk for bipolar disorder.

Face memory deficits may be a bipolar disorder (BD) endophenotype. BD (n=27) and unaffected youth at risk (n=13) exhibited middle frontal gyrus hypoactivation during successful vs. unsuccessful encoding. Parahippocampal gyrus dysfunction was found in BD and at-risk youth (vs. low-risk, n=37). Middle occipital gyrus hypoactivation was only present in BD.

An economic analysis of aseptic revision hip arthroplasty: calculation of partial hospital costs in relation to reimbursement.

INTRODUCTION: Aseptic loosening is one of the most common intermediate and long-term complications after total hip replacement (THR). These complications cause suffering and require expensive revision surgery. Little concrete data on direct costs are available from the hospital's, moreover operating department's perspective. We here provide a detailed analysis of the costs of THR revision and relate them to reimbursement underlying the German diagnosis-related groups (DRG) system. MATERIALS AND METHODS: Major cost parameters were identified using for orientation the cost matrix of the German Institute for Hospital Reimbursement (InEK GmbH). We then retrospectively analysed the major direct costs of aseptic revision THR in terms of contribution margins I and II. The analysis included a total of 114 patients who underwent aseptic revision from 1 January 2009 to 31 March 2012. Data were retrieved from the hospital information system and patient records. All costs of surgery, diagnostic tests, and other treatments were calculated as purchase prices in EUR. The comparative analysis of direct costs and reimbursements was done for DRG I46A and I46B from the hospital's, especially treating department's rather than the society or healthcare insurance's perspective. RESULTS: The average direct cost incurred by the hospital for a THR revision was 4,380.0. The largest share was accounted for surgical costs (62.7 % of total). Implant and staff costs were identified as the most important factors that can be influenced. The proportion of the daily contribution margin that was left to cover the hospital's indirect cost decreased with the relative cost weight of the DRG to which a patient was assigned. CONCLUSION: Our study for the first time provides a detailed analysis of the major direct case costs of THR revision for aseptic loosening from the provider's perspective. Our findings suggest that these revision operations could be performed cost-beneficially by the operating unit. From an economic perspective, cases with higher cost weights are more favorable for a hospital. These results need to be confirmed in multicenter studies.

Osseofix® system for percutaneous stabilization of osteoporotic and tumorous vertebral compression fractures - clinical and radiological results after 12 months.

PURPOSE: Determining whether implantation of an expandable titanium mesh cage (Osseofix® system) is a successful and safe minimally invasive therapy for osteoporotic and tumorous vertebral compression fractures (VCFs). MATERIALS AND METHODS: 32 patients (25 women, 7 men, mean age 71) with 46 osteoporotic or tumorous VCFs (T6 to L4) from June 2010 to January 2012 were included. All of them were stabilized with the Osseofix® system. Preinterventionally we performed X-ray, MRI, and bone density measurements (DXA). The clinical and radiological results were evaluated preop, postop and 12 months postop based on the visual analog scale (VAS) and the Oswestry Disability Index (ODI), X-ray (Beck Index, Cobb angle) and CT. RESULTS: There was a significant improvement in pain intensity (VAS) (7.8 to 1.6) as well as a significant reduction in the mean ODI (71.36 % to 30.4 %) after 12 months. The mean kyphotic angle according to Cobb showed significant improvements (12.3° to 10.8°) after 12 months. Postinterventional imaging showed one case of loss of height in a stabilized lumbar vertebral body (2.2 %) in osteoporosis and one case with adjacent fracture (2.2 %) in osteoporosis. We saw no changes in the posterior vertebral wall. Except for one pronounced postoperative hematoma, we saw no surgical complications including no cement leakage. CONCLUSION: The clinical mid-term results are good at a low complication rate. The stabilization of symptomatic osteoporotic and tumorous VCFs with the Osseofix® system is a safe and effective procedure, even in fractures with posterior wall involvement. The Osseofix® system is an interesting alternative to the established procedures of cement augmentation. KEY POINTS: • The Osseofix® system is well suited for stabilizing osteoporotic and tumorous VCFs.• It is a safe and effective procedure without cement leakage and with a low complication rate.• The procedure is an interesting alternative to established cement augmentation procedures.

