[Findings from 10 years of CIRS-AINS : An analysis of usepatterns and insights into new challenges]. / Erkenntnisse aus 10 Jahren CIRS­AINS : Eine Analyse von Nutzerverhalten und Ausblick auf neue Herausforderungen.

BACKGROUND: Critical incident reporting systems (CIRS) serve to sensitize organizations and individuals to unknown events relevant to patient safety and therefore help in developing safer systems; however, the use and impact of these systems in healthcare has recently been questioned for a variety of reasons, among them unclear and imprecise reporting criteria. Some authors claim that fundamental aspects of successful CIRS have been misunderstood, misapplied or entirely missed during the adaptation to the healthcare context. The aim of this study was the analysis of all reports accumulated over 10 years in the German system CIRSmedical Anesthesiology (CIRS-AINS) as a basis for improved reporting guidelines, user training and generation of further hypotheses. METHODS: In a retrospective analysis all reports from CIRS-AINS entered between April 2010 and June 2019 were analyzed for structure and content. RESULTS: A total of 6013 reports were filed consisting of 3492 incidents (58.1%), 1734 near misses (28.8%) and 787 others (13.1%). Those other reports contained 21 interpersonal conflicts (0.4%), 102 general complaints (1.7%), 89 stress or workload complaints (1.5%) and 575 reports that did not contain any critical incident or safety-related content (9.6%). Since 2015 these other reports have increased 2.8-fold from 7.4% to 20.8%. Of the reports 20.1% contained information about technical problems and 27.7% about certified medical devices. Medication was mentioned in 10.7% of reports, 47.8% of inpatient incidents concerned the perioperative setting, 24.6% were reported from intensive care units (ICU) and postanesthesia care units (PACU). Of the cases 198 (3.3%) explicitly mentioned communication issues, 346 cases (5.8%) concerned incomplete or inadequate documentation involving orders, blood products or laboratory tests. Of the reports 36.1% were analyzed and commented on by the CIRS team of the German Society of Anesthesiologists (BDA). CONCLUSION: The analysis provides insights into reporting practices and can influence both reporting guidelines as well as user training. Report format, content and context are of utmost importance for further analysis: A distinction has to be made between reports that contain locally rational information and cannot be understood without further context and reports that may help inform about patient safety activities on a national level. Especially in light of the limited resources for incident analysis, the content should be critically reflected upon by the user when submitting a report to support a wise allocation of available capacities. In this respect, the increase of non-CIRS reports has to be considered in the future implementation of nationwide IRS. Also, it has to be questioned whether adequate alternative means of communication for these non-CIRS reports exist. The majority of reports were made by physicians, which is in contrast to international experiences with increased engagement of nursing staff and underlines the need for increased interprofessional collaboration with incident reporting and analysis activities in Germany. Reports containing workload complaints, while constituting important signals on a local level, usually fail to address the idea of learning from others inherent to the philosophy of national IRS.

Super-micro-bland particle embolization combined with RF-ablation: angiographic, macroscopic and microscopic features in porcine kidneys.

PURPOSE: To describe angiographic, macroscopic and microscopic features of super-micro-bland particle embolization in combination with RF-ablation in kidneys. Thereby, a special focus was given on the impact of the sequence of the different procedural steps. MATERIALS AND METHODS: In ten pigs, super-micro-bland particle embolization combined with RF-ablation was carried out. Super-micro-bland embolization was performed with spherical particles of very small size and tight calibration (40 ± 10 µm). In the left kidneys, RF-ablations were performed before embolization (I). In the right kidneys, RF-ablations were performed after embolization (II). The animals were killed three hours after the procedures. Angiographic (e.g. vessel architecture), macroscopic (e.g. long and short axes of the RF-ablations) and microscopic (e.g. particle distribution) study goals were defined. RESULTS: Angiography detected almost no vessels in the center of the RF-ablations in I. In II, angiography could not define the RF-ablations. Macroscopy detected significantly larger long and short axes of the RF-ablations in II compared to I (52.2 ± 3.2 mm vs. 45.3 ± 6.9 mm [P<0.05] and 25.1 ± 3.5mm vs. 20.0 ± 1.9 mm [P<0.01], respectively). Microscopy detected irregular particle distribution at the rim of the RF-ablations in I. In II, microscopy detected homogeneous particle distribution at the rim of the RF-ablations. Microscopy detected no particles in the center of the RF-ablations in I and II. CONCLUSION: The sequence of the different procedural steps of super-micro-bland particle embolization combined with RF-ablation impacts angiographic, macroscopic and microscopic features in kidneys in the acute setting.

