Screening for Acromegaly in Patients with Carpal Tunnel Syndrome: A Prospective Study (ACROCARP).

Early diagnosis of acromegaly prevents irreversible comorbidities and facilitates surgical cure. Carpal tunnel syndrome (CTS) is common in acromegaly and patients have often undergone surgery for CTS prior to the diagnosis of acromegaly. We hypothesized that screening CTS-patients for acromegaly could facilitate active case-finding. We prospectively enrolled 196 patients [135 women, 56.9 (range 23-103) years] who presented with CTS for surgery. Patients were asked about 6 symptoms suggestive of acromegaly using a questionnaire calculating a symptom score (0-6 points), and insulin-like-growth factor 1 (IGF-1) was measured. If IGF-1 was increased, IGF-1 measurement was repeated, and random growth hormone (GH) and/or an oral glucose tolerance test (OGTT) with assessment of GH-suppression were performed. The mean symptom score was 1.7±1.3 points. Three patients reported the maximal symptom score of 6 points, but none of them had an increased IGF-1. There was no correlation between the symptom score and IGF-1-SDS (standard deviation score) (r=0.026; p=0.71). Four patients had an IGF-1>2 SDS. In 2 patients acromegaly was ruled out using random GH and OGTT. One patient had normal IGF-1 and random GH at follow-up. One patient refused further diagnostics. In this prospective cohort of patients with CTS, the observed frequency of acromegaly was at most 0.51% (95% CI 0.03 to 2.83%). In this prospective study, none of the 196 patients with CTS had proven acromegaly. Thus, we see no evidence to justify general screening of patients with CTS for acromegaly.

[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)

[Intraoperative pressure measurement at the median nerve in carpal tunnel syndrome and its surgical significance]. / Intraoperative Druckmessung am N. medianus beim Karpaltunnelsyndrom und deren operative Bedeutung.

The authors measured the intraoperative pressures on the median nerve in local anesthesia in thirty patients. Pressures were recorded at the distal antebrachial fascia near the carpal tunnel, at the proximal and distal carpal tunnel and at the level of the palmar fascia distal to the carpal tunnel. The two passive and three active movements examined generally led to a pressure elevation. Passive movements had a greater effect on pressure at the proximal carpal tunnel. Active movements led to a high pressure level in the proximal and distal carpal tunnel higher than those observed during passive movements. Beneath the distal antebrachial fascia near the carpal tunnel, the pressure level was higher than beneath the antebrachial fascia at a greater distance from the carpal tunnel. Pressure levels beneath the distal antebrachial fascia correlated with the patient's age. Pressure values beneath the palmar fascia were low during passive and active movements. As a consequence, division of the flexor retinaculum and the distal antebrachial fascia up to 3 cm proximal of the carpal tunnel is necessary, whereas dissection of the palmar fascia distal to the carpal tunnel is not.

[A case of osteopoikilosis combined with dermal changes and compression syndromes of peripheral nerves]. / Ein Fall von Osteopoikilie kombiniert mit dermalen Veränderungen und Kompressionssyndromen peripherer Nerven.

In the case of combination of osteopoikilosis with dermal alterations we wanted to know if the hereby discussed general mesenchymal lesions are the cause of the additional entrapment syndromes of peripheral nerves present in our case. For this purpose we recorded the pressure at the distal median and ulnar nerves within and out of the entrapment location. The results of the pressure recording of not point to a primary nerve lesion by a elevated pressure susceptibility or a pressure elevation at the peripheral nerve out of a defined entrapment location e.g. by an increase of connective tissue. Because of a hypertrophic scar formation in this case it should be paid attention to the wound healing of all patients with osteopoikilosis. The histologically verified nevoid mesenchymal alterations of the connective tissue found in this case, are to be delineated from the disseminated lenticular dermatofibrosis of the Buschke-Ollendorff syndrome.

[Diagnostic tests in carpal tunnel syndrome]. / Diagnostische Tests beim Karpaltunnelsyndrom.

In a first series 100 patients underwent surgical treatment for carpal tunnel syndrome (CTS) after being tested by provocative tests for sensory disturbances preoperatively. In addition to the well-established tests like passive wrist flexion (Phalen's test) or wrist extension, active movement tests of the patient against resistance were investigated. Tests of active movement were introduced because of the high values of intraoperatively measured pressure at the median nerve, similar to those recorded with passive movements. All investigated provocative tests for sensory disturbances related to CTS, investigated by active and passive movements, were positive in 72% to 84% of patients. Average delay times for reaction of these provocative tests ranged between 15.7 and 19.5 s. Furthermore Tinel's sign showed a sensitivity of 64% and the flick sign one of 69%. The specificity of tests and signs for the CTS was assessed on a group of 50 surgically treated patients with cervical nerve root entrapment at the C5-C8 level. In this group and a second CTS group the most sensitive of each test in the first series (active and passive provocational movement), Tinel's sign and flick sign were investigated. By forming subgroups in both diseases we showed that the results of the total groups were not influenced by a possible double crush. We could demonstrate high sensitivities in cervical nerve root entrapment for Phalen's sign with 74% and for active thumb abduction with 68% and a medium sensitivity for Tinel's sign with 40%--thus implying low specificity for CTS. Only the flick sign turned out to be relatively specific for CTS--its sensitivity in cervical nerve root entrapment was around 26%--indicating its potential to function as a valid criterion for the differential diagnosis of CTS and cervical nerve root entrapment syndrome.

