[Significance of the intervertebral disk in failed reduction of surgically stabilized fractures of the truncal spine]. / Die Bedeutung der Bandscheibe für den Repositionsverlust operativ stabilisierter Frakturen der Rumpfwirbelsäule.

In 112 patients with a traumatic fracture of the thoraco-lumbar spine operatively treated with different dorsal stabilization techniques from 1983 to 1988, the frontal and sagittal planes of the spine were analyzed over a follow-up period of 5 years. In 14 cases Harrington instrumentation was used, in 81 cases, transpedicular plates, and in 17 cases, a fixateur interne. With regard to the frontal plane the overall loss of correction was 2.3 degrees: with Harrington stabilization 0.7 degrees, with fixateur interne 2.6 degrees, and with plate fixation 3.7 degrees. In the sagittal plane the height of the damaged spinal segment and the kyphotic angulation were determined. The mean height loss after operative repositioning was 12%. With Harrington stabilization it was 16%, with plate fixation 12%, and with fixateur interne 9%. Kyphosis of 9.6 degrees was determined before surgery, and 0.9 degrees after. The angle subsequently deteriorated, reaching 12.6 degrees by the end of 5 years. The loss of correction was 9.3 degrees in the fixateur interne group, 10.9 degrees in the Harrington stabilization group, and 15 degrees in patients in whom plate fixation had been performed. The cause of deterioration was destruction of the invertebral disc in 66% of cases, and angulation of the fractured vertebral body in only 33%. Only in the first 2 years after operation was loss of reposition in the vertebral body observed. In conclusion, stabilization should be complemented by removal of the damaged adjacent disc and intercorporeal autogenous bone grafting from the dorsal or ventral approach.

[Comparative study of various dorsal stabilization procedures in recent fractures of the thoracic spine]. / Vergleichende Untersuchung unterschiedlicher dorsaler Stabilisierungsverfahren bei frischen Frakturen der Rumpfwirbelsäule.

After giving a brief summary describing the development of different methods for stabilisation of traumatic spine fractures the authors discuss their own results on 125 patients, who were treated between January 1st 1983 and September 15th 1988. The different surgical procedures (Harrington-instrumentation, transpedicular osteosynthetic stabilisation, fixateur interne) are compared. In the neurological physical examination 25% of the patients improved at least one degree in the Frankel-scale. In four patients there was worsening of the neurological findings. The radiological postoperative studies analyzed the angles of kyphosis and scoliosis within the traumatized spine segments. In overall-comparison of surgical procedures the fixateur interne showed best results (repositional loss of kyphosis angle 6.8 degrees, no fracture instability). Worse results were found for Harrington-stabilisation (repositional loss 9.1 degrees, fracture instability in three cases) and for transpedicular osteosynthetic stabilisation (repositional loss 12.4 degrees, fracture instability in two cases). In conclusion the authors describe the possible different complications for the three methods of judging from the clinical aspect and propose the following standard way of procedure: Fusion of the vertebral bodies with a stable implant and the possibility for intraoperative repositioning, postero-lateral spongiosa-grafting, fusion of the vertebral arc joints, transpedicular spongiosal filling of the traumatized vertebral body, resection of traumatized tissue from intervertebral discs and intercorporal blocking.

Comparative study of different dorsal stabilization techniques in recent thoraco-lumbar spine fractures.

The authors initially outline the development of operative techniques to stabilize traumatic thoraco-lumbar spine fractures. Thereafter their own results in 125 patients, treated operatively between 1.1.1983 and 15.9.1988, are presented. The different techniques (Harrington-instrumentation, transpedicular plate stabilization, fixateur interne) are evaluated. In the clinical neurological examination 25% of the patients experienced an improvement by at least one point in the FRANKEL classification. Four patients suffered neurological deterioration. In the radiological follow-up the "Sintering" process, the kyphotic and scoliotic deformity of the spinal segment were measured. The fixateur interne had the best overall results (loss of reposition averaged a kyphosis of 6.8 degrees, no fracture instability). Less good results were obtained with both the Harrington stabilization (loss of reposition 9.1 degrees, fracture instability in 3 cases) and with the transpedicular plate stabilization (loss of reposition 12.4 degrees, fracture instability in 2 cases). Finally the complications are described. The optimal approach is based on the clinical development. The fusion should be as short as possible with a stable angle implant and the possibility to reposition intraoperatively should be given. Postero-lateral spongiosa application, fusion of the vertebral arch joints, diskectomy with transpedicular spongiosa application and intercorporal blocking should be considered.