Dual-energy CT-cholangiography in potential donors for living-related liver transplantation: improved biliary visualization by intravenous morphine co-medication.

PURPOSE: To prospectively evaluate whether intravenous morphine co-medication improves bile duct visualization of dual-energy CT-cholangiography. MATERIALS AND METHODS: Forty potential donors for living-related liver transplantation underwent CT-cholangiography with infusion of a hepatobiliary contrast agent over 40 min. Twenty minutes after the beginning of the contrast agent infusion, either normal saline (n=20 patients; control group [CG]) or morphine sulfate (n=20 patients; morphine group [MG]) was injected. Forty-five minutes after initiation of the contrast agent, a dual-energy CT acquisition of the liver was performed. Applying dual-energy post-processing, pure iodine images were generated. Primary study goals were determination of bile duct diameters and visualization scores (on a scale of 0 to 3: 0--not visualized; 3--excellent visualization). RESULTS: Bile duct visualization scores for second-order and third-order branch ducts were significantly higher in the MG compared to the CG (2.9±0.1 versus 2.6±0.2 [P<0.001] and 2.7±0.3 versus 2.1±0.6 [P<0.01], respectively). Bile duct diameters for the common duct and main ducts were significantly higher in the MG compared to the CG (5.9±1.3 mm versus 4.9±1.3 mm [P<0.05] and 3.7±1.3 mm versus 2.6±0.5 mm [P<0.01], respectively). CONCLUSION: Intravenous morphine co-medication significantly improved biliary visualization on dual-energy CT-cholangiography in potential donors for living-related liver transplantation.

Microwave ablation of porcine kidneys in vivo: effect of two different ablation modes ("temperature control" and "power control") on procedural outcome.

PURPOSE: This study was designed to analyze the effect of two different ablation modes ("temperature control" and "power control") of a microwave system on procedural outcome in porcine kidneys in vivo. METHODS: A commercially available microwave system (Avecure Microwave Generator; MedWaves, San Diego, CA) was used. The system offers the possibility to ablate with two different ablation modes: temperature control and power control. Thirty-two microwave ablations were performed in 16 kidneys of 8 pigs. In each animal, one kidney was ablated twice by applying temperature control (ablation duration set point at 60 s, ablation temperature set point at 96°C, automatic power set point; group I). The other kidney was ablated twice by applying power control (ablation duration set point at 60 s, ablation temperature set point at 96°C, ablation power set point at 24 W; group II). Procedural outcome was analyzed: (1) technical success (e.g., system failures, duration of the ablation cycle), and (2) ablation geometry (e.g., long axis diameter, short axis diameter, and circularity). RESULTS: System failures occurred in 0% in group I and 13% in group II. Duration of the ablation cycle was 60±0 s in group I and 102±21 s in group II. Long axis diameter was 20.3±4.6 mm in group I and 19.8±3.5 mm in group II (not significant (NS)). Short axis diameter was 10.3±2 mm in group I and 10.5±2.4 mm in group II (NS). Circularity was 0.5±0.1 in group I and 0.5±0.1 in group II (NS). CONCLUSIONS: Microwave ablations performed with temperature control showed fewer system failures and were finished faster. Both ablation modes demonstrated no significant differences with respect to ablation geometry.

