[Degenerative cervical spine diseases: fusion vs. total disc replacement : What can be done when?] / Degenerative Halswirbelsäulenerkrankungen: Fusion vs. bewegungserhaltende Verfahren : Wann ist was sinnvoll?

Motion preserving surgery within the cervical spine may be performed by special implants, for example, c spine disc prosthesis or total disc replacement (cTDR), or by simple decompression of the cervical nerve roots. However, also fusion surgery may be performed with good results. Here, we summarize indications as well as contraindications for motion preserving techniques and indications for fusion surgery. cTDR is indicated in special cases of soft disc herniation, especially in younger individuals without signs of myelopathy. Posterior decompression may be used as an alternative, especially if anterior surgery is not possible. If degeneration is severe, in the presence of kyphosis, severe canal encroachment, instability, and in cases of myelopathy, cervical spine fusion seems to be the better way.

[Challenges and characteristics of spondylodiscitis of the cervical spine]. / Herausforderungen und Besonderheiten der Spondylodiszitiden der Halswirbelsäule.

The human cervical spine is a unique structure that differs dramatically from the thoracic and lumbar spine. The main differences concern the topographic anatomy of the spinal cord, anatomy and physiology of the occipito-atlanto-axial joint complex, the close course of the vertebral artery to the cervical spine and the very close relationship of the esophagus, vessels, peripheral and cranial nerves to the spine. To avoid serious complications during surgical treatment of spondylodiscitis within the cervical spine, these aspects must be kept in mind. They will be explained in detail in this article.

Anti-hepatitis C virus activity and toxicity of type III phosphatidylinositol-4-kinase beta inhibitors.

Type III phosphatidylinositol-4-kinase beta (PI4KIIIß) was previously implicated in hepatitis C virus (HCV) replication by small interfering RNA (siRNA) depletion and was therefore proposed as a novel cellular target for the treatment of hepatitis C. Medicinal chemistry efforts identified highly selective PI4KIIIß inhibitors that potently inhibited the replication of genotype 1a and 1b HCV replicons and genotype 2a virus in vitro. Replicon cells required more than 5 weeks to reach low levels of 3- to 5-fold resistance, suggesting a high resistance barrier to these cellular targets. Extensive in vitro profiling of the compounds revealed a role of PI4KIIIß in lymphocyte proliferation. Previously proposed functions of PI4KIIIß in insulin secretion and the regulation of several ion channels were not perturbed with these inhibitors. Moreover, PI4KIIIß inhibitors were not generally cytotoxic as demonstrated across hundreds of cell lines and primary cells. However, an unexpected antiproliferative effect in lymphocytes precluded their further development for the treatment of hepatitis C.

Balloon kyphoplasty improves back pain but does not result in a permanent realignment of the thoracolumbar spine.

INTRODUCTION: Balloon kyphoplasty (BKP) has been established as a standard procedure for treatment of osteoporotic compression fractures of the spine in elderly patients, as it results in pain relief for most of the patients. Moreover, BKP may result in a partial realignment of the sagittal shape of the vertebra and the spine. However, it is unclear whether BKP may result in long-term improvement of the sagittal alignment of the spine. The aim of the current study was to investigate if there is a significant loss of correction of the sagittal alignment of the thoracolumbar spine following BKP. METHODS: A prospective, noncontrolled, nonrandomized study, consisting of 71 patients treated for single level osteoporotic compression fracture by BKP at 1 institution and by 1 surgeon, was done. We checked the following radiographic outcome parameters: Beck's ratio, the kyphosis angle of the treated vertebra, the angle of kyphosis including the treated vertebra and the adjacent disc (monosegmental angle), the angle of kyphosis, including the treated segment, the adjacent disc as well as the adjacent vertebra (bisegmental angle). RESULTS: BKP resulted in significant pain relief with a score decreasing from 7.11 to 1.73 on a visual analogue scale immediately after the procedure. The effekt persisted after 1 year with a score of 1.58 VAS points. BKP also led to an improvement of each radiographic outcome parameter immediately after surgery. Beck's ratio was improved from 0.71 to 0.83. The Cobb's angle of the relevant vertebral bodies decreased from 11.4° to 6.8°. Monosegmental and bisegmental kyphosis angles decreased from 8.12° to 4.9° and from 6.9° to 4.5° respectively. Within 1 year, however, there was a significant loss of correction in each radiographic parameter analyzed. Beck's ratio decreased to 0.72, Cobb's angle increased to 10.8°, and the mono- and bisegmental kyphosis angles to 8.8° and 8.3°, respectively.BKP does not result in a permanent realignment of the thoracolumbar spine following treatment of single level osteoporotic compression fractures.