Clinical follow-up after surgery of lumbar disc prolapses. A critical analysis.

A retrospective clinical study was made on 987 patients with lumbar disc disease treated by discectomy. All patients had been operated on in the Department of Neurosurgery (University-Hospital Mainz). 545 patients were males, and 442 females (1.2:1). Patients in the 4th decade of life were affected most often (33.5%). Perioperative complications occurred in 5.4%, with discitis as the single major complication (1.9%). 83% of all patients who underwent discectomy could return to their normal occupation.

Dose-response relation for dexamethasone in cold lesion-induced brain edema in rats.

A dose-response relation was established for the antiedematous effect of dexamethasone in the rat brain, using the model of cold lesion-induced brain edema. Four doses corresponding to a human dose of 20 mg, 100 mg, 500 mg, and 2,500 mg dexamethasone (Fortecortin, E. Merck, Darmstadt, Germany) resulted in a highly significant edema reduction by 25%, 30%, and 50%, respectively, although the megadose of 2,500 mg showed less effect, only 30% reduction. Reproducible conditions with regard to animal material and sophisticated method used, exact analysis, manufacture and stability of the test substance dexamethasone, and scatter-reducing techniques and calculation procedures were the prerequisites for the clear result of the study. These results with the optimal dose of 500 mg dexamethasone obtained confirm recent therapy concepts in antiedematous therapy with ultra-high doses of dexamethasone in head injury. Carefully designed clinical studies on the subject of head injury and glucocorticoids may therefore be considered as extremely promising.

[Dose- and time-dependent dexamethasone effects in cold lesion-induced brain edema in the rat. Experimental research accompanying the German Ultrahigh Dexamethasone Head Injury Study (GUDHIS)]. / Dosis- und zeitabhängige Dexamethasonwirkungen beim Kälteläsioninduzierten Hirnödem der Ratte. Experimentelle Begleitforschung zur "German Ultrahigh Dexamethasone Head Injury Study (GUDHIS).

Experiments in 157 rats were carried out to establish that dose and time of initial dexamethasone therapy after head injury to counteract brain edema are decisive for the antiedematous effect (dose/time response relationship). For this purpose various human doses (weight-related conversion): 20 mg, 100 mg, 500 mg or 2500 mg of dexamethasone with different intervals from the injury: 10 min, 20 min, 40 min or 80 min, were administered in the model of cold lesion induced brain edema. Injury-induced (without therapy), the edema and sodium values increased markedly, and the potassium values decreased. Administration of dexamethasone produced statistically significant dose- and time-dependent effects tending to achieve physiological conditions: An optimal dose of 500 mg of dexamethasone had the highest antiedematous effect, while with still higher doses the effects must be expected to recede again or even be damaging. As expected, pretraumatic dexamethasone doses had the greatest antiedematous effect: reduction by 49%. On administration up to about half an hour after the injury, clearly relevant effects (up to 28%) were still measurable. With longer time intervals between injury and initial dexamethasone administration, e.g. 1 1/2 hours, a measurable but less relevant edema reduction by about 10% can be expected. All posttraumatic effects were achieved experimentally with a maximal dexamethasone therapy period of 21 hours. If similar results are obtained in corresponding clinical studies, the practical recommendation--at least from the animal experimental viewpoint--would be to administer ultra-high cortisone doses (e.g. 500 mg of dexamethasone) as early as possible within the first 2-3 hours after head injury. A cortisone therapy period of more than 2 or 3 days does not appear appropriate. In general no side effects are to be expected with this therapy regimen.

Dose- and time-dependent effects of dexamethasone on rat brain following cold-injury oedema.

Experiments were carried out with a rat model of brain-injury oedema to establish the most efficacious dose and administration schedule for dexamethasone treatment. The results indicate that there are statistically significant dose- and time-dependent effects for dexamethasone treatment of cold-injury oedema. The equivalent of a 500 mg dose of dexamethasone had the highest anti-oedematous effect. With higher doses no further improvement could be achieved and the potential of hazardous effects increased. As expected, pretraumatic drug treatment had the greatest therapeutic effect. Dexamethasone administration up to about 30 min after cold injury led to measurable beneficial results. Drug injection from 90 min or longer after injury only slightly reduced cerebral oedema. No therapeutic effects were found when dexamethasone was administered more than 21 hours after inducing cerebral oedema. If similar results are obtained in corresponding clinical studies, the recommended dexamethasone dose and schedule for treating traumatic cerebral oedema would be: 1) high doses of drug (e.g. 500 mg); 2) drug administration to begin as early as possible, preferably within the first 2-3 hours after head injury; and 3) treatment should be terminated within 2-3 days to avoid major side effects.