Identification and stability of a new bichalcone in Achyrocline satureioides spray dried powder.

A new chemical structure, the 4,2',4",2'''-tetrahydroxy-6',6'''-dimethoxy-4'-O-4'''- bichalcone, named achyrobichalcone was isolated and identified from an Achyrocline satureioides spray-dried powder (SDP80). The thermal and photo stability of this new compound as well as that of the main polyphenols present in the spray dried powder, quercetin, luteolin, 3-O-metylquercetin and the corresponding kinetics of degradation are reported. In the long-term testing (30 +/- 2 degrees C/75 +/- 5% RH, 12 months), the total polyphenols contained in SDP80 demonstrated to be stable, remaining higher than 90% after a 12 month exposure. The photo stability testing revealed that all polyphenols were stable for 48 h when SDP80 was conditioned in amber or transparent flasks and exposed to UV-C radiation (light express LE UV, 254 nm, 30W). In contrast, when unprotected, the polyphenols demonstrated to be sensitive to both, thermal stress testing (80 +/- 2 degrees C), for 14 days and to UV-C radiation. Luteolin showed to be the most stable against UVC light and 3-O-methylquercetin against temperature. The achyrobichalcone demonstrated to be the more unstable against both, temperature and light. The kinetics of polyphenol thermal degradation (80 +/- 2 degrees C, 49 days) and photodegradation (UV-C radiation, 96 h) followed, 2nd and 1st order reaction, respectively.

Thermal and photo stability of phenolic constituents of an Achyrocline satureioides spray-dried powder.

Thermal and the photo stabilities of an Achyrocline satureioides powder (SDP40) were evaluated in particular concerning the total polyphenol content as well as the main identified constituents quercetin, luteolin, 3-O-methylquercetin and caffeic acid. SDP40 presented good stability for nine months under normal storage conditions of 25 degrees C temperature and 60% relative humidity (RH). In accelerated term testing, 50 degrees C temperature and 90% RH and also in stress testing, 80 degrees C, caffeic acid and a non-identified constituent P3 were the most instable constituents. Luteolin and 3-O-methylquercetin were the most stable constituents. Quercetin presented an unusual behavior, improving its concentration after 1 month at 50 degrees C or 2 days at 80 degrees C exposition, followed by a decrease in its concentration. The hypothesis that this observation is related to the simultaneous decreasing of a non-identified peak P3 or to the hydrolysis of a non-identified precursor as a quercetin heteroside is being investigated. The SDP40 presented good stability against UV-C light when conditioned in amber or transparent containers, but it suffered degradation when stored in open-dishes. In summary, the total polyphenol content remains within acceptable limits of 10% under normal storage conditions for nine months. However, the LC polyphenol analysis demonstrated that the behavior of individual constituents has still to be enlightened.

Validation of a LC method for the analysis of phenolic compounds from aqueous extract of Phyllanthus niruri aerial parts.

A reversed-phase high-performance liquid chromatographic separation and quantitative method using a phosphoric acid-acetonitrile gradient was developed to analyze phenolic compounds present in aqueous extract from the aerial parts of Phyllanthus niruri. The chromatographic method was validated for linearity, precision and accuracy for both reference substance (gallic acid) and for three well resolved peaks from P. niruri aqueous extract. Both calibration curves were linear with correlation coefficients higher than 0.999. The reproducibility for the three peaks ranged from 2.3% to 4.6% and the accuracy for gallic acid in the aqueous extract was 103%. The method allowed the complete resolution of three peaks, one of them was identified by diode array detection as gallic acid. The analysis of the botanic morphological elements of the aerial parts from P. niruri showed that the leaves have a higher amount of phenolic compounds than the branches.

Rapid evaluation of S-100 serum levels. Case report and comparison to previous results.