[Microsurgical decompression of lumbar spinal stenosis]. / Mikrochirurgische Dekompression der lumbalen Spinalkanalstenose.

Lumbar spinal stenosis in most cases is due to progressive degeneration of the spine, resulting in thickening of facet joints and flaval ligament. Thus the diameter of the lumbar spinal canal is reduced to less than 12 mm in the AP direction. Typically complaints consist in neurogenic claudication. Patients usually experience improvement of pain when bending their back or walking up a hill. Diagnosis of lumbar spinal stenosis is confirmed by MRI. CT myelography may help detect where compression is most pronounced. Surgical treatment should be based on the clinical symptoms of the mostly elderly people and should be performed as microsurgical decompression or in cases of clinical instability as TLIF.

[Biomechanics of interspinous spacers]. / Biomechanik der interspinösen Platzhalter.

Interspinous spacers are commonly used to treat lumbar spinal stenosis or facet joint arthritis. The aims of implanting interspinous devices are to unload the facet joints, restore foraminal height, and provide stability especially in extension but still allow motion. This paper summarizes several in vitro studies, which compared four different interspinous implants - Coflex, Wallis, DIAM, and X-STOP - in terms of their three-dimensional primary stability, the intradiscal pressure, and stability after cyclic loading. 24 human lumbar spine specimens were divided into four equal groups and tested with pure moments in flexion/extension, lateral bending, and axial rotation: intact, after decompression with hemifacetectomy, and after implantation. Implantation had similar biomechanical effects with all four implants. In extension, they overcompensated the instability caused by the defect and restricted extension to about 50% compared to the intact state. In contrast, in flexion, lateral bending, and axial rotation the values of the range of motion stayed similar compared to the defective state. Intradiscal pressure after implantation was similar to that of the intact specimens in flexion, lateral bending, and axial rotation but much smaller during extension; 50,000 load cycles increased the range of motion in all motion planes by no more than 20%, but in extension motion this was still less than in the intact state.

Diagnostic accuracy of hand-held Doppler in the management of acute scrotal pain.

We evaluate the reliability of hand-held Doppler (HHD) in the management of acute scrotal pain of 24 h or less duration. Between October 2003 and December 2004, patients presenting with acute scrotal pain were enrolled in this prospective study. After clinical examination, all patients had a HHD assessment. Presence or absence of Doppler arterial signals and its intensity were recorded. A blinded assessor corroborated HHD findings with the clinical, ultrasound, operative findings and final diagnosis. Primary outcome measured were sensitivity and specificity of HHD in the diagnosis of testicular torsion. Twenty-five patients presented during the study period with acute scrotal pain. The final diagnosis was testicular torsion in nine, epididymitis in 13, twisted cyst of Morgagni in two and Henoch-Schoenlein purpura in one patient. The HHD predicted all patients of testicular torsion correctly, preoperatively. HHD is a reliable diagnostic tool in the management of patients with acute scrotal pain.

Biomechanical effect of different lumbar interspinous implants on flexibility and intradiscal pressure.

Interspinous implants are used to treat lumbar spinal stenosis or facet joint arthritis. The aims of implanting interspinous devices are to unload the facet joints, restore foraminal height and provide stability especially in extension but still allow motion. The aim of this in vitro study was to compare four different interspinous implants--Colfex, Wallis, Diam and X-Stop--in terms of their three-dimensional flexibility and the intradiscal pressure. Twenty-four human lumbar spine specimens were divided into four equal groups and tested with pure moments in flexion/extension, lateral bending and axial rotation: (1) intact, (2) defect, (3) after implantation. Range of motion and the intradiscal pressure were determined. In each implant-group the defect caused an increase in range of motion by about 8% in lateral bending to 18% in axial rotation. Implantation had similar effects with all four implants. In extension, Coflex, Wallis, Diam, and X-Stop all overcompensated the instability caused by the defect and allowed about 50% of the range of motion of the intact state. In contrast, in flexion, lateral bending and axial rotation the values of the range of motion stayed about the values of the defect state. Similarly the intradiscal pressure after implantation was similar to that of the intact specimens in flexion, lateral bending and axial rotation but much smaller during extension. All tested interspinous implants had a similar effect on the flexibility: they strongly stabilized and reduced the intradiscal pressure in extension, but had almost no effect in flexion, lateral bending and axial rotation.