[Changes in regional cortical blood flow in hypnosis]. / Anderungen der regionalen kortikalen Durchblutung unter Hypnose.

Regional cerebral blood flow (rCBF) was measured by means of the 133-Xenon inhalation method in 12 healthy male volunteers experienced in self-hypnosis for several months. During a well performed levitation of the right arm in hypnosis as compared to resting conditions, we found a global increase of cortical blood flow and a regional activation of temporal areas; the latter finding is considered to reflect acoustical attention. In addition, a so far unexplained desactivation of inferior temporal areas was observed during successful self-hypnosis and hypnosis. While there was a global absolute increase of cortical blood flow bilaterally, we could not observe a relative increase of the right as compared to the left hemisphere during hypnosis. Several subjects successfully performed the levitation of the right arm, despite a relative left hemispheric activation, provided the absolute right hemispheric activation remained dominant.

[Short and long-term changes in cortical circulation caused by autogenic training]. / Kurz- und langfristige Anderungen der kortikalen Durchblutung bei Autogenem Training.

The well-known hyperfrontal pattern of hemispheric blood flow measured with 133-Xenon is not found in 12 healthy resting men who have been practicing Autogenic Training for at least six months. This might indicate a long-term decrease in the level of activation. Successfully practiced exercises of Autogenic Training lead to an increased blood flow in the Rolandic area representing the body sceme and to a decreased blood flow in regions related to acoustical attention and to autonomic functions. Left hemispheric cerebral blood flow ist lower in rest. The relative activation of the left hemisphere during Autogenic Training is discussed.

Cerebral blood flow in autogenic training and hypnosis.

In 12 healthy volunteers with at least an experience of six months in autogenic training (AT), the cerebral blood flow (CBF) was measured at rest, in AT and in hypnosis (H). The results were correlated with individual test profiles. The cortical flow pattern at rest of our AT trained volunteers did not show the hyperfrontality which is described in the literature. This may be interpreted as an effect of better and habitualized relaxation in long trained AT practitioners. This flow pattern corresponds to the low grades of neuroticism and aggressivity found in the tests. Furthermore an activation in central cortical areas and a deactivation in regions which are associated with acoustic and autonomous functions occur. Possible explanations for these phenomena as well as for the relatively low perfusion of the left hemisphere at rest and activation in AT are discussed. The global rise of CBF in H may be an activation effect caused by resistance against the hypnotizer: the deeper the trance, the smaller the CBF increase in the motor cortical area needed for maintaining catalepsy of the right arm and in temporal cortical fields processing acoustic inputs.

Cerebral blood flow, computerized tomography and angiography in 562 cases of cerebrovascular insufficiency.

The measurement of cerebral blood flow (CBF) in addition to cerebral computerized tomography (CT) and angiography is most reliable in cases of transient ischemic attacks (TIA) and prolonged reversible ischemic neurologic deficits (PRIND). Alterations of CBF can be detected in symptom-free intervals. The cerebrovascular reactivity to CO2 stimulus is regarded as an especially suitable tool to prove the cerebrovascular reserve. If it is diminished, cerebral angiography should be carried out since it will often show major obstructive lesions. Angiography shows no sure correlation between CBF and collateral circulation. Strong opthalmic pathways in unilateral occlusion of the internal carotid artery (ICA) often coincide with compensated or only slightly alterated CBF and relatively small infarcts in CT. In about 70% of cases of ICA occlusion, CT shows an infarct mostly in region of the middle cerebral artery (MCA). Largest infarct volumes were found in the anterior area. Although resting CBF was normal in 55% of cases of unilateral ICA occlusion, CO2 reactivity was impaired in 68% of these Cases.

Cerebral angiomas: influence of morphological aspects such as size and site on their clinical behavior with special reference to the mode of bleeding.

The following paper presents analysis of 182 cases of arteriovenous malformations treated surgically at the Neurosurgical Department of the Johannes Gutenberg-Universität Mainz, FRG. Although the behavior of AVMs remains unpredictable, morphological features of AVMs have an important bearing on their clinical presentation, especially the mode of bleeding.

Nimodipine treatment of ischemic neurological deficits due to cerebral vasospasm after subarachnoid hemorrhage. Clinical results of a multicenter study.