The aim of this case report is to describe the time course of S-100 serum levels of a patient, after severe head injury, whose blood sample could be drawn very soon after injury. The results were compared to a group of patients in which a correlation between S-100 serum levels and outcome after traumatic brain injury could be demonstrated. Blood samples were taken on admission (mean 2.3 hours), 6, 12 and 24 hours after trauma and then every 24 hours up until and including the fifth day. The outcome was estimated on discharge using the Glasgow Outcome Scale. The S-100 serum level of the patient described in the case report with a favourable outcome had initially risen to 10.0 micrograms/l and showed a rapid decline. In the previous group, patients with unfavourable outcome had a S-100 serum level of 7 micrograms/l mean concerning the first probe (after 2.3 hours mean) compared to 1.5 micrograms/l mean (after 2.23 hours mean) in patients with favourable outcome (p < 0.05). In comparison to the literature, there seems to be differences regarding the enzyme liberation in stroke and head injury. Therefore, S-100 serum levels need to be interpreted with regard to collection time and underlying pathology.

Variability of outcome after lumbar disc surgery.

STUDY DESIGN: A prospective, consecutive study of patients' outcome at three subsequent follow-up times after lumbar disc surgery. OBJECTIVES: To evaluate how consistent outcome remained in a group of patients after lumbar disc surgery. SUMMARY OF BACKGROUND DATA: Despite similar results concerning the overall outcome, results in most studies show different prognostic factors for lumbar disc surgery at different follow-up times. A reason for this observation could be that patients shift to a different outcome group during the observation period. METHODS: Before surgery and at the three follow-ups (3, 12, and 28 months after surgery) the Low Back Outcome Score was calculated. Groups with favorable and unfavorable outcome were determined after each follow-up according to the scores. RESULTS: Ninety-eight patients were studied. Forty percent showed an unstable outcome at different follow-up times. For each follow-up, three prognostic factors were determined. No prognostic factor showed significance at all follow-up examinations. CONCLUSIONS: Patients whose outcome after lumbar disc surgery does not remain stable present a major problem in the calculation of prognostic factors.

Are prognostic factors still what they are expected to be after long-term follow-up?

The aim of this prospective study of 121 patients was to investigate whether or not the predicting factors of lumbar disc surgery become lost over an increased follow-up time. Preoperatively, the patients classified their pain on the visual analogue scale, and general data, case histories, and neurologic findings were recorded. Follow-up examinations were carried out at 3, 12, and 28 months. At the 3-month follow-up examination, six predictive factors were calculated, after 1 year there were only four, and after 28 months only two predictive factors were found. After reviewing these results, it was apparent that the number of prognostic factors diminished over time. To obtain reliable surgery-related results for the prognostic factors in lumbar disc surgery, we believe that the follow-up period should not exceed 1 year.

S-100 serum levels after minor and major head injury.

BACKGROUND: S-100, a protein of astroglial cells, is described as a marker for central nervous system damage. The aim of this study was to evaluate whether the marker could give information about the severity and possibility of functional recovery after minor and severe head injury. METHODS: Thirty patients after severe head injury (Glasgow Coma Scale score < 9) and 11 patients after minor head injury (Glasgow Coma Scale score > 12) were included. In each case, blood samples were drawn within 6 hours after injury. Outcome was estimated at hospital discharge using the Glasgow Outcome Scale. RESULTS: All patients who sustained minor head injury had reached a favorable outcome by the time they were discharged from the hospital. Their mean S-100 serum level was 0.35 microg/L. Patients who sustained severe head injury and were classified as having an unfavorable outcome (31%) showed a mean serum concentration of 4.9 microg/L, whereas patients classified as having a favorable outcome (69%) had a mean S-100 level of 1.2 microg/L. All groups differed significantly (p < 0.05). CONCLUSION: S-100 appears to be a promising marker for the severity of head injury and neuronal damage.

Jugular bulb monitoring of cerebral oxygen metabolism in severe head injury: accuracy of unilateral measurements.