[Learning and teaching abilities of a newly inaugurated operation technique. Analysis of learning curves and transferability exemplified by Kypho-IORT]. / Lehrfähigkeit und Erlernbarkeit einer neu inaugurierten Operationsmethode. Analyse der eigenen Erfahrungskurve und des Weitergabeerfolgs am Beispiel der Kypho-IORT.

The Kypho-IORT procedure is a recently developed surgical technique to combine intraoperative radiotherapy with cement augmentation of the vertebra for spinal metastases. The technical feasibility and the operation principle of this new method have been described. In the following article the refinement of the standard operation procedure and the technical development of the method are described. Not only the procedural improvements but also the learning curves of the inaugurators are pointed out. Moreover, the article presents the measures which were necessary to educate trainees during surgical master classes in this new method and to transfer the method. The learning success was quantified by recording the accuracy reached by the trainees in the key procedure during hands-on cadaver exercises. Improvements of the standard operation procedure could be successfully transferred in a second master class. The method of Kypho-IORT and the demonstrated way of postgraduate education is feasible to instruct trainees. The Kypho-IORT procedure can be learnt and performed safely by running through the surgical master class.

[Kyphoplasty in combination with intraoperative radiotherapy. Technical and regulatory characteristics of a concept for treatment of vertebral metastases]. / Kyphoplastie in Kombination mit intraoperativer Radiotherapie. Technische und regulatorische Besonderheiten eines Konzepts zur Behandlung von Wirbelkörpermetastasen.

BACKGROUND: Operative and radiotherapeutic procedures are available for the treatment of symptomatic vertebral metastases. The method for treatment of vertebral metastases presented in this article involves a combination of intraoperative radiotherapy (IORT) and kyphoplasty. METHODS AND RESULTS: Kyphoplasty-IORT allows treatment of symptomatic vertebral metastases between vertebrae T3 and L5. With the patient under intubation narcosis an extrapedicular or bipedicular access to the vertebra is selected as for conventional kyphoplasty. This is followed by insertion of special sheaths of the radiation applicator and radiation therapy is intraoperatively administered via a radiation generator (Intrabeam®, Carl Zeiss Surgical, Oberkochen, Germany). The radiation dose is 8 Gy at a depth of 5-10 mm depending on the study protocol (50 kV X-radiation). Following radiation a conventional kyphoplasty procedure (Medtronic, USA) is carried out and the vertebra stabilized with cement. CONCLUSIONS: The procedure presented demonstrates a new approach to treatment of vertebral metastases and represents a valuable alternative to previously established methods.

[Manual-medical differential diagnosis of low back pain including osteopathic procedures]. / Differenzialdiagnostik manualmedizinischer Syndrome bei unteren Rückenschmerzen unter Einbeziehung osteopathischer Verfahren.

The differential diagnostic evaluation of painful functional disorders of the lumbosacral and lumbopelvic region, i. e. the so-called "low back pain" is very extensive, but is often reduced to the question of chronicity. The manual medical diagnosis can make a valuable contribution in such cases for determination of structural and functional pathology. Early application of manual medical therapies seems to be effective for peracute complaints. The mobilization of restrictions of the pelvic visceral attachments should be included. In the following review manual medical syndromes are presented that summarize the findings from the musculoskeletal and visceral system. This is intended to facilitate the primary differential diagnostic evaluation, as well as treatment planning. The combination with osteopathic methods is very profitable. A necessary specialist differential diagnosis remains essential.

[Sledge versus bicondylar surface treatment in the endoprosthetic therapy for unicompartmental knee arthrtitis--a comparative cost analysis]. / Kostenvergleichskalkulation der Schlitten- vs. bikondylären Oberflächenversorgung am Kniegelenk.