Current trends in the management of acute appendicitis.

BACKGROUND: While laparoscopic appendectomy (LA) has become established in the diagnosis and treatment of acute appendicitis, its utilisation compared to open appendectomy (OA) is variable. AIM: To compare the utilisation and outcome of laparoscopic (LA) versus OA in an Irish regional hospital setting. METHOD: Retrospective review of OA and LA performed from 2003 to 2005. RESULTS: Intention-to-treat analysis of 787 patients in this study revealed that 149 patients (19%) had LA and 638 patients (81%) had OA. Consultants were significantly more likely than trainees to undertake a LA (P < 0.0001). Twenty-two complications (2.8%) were recorded in the post-operative period. The overall negative appendectomy rate by histopathology was 17% with no significant difference between the rate in the LA group (19%) and the OA (17%) group. CONCLUSION: Mean length of stay and complication rate were comparable between the LA and OA groups.

Can a modified interspinous spacer prevent instability in axial rotation and lateral bending? A biomechanical in vitro study resulting in a new idea.

BACKGROUND: Interspinous spacers are mainly used to treat lumbar spinal stenosis and facet arthrosis. Biomechanically, they stabilise in extension but do not compensate instability in axial rotation and lateral bending. It would therefore be desirable to have an interspinous spacer available, which provides for more stability also in these two planes. At the same time, the intervertebral disc should not completely be unloaded to keep it viable. To meet these requirements, a new version of the Coflex interspinous implant was developed, called "Coflex rivet", which can be more rigidly attached to the spinous processes. The aim was to investigate whether this new implant compensates instability but still allows some load to be transferred through the disc. METHODS: Twelve human lumbar spine segments were equally divided into two groups, one for Coflex rivet and one for the original Coflex implant. The specimens were tested for flexibility under pure moment loads in the three main planes. These tests were carried out in the intact condition, after creation of a destabilising defect and after insertion of either of the two implants. Before implantation, the interspinous spacers were equipped with strain gauges to measure the load transfer. FINDINGS: Compared to the defect condition, both implants had a strong stabilising effect in extension (P<0.05). Coflex rivet also strongly stabilised in flexion and to a smaller degree in lateral bending and axial rotation (P<0.05). In contrast, in these three loading directions, the original Coflex implant could not compensate the destabilising effect of the defect (P>0.05). The bending moments transferred through the implants were highest in extension and flexion. Yet, they were no more than 1.2 Nm in median. INTERPRETATION: The new Coflex rivet seems be a suitable option to compensate instability. Its biomechanical characteristics might even make it suitable as an adjunct to fusion, which would be a new indication for this type of implant.

Encrusted cystitis--an unusual cause of recurrent frank haematuria.

BACKGROUND: Encrusted cystitis associated with malakoplakia is described in the literature as a rare condition characterized by the formation of calcified plaques adherent to or embedded in the bladder mucosa. AIMS: We present the case of a 51-year-old male, presenting with recurrent haematuria associated with minimal exercise. Despite normal ultrasound, IVP, two calcified lesions on his bladder were found on cystoscopy. Conservative management was ineffective thereby necessitating a curative partial cystectomy. CONCLUSION: We would like to illustrate/discuss this rare but problematic condition with gross and microscopic pictures.

Non-orthopaedic paediatric trauma in a regional hospital.