To investigate the accuracy of unilateral jugularvenous monitoring, we performed bilateral jugularvenous monitoring in 22 comatose head injured patients. Fiberoptic catheters were placed upstream in both internal jugular veins and advanced into the jugular bulbs. Arterial and bilateral jugularvenous blood samples were obtained simultaneously for in vitro determination of jugularvenous oxygen saturation (SJO2), arterial minus jugularvenous lactate content difference (AJDL) and modified lactate-oxygen-index (mLOI). Ischemia was assumed, if one of the following pathologies occurred at least unilaterally: SJO2 < 55%, AJDL < -0.37 mmol/L, mLOI > 0.08. The mean and maximum bilateral SJO2 differences varied between 1.4% to 21.0%, and 8.1% to 44.3% respectively. The bias and limits of agreement (mean differences +/- 2SD) between paired samples were -0.4% +/- 12.8%. Regarding AJDL bias and limits of agreement were -0.01 mmol/L +/- 0.18 mmol/L. At best 87% of defined ischemic events could be evaluated by monitoring at the side of predominant lesion or, in diffuse injuries, at the side of the larger jugular foramen in CT scan (CT approach). We conclude, due to the wide limits of agreement in bilateral SJO2 and AJDL the reliability of unilateral jugularvenous monitoring in patients with intracranial pathology is questionable. For diagnosing ischemia the CT approach has the highest sensitivity and is therefore recommended.

Brain ischemia detected by tissue-PO2 measurement and the lactate-oxygen index in head injury.

The aim of the study was to find out whether there is a correlation between the tissue-pO2 (ti-pO2) measurement and the lactate-oxygen index (mLOI). Both methods are to be considered as methods to detect brain ischemia. We studied 7 patients after severe head injury (GCS < 8) with a jugular bulb catheter and a tissue pO2 probe. Possible ischemia was defined with ti-pO2 below 10 mm Hg and mLOI above 0.08. 67 pairs of ti-pO2 and corresponding mLOI were found. In 5 cases out of the 7 cases with a ti-pO2 below 10 we found a pathological mLOI above 0.08. In 11 cases with pathological mLOI values, however, we found only 6 cases of decreased ti-pO2. The absolute values did not correlate. The sensitivity to predict normal values is above 85% with both methods. The specifity to predict ischemia is low (< 72%). The reason is the fact, that ti-pO2 is a local method in contrast to the mLOI values. In cases of diffuse brain injury without major contusions there should be a correlation between ti-pO2 and the mLOI.

Is there a clinical correlate to the histologic evidence of inflammation in herniated lumbar disc tissue?

STUDY DESIGN: The presence of inflammatory cells was examined immunohistochemically in routinely processed resection specimens of the lumbar disc. The histologic results were compared with prospectively obtained clinical data. OBJECTIVES: To assess the clinical relevance of inflammatory cells in herniated lumbar disc specimens. SUMMARY OF BACKGROUND DATA: It is postulated that in addition to nerve root compression, an inflammatory stimulus of the herniated lumbar disc is responsible for sciatic pain and radiculopathy. However, the clinical relevance of the histologically described inflammatory infiltrates is not defined clearly. METHODS: Disc specimens from 44 patients who underwent surgery for lumbar disc herniation were studied immunohistologically. Before surgery, severity of pain was classified in each patient according to a visual analog scale, and general clinical data were recorded prospectively. RESULTS: Varying amounts of inflammatory cells could be demonstrated in the resected disc tissue. In the statistical analysis, no statistically significant correlation between the histologic evidence of macrophage infiltrates and the pain grading scale or the clinical data was noted. CONCLUSIONS: There is no statistically significant correlation between macrophage infiltrates in herniated lumbar disc specimens and the obtained clinical data.

Short-term prognostic factors in lumbar disc surgery: the low back prognostic score is of predictive value.