[Distal ulnar nerve compression syndrome. Intra-operative pressure measurement and surgical procedure]. / Das distale Nervus-ulnaris-Kompressionssyndrom. Intraoperative Druckmessung und operatives Vorgehen.

Four cases of different distal ulnar nerve lesions are presented. Compared with the median nerve in the carpal tunnel syndrome (CTS), the surgical procedure with the distal ulnar nerve has to be determined more by the location of the nerve lesion. Because of the small number of cases and the different types of lesion, pressure on the nerve in the "Loge de Guyon" cannot yet (in contrast to the CTS) be defined by intraoperative pressure recording. An extreme pressure elevation with active movements by the patient might point to a nerve entrapment syndrome. Compared with phalen's test in the carpal tunnel syndrome, and because of its low specificity abduction of digit 5 as a sensitive sign of sensory disturbances in the "Loge de Guyon" is unreliable.

[Significance of reprocessed 3D gradient echo sequences in spinal MRT for surgical interventions in syringomyelia]. / Bedeutung der nachverarbeiteten 3D-Gradienten-Echosequenzen bei spinaler MRT für operative Massnahmen bei Syringomyelie.

Taking a patient with advanced syringomyelia as an example, the article presents a method in which reprocessed 3D-gradient echo sequences from spinal MRI allow centred reconstructions which show all sections of the syrinx, even where the spinal column is curved. This method played an essential role in satisfactorily determining the position of the syrinx for a median myelotomy which, according to clinical criteria, brought about an effective reduction in pressure from the syrinx.

[Trans-sphenoid gunshot injury of the head. Anatomic viewpoints]. / Die transsphenoidale Kopfschussverletzung. Anatomische Gesichtspunkte.

The transsphenoidal gunshot injury of the head is a subgroup of the temporal gunshot injury, generally with a bad prognosis quoad vitam. Important neural and vascular structures could be damaged by penetration of the missile. In our case the important structures were "missed" exactly and the patient survived without severe neurological deficits. With this case anatomical considerations of the transsphenoidal gunshot injury are made.

[Is extracranial metastatic malignant glioma iatrogenic?]. / Das extrakraniell metastasierende maligne Gliom--iatrogen?

A case of an extracranial malignant astrocytoma metastasising to the parotid gland is reported. Cases of extracranial metastasis of a glioma are very rare and largely connected to surgical intervention at the tumour. The impact of surgery on tumour dissemination and the possible pathways of dissemination are discussed.

Primary cilia in normal human neocortical neurons.

Human neocortical neurons from the frontotemporal region were examined by serial ultrathin sectioning with the intention to establish the morphology and frequency of primary cilia (with a 9 + 0 tubular structure) in these cells. Each cell examined thoroughly showed one single cilium with a characteristic position and structure. The constant presence of these organelles may be a hint at an important function.

[A case of symmetrical pericallosal aneurysms with recurrent hemorrhage]. / Ein Fall von symmetrischen Pericallosaaneurysmen mit rezidivierender Blutung.

Aneurysms of the pericallosa cerebral artery are rare, representing only 2-4% of all intracranial aneurysms. Our case with symmetrical pericallosal aneurysms presented diagnostic problems. Diagnosis and surgery of the first aneurysm were followed by brief time-lag and recurrent bleeding by diagnosis and surgery of the second.

Anterior interosseous nerve syndrome with atypical nerve course in relation to the pronator teres.

A case of anterior interosseous nerve palsy is demonstrated due to an anatomical variation not recorded before causing this syndrome. Main median-nerve trunk and anterior interosseous nerve passed differently in relation to the pronator teres muscle. Surgery led to a rapid recovery of nerve function.

[Anatomic principles of lumbar intervertebral disk operations]. / Anatomische Grundlagen der lumbalen Bandscheibenoperation.

The important anatomical structures and the topographic relationships of lumbar disc surgery are described. Recent examinations about the epidural venous plexuses, the vascular supply of the spinal cord and nerve roots in the spinal canal enlarged our knowledge. Anterior and posterior spinal nerve roots differ in reaction to horizontally directed pull. The prevertebral anatomical structures which can be damaged by iatrogenic ventral perforation of the lumbar disc are demonstrated and their clinical importance is discussed.

The TP-levanol fast cyanine 5RN staining procedure for proteins of the myosin-fibrin group. Fibrin staining and other remarks.

The tannic acid-phosphomolybdic acid-Levanol (Supranol) Fast Cyanine 5RN (TP-L) procedure for staining muscle cells and blood platelets was used because, with this method, proteins of the myosin-fibrin group should be selectively stained. However, in human blood and blood plasma clots and in vivo thrombi, fibrin was not stained. Blood platelets probably due to their content of contractile proteins were very well stained. Apparent fibrin staining in human autopsy thrombi may be due to the staining of disintegrated platelets and the absorbance of fibrin by stained hemoglobin. Problems encountered using Nuclear Fast Red as the nuclear stain were solved by changing the dye concentration or by using a differentiating agent. Myosin staining by the TP-L method depended on the pH of the tannic-acid solution used. Raising the pH to 7.4-8.0 changed the staining result, and collagen fibers were then stained.