BACKGROUND: In the Republic of Ireland there are no paediatric surgeons outside Dublin. Most paediatric trauma is managed in general hospitals by general or orthopaedic surgeons. AIM: In this study we audited our experience with paediatric trauma in a regional setting. METHODS: We carried out a retrospective review of all non-orthopaedic paediatric trauma patients admitted to our institution over a two-year period.The method of injury, management and outcome were recorded and the TRISS (revised trauma injury severity score) method was used to calculate the probability of survival. RESULTS: One hundred and fifty four paediatric patients were admitted following trauma. Falls, RTAs and burns were the commonest reasons for admission. Twenty nine of these patients (19%) required surgical procedures. There were no unexpected deaths. CONCLUSION: The majority of paediatric trauma admissions were for minor injuries. A number of seriously injured children were successfully treated with no unexpected deaths.

Contralateral groin exploration is not justified in infants with a unilateral inguinal hernia.

BACKGROUND: Contralateral groin exploration in children with unilateral inguinal hernia is still controversial, particularly in infants. The patency rate of processus vaginalis is highest in infants but there are few data on the subsequent risk of contralateral hernia development in infants. In this retrospective study, we aimed to find out the incidence of contralateral inguinal hernia following unilateral inguinal herniotomy in infants aged less than one year. METHODS: All infants who underwent a unilateral Inguinal herniotomy between January 1990 and December 1998 were studied retrospectively. Infants with bilateral hernia (n = 7) were excluded from the study. RESULTS: One hundred and one infants (93 boys and 8 girls) were studied. Median age at operation was 23 (range 2-52) weeks. The herniotomy was right-sided in 75% of the infants. Follow-up ranged from three and a half years to 11 years. A contralateral hernia developed in nine infants (9.0%). One of the initial hernias was incarcerated. Median time from operation to occurrence of contralateral hernia was 18 (range 2-60) months. None of the contralateral hernia was incarcerated. Age, sex, incarceration and side of initial hernia did not influence the development of contralateral hernia. CONCLUSION: The low incidence and benign nature of contralateral hernia development in infants undergoing a unilateral inguinal herniotomy does not justify routine contralateral groin exploration.

Absence of germline infection in male mice following intraventricular injection of adenovirus.

The possibility of inadvertent exposure of gonadal tissue to gene therapy vectors has raised safety concerns about germline infection. We show here that the receptor for coxsackie B viruses and adenoviruses 2 and 5 (CXADR) is expressed in mouse germ cells, suggesting the possibility that these viruses could infect germ cells. To directly assess the risk of germline infection in vivo, we injected an adenovirus carrying the germ-cell-specific protamine promoter fused to the bacterial lacZ reporter gene into the left ventricular cavity of mice and then monitored expression of the reporter gene in germ cells. To differentiate between infection of stem cells and differentiating spermatogenic cells, we analyzed expression of the reporter cassette at different times after viral delivery. Under all conditions tested, mice did not express the Escherichia coli beta-galactosidase protein in developing spermatids or in mature epididymal spermatozoa. Primary germ cells cultured in vitro were also refractory to adenoviral infection. Our data suggest that the chance of vertical germline transmission and insertional mutagenesis is highly unlikely following intracoronary adenoviral delivery.

Treatment of surgical patients is evidence-based.

OBJECTIVES: To assess the type of evidence that supported our management of surgical patients. DESIGN: Retrospective audit. SETTING: Teaching hospital, Republic of Ireland. PATIENTS: All 222 patients admitted by two surgical teams during one month. Patients admitted for diagnostic procedures were included if they were treated as a result. MAIN OUTCOME MEASURES: Diagnosis and treatment were established from the notes. Evidence for each intervention was then sought in MEDLINE 1986-1999, Best Evidence 1991-1999, and the Cochrane Database of Systematic Reviews Issue 3, 1999, and graded into one of five categories: systematic review, meta-analysis, randomised controlled trial, prospective study, or retrospective study. RESULTS: Treatment was supported by systematic review in 14, by meta-analysis in 12, by randomised controlled trial in 75, by prospective studies in 55, by retrospective studies in 58, and by no evidence in 8. CONCLUSIONS: Everyday surgical practice in our unit is supported by good quality evidence from recent publications.

A prospective evaluation of the efficiency of early postoperative bladder emptying after the Stamey procedure or pubovaginal sling for stress urinary incontinence.