In order to determine prognostic factors of lumbar disc surgery, we examined 107 patients who were conventionally operated on in a prospective, consecutive study. We analysed general data, the case history, the neurological examination at admission and all data from imaging examinations and therapy. In addition, all patients received a questionnaire based on the Low Back Outcome Score [9, 10]. The patients were re-examined after 2-8 months (103 days mean). According to their ratings on a pain grading scale, the patients were divided into a group with favorable and another with unfavorable results. These groups were analysed in relation to the patients' initial condition. At follow up, 88% of the patients had either completely recovered or their complaints had been relieved. According to the Low Back Outcome Score (LBOS), 64.5% went well. Used to evaluate the initial condition of the patients on admission the LBOS was able to predict favorable outcome in 68% and unfavorable outcome in 50%. To improve the prognostic value, we combined significant questions of the LBOS with the pain grading scale and significant prognostic factors to form a new prognostic score (Low Back Prognostic Score). With this new score we were able to predict a favorable outcome in 84% of our patients, and an unfavorable outcome in 71%. The Low Back Prognostic score seems to provide a sensitive method for predicting a favorable or unfavorable outcome for patients scheduled to undergo lumbar disc surgery.

Clinical evaluation of the InnerSpace fibreoptic intracranial pressure monitoring device.

OBJECTIVE: The aim of this study is the clinical evaluation of the intraparenchymal ICP monitor InnerSpace OPX 100. METHODS: Sixty-four Inner Space OPX 100 transducers in 51 patients with severe head injury (42), intracranial spontaneous bleeding (6) or hypoxia (3) were studied. The transducer was placed in the frontal white matter. Thirty-nine patients received one catheter, eleven patients two catheters and one patient three catheters. The study period ranged from 10 hours-25 days; total study time was 421.5 days (mean duration 6.6 days). RESULTS: In nine cases (14.1%) an inadequate location of the ICP transducer was found, but the accuracy of the measurement was not influenced. Dislocation of the transducer occurred in eight cases (12.5%) due to inadequate handling. A failed transducer was observed in four cases (6.3%) because of a damaged optical fibre (1) or inadequate handling (3). In one patient (1.9%) a minor local infection developed. In eleven cases (17%) a haematoma around the ICP sensor was observed. Six haematomas were small; five haematomas were larger than 1 cm in diameter. In two patients a large frontal haematoma developed after exchange of the transducer. Operative evacuation was necessary in both cases. Zero shift was below 2 mmHg in all catheters. CONCLUSION: It is concluded that the InnerSpace intraparenchymal ICP monitor is a reliable device: the rate of catheter related intracerebral haematomas, however, is not acceptable. This could be improved by a better fixation of the catheter in the burr hole in order to avoid micromovements of the transducer.

Monitoring of cerebral oxygen metabolism in the jugular bulb: reliability of unilateral measurements in severe head injury.

To investigate the reliability of unilateral jugular venous monitoring and to determine the appropriate side, we performed bilateral jugular venous monitoring in 22 head-injured patients. Fiberoptic catheters were placed in both jugular bulbs. Arterial and bilateral jugular venous blood samples were obtained simultaneously for in vitro determination of jugular venous oxygen saturation (SJO2), arterial minus jugular venous lactate content difference (AJDL), and modified lactate-oxygen index (mLOI). Ischemia was assumed if one of the following pathologic values occurred at least unilaterally: SJO2 <54%, AJDL <-0.37 mmol/L, mLOI >0.08. The sensitivity of calculated unilateral monitoring in detecting ischemia was evaluated by comparing the incidence detected unilaterally with that disclosed bilaterally. The mean and maximum bilateral SJO2 differences varied between 1.4% and 21.0%, and 8.1% and 44.3%, respectively. The bias and limits of agreement (mean differences +/- 2 SD) between paired samples were 0.4% +/- 12.8%. There was no significant variation in bilateral SJO2 differences with time. Decreasing cerebral perfusion pressure (r = -0.559, P < 0.001) and arterial PCO2 (r = -0.342, P < 0.001) were associated with increasing bilateral SJO2 differences. Regarding AJDL, the maximum bilateral differences varied between 0.04 mmol/L and 1.52 mmol/L. The bias and limits of agreement were -0.01 +/- 0.18 mmol/L. At best, 87% of ischemic events were disclosed by monitoring on the side of predominant lesion or, in diffuse injuries, on the side of the larger jugular foramen (computed tomographic [CT] approach). We conclude that in severe head injury, even calculated unilateral jugular venous monitoring has an unpredictable risk for misleading or missing data. Therefore, the reliability of unilateral jugular venous monitoring appears suspicious. For diagnosing ischemia the CT approach is recommended.