BACKGROUND: The G-DRG system reimburses sledge endoprosthetic implantations (UKA) at a much lower rate than surface replacements (TKA), at significantly different cost weights (CW). Therefore, when only G-DRG payments are considered, the complete endoprosthesis implantation produces higher gains. An orientation on these revenues alone, however, does not provide the basis for an economically sound decision-making process. The aim of this study is to present a comparison of the variable costs of the two procedures. MATERIAL AND METHODS: The mean cost and performance data of 28 Endo-Model UKA implantations and of 85 NexGen CR TKA replacements were compared with each other in 2007. RESULTS: From the perspective of the hospital, when the correct medical indication is present, UKA treatment is of greater economic advantage. In this way the total unit contribution margin can be improved, and although the relative weighting is comparatively low, the costs are significantly lower than in a comparative analysis of the TKA. CONCLUSION: For the desired maximisation of the unit contribution margin, assuming that it is the proper medical indication, the recommendation for the hospital would be implantation of the UKA. Considered from the economic perspective of gains and costs, the assumption that a TKA would be advantageous could not be confirmed in the present study.

[Stabilization of the osteoporotic spine from a biomechanical viewpoint]. / Stabilisierung der osteoporotischen Wirbelsäule unter biomechanischen Gesichtspunkten.

The altered trabecular structure of the osteoporotic spine leads to an increased vulnerability of its biomechanical characteristics and reduction of load resistance. Therefore, any surgical procedure must account for these circumstances. In cement-augmented vertebrae, both the overall stability and load transfer to the adjacent structures are influenced by a variety of factors. This has been demonstrated by different findings regarding volume, special characteristics, choice of approach and application, as well as distribution of the cement within the vertebral body. Independent of the well-known good clinical results, these features leave the discussion regarding the most appropriate form of cement-augmenting technique open. In cases where implants are required, there are increasing data to allow for an appropriate choice of stabilizing devices to fit the biomechanical demands in poor bone quality. Thereby, multilevel instrumentation, additive stabilization techniques, cement-augmented pedicle screws and adapted implant designs ensure and increase patient safety. However, regardless of the procedure chosen to stabilize the osteoporotic spine, reconstruction of the column profile appears to be of pre-eminent importance.

[Manual medicine]. / Manuelle medizin.

The techniques of manual medicine provide the basis for the palpatory recognition of dysfunction, primarily in the musculoskeletal system. The essential criterion of manual medicine is inclusion of the segmental level of function. One criterion of evaluation is, most notably, segmental hypomobility. The purpose of manual diagnostics is to determine segmental blockage. Manual therapy techniques lead first to improved function of the segment and, consequently, to improved function of the whole organism. Manual medicine focuses on the (peri)articular and myofascial levels as well as on the nervous control level of the motion segment and may interact with therapeutic methods. For therapeutic purposes, the joint may be manipulated with impulse as well as without therapeutic impulse for soft techniques. Different muscle relaxation techniques are used on the myofascial system to achieve improved function of reflectory or structurally altered musculature and of the myofascial system.

[Concepts of in-patient gradual diagnostics for patients with lumbar back-pain]. / Das Konzept der stationären Stufendiagnostik bei Patienten mit lumbalem Rückenschmerz : Orthopädische Kompetenz bei der Diagnostik und Behandlung von Rückenschmerzpatienten.

Concepts for treating back pain by considering recent advancements in understanding chronic pain have been increasingly discussed over the last years. In general, any kind of therapy requires a most accurate diagnosis; however, in cases of lumbar back pain matching clinical observations with known structural pathologies is not always straight forward. Here, we suggest a concept of in-patient gradual diagnosis of patients with back pain that includes stepwise structural and functional components. We emphasize that in addition to the specific (classifiable) factors causing back pain (e.g. compression of lumbar nerve roots, facet joint associated pain syndrome, sacroiliacal dysfunction, segmental instability) also unspecific (non-classifiable) causes as well as disease-associated and/or determining bio-psychological or social factors need to be considered. With this study, we aim to introduce the procedure and assess the value of in-patient gradual diagnostics. We will describe different approaches, which we will evaluate for specific indications.

[Treatment options for problematic thoracic and lumbar osteoporotic fractures]. / Behandlungsmöglichkeiten bei thorakalen und lumbalen osteoporotischen Problemfrakturen.