Intravenous Nimodipine was administered to 109 patients (65 female and 44 male) with either pre- or post-operative progressive neurological deterioration from cerebral vasospasm following subarachnoid hemorrhage from a ruptured aneurysm. In 91 of the patients the efficacy of Nimodipine in relieving ischemic symptoms was assessed and in all of the 109 patients the tolerance was evaluated. The aneurysms were related to following arteries: anterior communicating artery (41%), middle cerebral artery (24%), internal carotid artery (10%), vertebro-basilar arteries (4%) and others (5.5%); 11% of the patients had multiple aneurysms. On 16 of the 91 patients no surgery was performed. On 16% of the remaining 75 patients surgery was performed within 72 hours after the hemorrhage, 57% were operated between day 4 and day 15 and 29% after day 16. The ischemic neurological deficits occurred preoperatively in 67% of the patients and post-operatively in 23%. At the beginning of treatment 84% of the patients were graded III-V according to the Hunt and Hess grading system. Most of the patients received doses of 24-48 mg Nimodipine daily as constant i.v. infusion for 7-10 days. The grade of neurological deficit at the end of the treatment was evaluated according to the Glasgow Outcome Scale. 59 (65%) of the patients showed complete recovery or marked improvement of the ischemic symptoms while 22% remained unchanged and 11% died due to severe vasospasm. Administration of Nimodipine seemed to be more efficient in cases where treatment was started within 24 hours. In the patient group which was treated pre-operatively, recurrent hemorrhage was recorded in 8% of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Balloon occlusion test before carotid ligature (author's transl)]. / Ballonokklusionstest vor Karotisligatur.

The risk of ligating one carotid artery was tested by balloon occlusion of that vessel for a period of 30 to 60 minutes, during which time contralateral carotid angiography was carried out as well as an EEG and xenon-133 blood flow measurements. The procedure was carried out on seven patients, two showed a reduction in cerebral blood flow without EEG changes. In one patient the contralateral circulation could not be demonstrated by angiography. Carotid ligation was carried out in 5 of 7 patients. Neurological complications were not observed.

Clinical, chemical, and CT evaluation of short-term and long-term antiedema therapy with dexamethasone and diuretics.

Three independent methods were used to quantify the therapeutic effect on peritumoral brain edema with respect to different forms of treatment (dexamethasone, furosemide, and their combination with different dosages and different periods of treatment). 1. The neurological deficit evaluated by frequency distribution analysis showed an improvement in nearly all cases. In a few cases the initial improvement was followed by a secondary deterioration. The various symptoms showed significant differences in regression with regard to the extent of the reduced deficit as well as the time dependence. 2. With a certain delay (compared to item 1), diminution of brain edema was detected by CT follow-up. The effect of dexamethasone and the combination with furosemide differed depending on the nature of the brain tumor. 3. Compared to the untreated patients, the water content was reduced by nearly 3% following dexamethasone treatment 4 x 4 mg for 4 to 6 days. Following dexamethasone/furosemide therapy for 4 to 6 days, it was reduced by about 4.5%. The result of long-term therapy with dexamethasone alone was similar. The sodium content changed parallel to the water content. Dexamethasone and dexamethasone/furosemide was most effective in patients with glioblastoma, where the water content decreased by nearly 6%. The data presented suggest that preoperative antiedema treatment with dexamethasone is necessary for several days or a few weeks in some cases. The period of treatment can be reduced significantly by dexamethasone/furosemide or extremely high doses of dexamethasone. On the other hand, the results of follow-up scoring of the neurological situation show that the optimal time of pretreatment must be limited with respect to the individual case. The therapeutic results presented allow inferences to be made concerning pathophysiology of the resolution of brain edema.

The influence of the decompressive operation on the intracranial pressure and the pressure-volume relation in patients with severe head injuries.

Measurements of intracranial pressure by ventricular catheter were performed in 47 patients with severe head injuries. Thirty-three patients with decompressive operations such as osteoclastic craniotomy and dilatation by means of duraplastic have been compared with 14 patients with closed heads with regard to volume pressure response (intracranial elasticity). This was determined either by intraventricular injection of 2ml saline or by drainage of cerebrospinal fluid. The examination clearly shows that patients with closed heads have a much higher intracranial elasticity than patients who have decompressive operations, so that in the first group minor differences of the intracranial volume cause extreme deviations of the intracranial pressure. Therefore, the decompressive operation has been advised in severe head injuries with increased intracranial pressure as a measure additional to high dose dexamethasone therapy and hyperventilation.