Clinical signs in patients with brachialgia and sciatica: a comparative study.

BACKGROUND: The aim of the study was to compare the clinical signs of patients with cervical and lumbar root affections. METHODS: From January 1994 to January 1995, we performed a prospective study on 395 patients. The study comprised 93 patients with a cervical and 302 patients with a lumbar root affection. 338 patients underwent surgery. General data, case histories, and neurological findings were analyzed. RESULTS: The patients with brachialgia had a nonradicular pain radiation in 67%, the patients with sciatica only in 35%. All other data showed no significant differences. The investigation also shows that a radicular pain radiation is significantly correlated with an unequivocal radicular deficit. In particular, the patients with a cervical radicular pain radiation had a highly significant incidence of a radicular neurological deficit. CONCLUSIONS: We could demonstrate in this prospective study that only about one third of the patients with a cervical root affection showed an unequivocal radicular pain radiation. This contradicts the traditional medical textbook concept of a cervical root compression syndrome. This difference in respect of the clinical signs of lumbar and cervical root compressions might be explained by the anatomical variations of cervical root anastomoses. To determine the affected cervical root level, further investigation of the myotomes is recommended.

Macrophage tissue infiltration, clinical symptoms, and signs in patients with lumbar disc herniation. A clinicopathological study on 179 patients.

It is postulated that in addition to nerve-root compression, an inflammatory stimulus of the herniated lumbar disc is responsible for sciatic pain and radiculopathy. The clinical relevance of the histologically described inflammatory infiltrates is, however, not clearly defined [8, 22]. It was the aim of this study to assess the clinical relevance of inflammatory cells in herniated lumbar disc specimens. The presence of inflammatory cells was examined immunohistochemically in routinely processed resection specimens of the lumbar disc. The histological results were compared to prospectively obtained clinical data. Disc specimens of 179 patients who underwent surgery for lumbar disc herniation were studied immunohistologically. Preoperatively each patient received a visual analogue scale for classification of the pain level and general clinical data were recorded prospectively. Varying amounts of inflammatory cells could be demonstrated in the resected disc tissue. In the statistical workup no statistically significant correlation between the histological evidence of macrophage infiltrates and the pain grading scale or the clinical data could be found. In our study there is no statistically significant correlation between macrophage infiltrates in herniated lumbar disc specimen and the obtained clinical data.

Are there differences in the symptoms, signs and outcome after lumbar disc surgery in the elderly compared with younger patients?

Age is claimed by several authors to be a predictor of bad outcome after lumbar disc surgery. The aim of this study is to evaluate the influence of the patients age on preoperative symptoms and the outcome. General data, symptoms, signs and neurological findings of 219 patients were recorded preoperatively Ninety-two per cent of the patients received a follow-up examination by an independent investigator after a mean of 298 days. All patients older than 59 years were defined as belonging to the group of elderly patients (n = 30). The other patients were defined as the younger group (n = 189). The outcome was measured by a visual analogue rating scale. Outcome was not statistically different in both groups. In our opinion, the indications for surgery for a lumbar disc herniation should be no different for older patients even though nerve root tension signs appear to be less marked in older patients.