Most osteoporotic sintering fractures are treated conservatively. However, persistent pain and consecutive spinal deformity may require certain cement-augmenting interventions. These procedures have proven their intermediate-term efficacy in pain reduction, prevention of progressive sintering and improvement of the overall quality of life in the majority of patients. In fractures with relevant spinal stenosis, persisting instability, gross deformity and trauma-associated osteoporotic fractures with or without neurological deficits, the therapeutic options may call for more extensive surgical procedures. In this regard, poor bone quality, age and respective comorbidities of the individual patient must be considered during preoperative planning and management. This article provides an overview of the diverse problem-solving strategies discussed in today's literature. It is generally acknowledged that any decision to perform surgery on an osteoporotic fracture is strongly case-dependent. Treating physicians must therefore master the complete therapeutic spectrum in order to meet this complex orthopedic challenge appropriately.

[Fatal complex fracture of the cervical spine in a patient with ankylosing spondylitis after a fall from a racing bicycle]. / Fatale komplexe HWS-Verletzung bei M. Bechterew nach Sturz mit dem Rennrad.

Patients with ankylosing spondylitis are endangered suffering from cervical spine fractures following falls caused by kyphosis, stiffness and osteoporotic bone quality of the spine. Risk sustaining neurological deficits is higher than average. We present a patient with ankylosing spondylitis, who was admitted to our hospital with a complex fracture pattern of the cervical spine after a fall from a racing cycle. In spite of early operative treatment the patient died in the follow up because of severe hypoxic brain damage. We discuss the area of conflict between the recommendation for sport activities in patients with ankylosing spondylitis and the resulting risks for the diseased spine.

Brown-Séquard syndrome caused by a high velocity gunshot injury: a case report.

STUDY DESIGN: Case report. OBJECTIVE: To present an unusual traumatic neurologic pathology caused by gunshot injury. SETTING: Spine unit of Department of Trauma and Orthopaedic Surgery, University Medical School, Charité - Campus Benjamin Franklin, Berlin, Germany. METHOD AND RESULT: A 35-year-old male sustained a gunshot injury from a machine gun. The projectile caused a fracture of the left pedicle of Th10. The spinal cord was indirectly damaged by cavitation that caused a Brown-Séquard syndrome (BSS). After a microscopically assisted posterior revision at T9/10 with removal of bullet and bone fragments from the spinal canal and debridement of the bullet cavity via extended fenestrectomy the patient gained his motor function back. The sensory deficit remained unchanged. CONCLUSION: BSS can be caused by bullet-related injury of the spinal canal with no direct damage of neural structures. The initial treatment is always based on the total injury pattern. Possible spinal cord injuries are only clarified after restitution of vital functions. Decompression of neural structures in shotgun injury is indicated in incomplete paraplegia, injury of intra-abdominal hollow organs or high velocity bullet wounds. Through debridement and decompression of neural structures and chronic damage caused by foreign body granulomas can be prevented. Secondary destabilization of the spine should be avoided.

[Direct osteosynthesis of instable Gehweiler Type III atlas fractures. Presentation of a dorsoventral osteosynthesis of instable atlas fractures while maintaining function]. / Die direkte Osteosynthese instabiler Atlasfrakturen Gehweiler Typ III. Präsentation einer dorsoventralen funktionserhaltenden Osteosynthese instabiler Atlasfrakturen.

This retrospective study evaluates eight patients with unstable fractures of the atlas vertebra, treated operatively in the Central Clinic Bad Berka between January 1995 and December 2001. In all cases, we were confronted with unstable and dislocated type III fractures according to Gehweiler, caused by an injured transverse ligament. Mean age was 34 years (range 20-49) in two women and six men. We introduce a new technique of direct reconstruction of the atlas vertebra. This technique leads to a stable ring construct that allows compression osteosynthesis of the fracture. Spinal fusion can be avoided, as can postoperative immobilization, since sufficient stability for functional postoperative treatment is achievable. The follow-up control 38 months (range 6-75) after surgery showed solid bony fusion in all cases, in one case after revision surgery. All patients showed good functional results, there was no need for analgesics and all patients could be reintegrated into their former occupation.

[Injuries to the craniocervical junction]. / Verletzungen des kraniozervikalen Ubergangs.

Injuries to the upper cervical spine (C0-C2) play a major role in surgical treatment of traumatic sequelae in the entire cervical spine. Even though the number of such operations has increased in recent years, there are no clear treatment recommendations for most types of cervical spine injuries. In view of the wide range of injury types and the correspondingly large number of treatment options, this review focuses mainly on the following types of injuries: C0 fractures, occipital condyle fractures (OCF), atlanto-occipital dislocation (AOD), atlas fractures, atlantoaxial dislocation (AAD), and axis fractures. Important aspects of the mechanisms of injury, clinical signs and symptoms, diagnostic procedures, and treatment options are discussed. Special emphasis is placed on comparatively reviewing the different treatment options discussed in the literature. A summary in table form is presented at the end of each chapter for quick reference.

[Functional disorders and functional diseases in the region of the upper cervical spine particularly regarding the cervical joints. Current status and clinical relevance]. / Funktionelle Störungen und funktionelle Erkrankungen im Bereich der oberen Halswirbelsäule unter besonderer Berücksichtigung der Kopfgelenke. Aktueller Stand und klinische Relevanz.

Functional disorders of the upper cervical spine may be responsible for or the primary cause of persistent complaints following an injury or illness. Functional disorders involving the cervical joints, especially C0/C1 and C1/2 but also the C2/3 junction are of particular clinical relevance. Range of motion assessment is extremely important for the diagnosis of joint disorders. Hypomobility or "blockade" can be diagnosed using special examination techniques that, in many cases, can be extended for direct manual therapy. Periarticular structures involved in these dysfunctional processes, especially muscles and fasciae, must also be examined and treated. Clinical manifestations may include locally restricted muscle extensibility (e.g., trigger points, tension or muscle shortening) with zones of radiating pain as well as referred problems distal to the primary lesion. Functional disorders in the region of the upper cervical spine may be accompanied by various types of reflexive compensatory problems. Although they must be diagnosed separately, these disorders frequently respond to the manual therapy techniques used to treat the underlying functional problem. Even if the exact correlations to functional medicine cannot be scientifically demonstrated in every case, functional assessment and treatment techniques are, in our view, a useful addition to the armamentarium for orthopedic diagnosis and treatment.

[Rare pathological alterations of the upper cervical spine requiring surgical treatment]. / Seltene krankhafte Veränderungen der oberen Halswirbelsäule mit operativer Behandlungsindikation.

Because of its unique anatomy, specific diseases and lesions arise in the upper cervical spine, which differ widely from the rest of the spine. During the last two decades standardised diagnostic and therapeutic algorithms have been defined for most of the craniocervical pathologies often occurring in combination with an underlying disease requiring surgical intervention as well. On the other hand there are some very rare phathological alterations: about 20% of the patients suffering from neurofibromatosis type I develop spinal deformities. These are mostly found in the thoracic and lumbar spine (dystrophic/non-dystrophic type). In rare cases the dystrophic neurofibromatosis type I involves the upper cervical spine leading to bizarre deformities endangering the spinal cord. An aggressive, timely and combined operative therapy is necessary. Patients with Down syndrome should be investigated regularly for affections of the upper cervical spine. Though only in about 1% of all patients with Down syndrome do instabilities require surgical intervention, the upper cervical spine should be screened on a regular basis, since neurological changes due to the pathognomy of the underlying disease often remain undetected for a long time. The operative therapy of the instable os odontoideum in Down syndrome follows the general principles of this pathoanatomical variation. Even though the Klippel-Feil syndrome is generally not linked with neuropathological findings, rare associated deformities of the upper cervical spine should be excluded by proper diagnostic procedures.

[Instability of the upper cervical spine due to rheumatism]. / Die rheumatisch bedingte Instabilität der oberen Halswirbelsäule.

Rheumatic manifestation at the cervical spine occurs in more than 50% of all cases in the natural course of this disease. The first cervical manifestation takes place in the upper cervical spine. The initial involvement of the C1/C2 segment leads to atlantodental subluxation. Progressive destruction can result in vertical instability, which is characterized by cranial subluxation of the odontoid process with the danger of resulting stenosis and cervical myelopathy. The goal of diagnosis has to be the early recognition of these changes to establish an effective treatment protocol. Persistent pain, neurological deficits, and progressive radiological signs for instability are indications for operative stabilizing procedures. These procedures avoid progressive destruction and improve the prognosis regarding pain decrease, regression of neurological deficits, and life expectancy.