PURPOSE: The pubovaginal sling has been criticized as having a higher incidence of postoperative voiding dysfunction than other surgical approaches for the management of stress urinary incontinence. In 2 similar patient groups we prospectively compared the rates of early postoperative voiding dysfunction after the pubovaginal sling or Stamey procedure. MATERIALS AND METHODS: Between June 1995 and January 1997, 50 consecutive patients underwent the pubovaginal sling or Stamey procedure. Emptying efficiency was measured 48 hours postoperatively by suprapubic catheter in the Stamey group and intermittent catheterization in the pubovaginal sling group. When emptying efficiency was greater than 75%, intermittent catheterization was stopped or the suprapubic catheter was removed. RESULTS: There was no statistically significant difference in emptying efficiency for the first 3 voids using the Dunn multiple comparison method. Median voiding efficiencies were 37%, 43% and 61% with the Stamey procedure in group 1 (mean 43%, 45% and 54%), and 60%, 75% and 75% with the pubovaginal sling in group 2 (mean 49%, 68% and 69%), respectively. The mean number of intermittent catheterizations performed in patients with the pubovaginal sling was 5.7 in less than 1 day. In the Stamey group the suprapubic catheter was removed an average of 6 days postoperatively. The mean duration of hospital stay was similar for the sling and Stamey groups (5.4 versus 6 days, respectively). There were 2 patients in each group who were voiding inefficiently after day 7. Voiding efficiency was restored at 53 and 86 days in the 2 patients with slings and at 18 days in 1 of the 2 who underwent the Stamey procedure, respectively. The second patient who underwent the Stamey procedure was able to void without using the catheter at all, and it was removed 30 days postoperatively when emptying efficiency was confirmed greater than 75%. CONCLUSIONS: These data show that early postoperative voiding dysfunction, measured using bladder emptying efficiency, after the pubovaginal sling is no more common than after the Stamey procedure and help justify the broadened indications for pubovaginal sling for treatment of stress urinary incontinence.

The future of paediatric surgery outside specialist paediatric hospitals.

BACKGROUND: In Ireland, general surgeons provide paediatric surgical services to patients remote from specialist paediatric units. AIM: To review general paediatric surgical services in the Mid-Western Health Board (MWHB) region with a view to informing future policy decisions in Ireland. METHODS: From 1995 to 2000, the paediatric surgical workload at the Mid-Western Regional Hospital was reviewed. Operations performed, level of operating surgeon, morbidity and mortality were recorded. RESULTS: There were 3,166 general paediatric surgical patients cared for by three general surgeons and one urologist, all with paediatric surgical training. There was an increase in day cases (55% to 70%) and operations at which the consultant was the main operator (40% to 67%). There was no mortality and the morbidity rate was less than 1%. CONCLUSIONS: General paediatric surgery and urology is well provided for in the MWHB by appropriately trained surgeons. Lack of opportunity for surgeons in training to obtain general paediatric surgical experience will put this service at risk as the current cohort of surgeons retire. Expansion in specialist paediatric surgical services, changes in general surgical training to include general paediatric surgery or proleptic appointments may be required.

Infantile hypertrophic pyloric stenosis in a regional centre.

BACKGROUND: It has been suggested that only specialist paediatric surgeons should manage infantile hypertrophic pyloric stenosis (IHPS). AIM: The aim of this retrospective study was to ascertain whether the majority of these infants might be managed in a well-equipped regional centre. METHODS: Using the Hospital Inpatient Enquiry database, all cases of IHPS within a single administrative health region were identified over a six-year period. A chart review was performed to obtain demographic and clinical information for each patient. Reports from the Central Statistics Office were used to obtain data on population and live births for the region. RESULTS: Seventy patients with IHPS were identified from this region from 1991 to 1996, 63 (90%) of which were treated in the region. Of the remaining seven, four were referred directly to specialised paediatric surgical hospitals because of prematurity (n = 1), low birth weight (n = 1), capillary haemangioma (n = 1) and severe metabolic derangement (n = 1) while three were assessed and treated in general hospitals outside the region. Of the 63 infants undergoing pyloromyotomy in this region, the duodenal mucosa was breached in four (6%); there were wound complications in three (5%); and one required a re-pyloromyotomy. The mean postoperative stay was eight days (range 2-42 days). CONCLUSION: The majority of infants with IHPS may be safely managed in regional centres with transfer to specialist paediatric centres reserved for 'high risk' cases. The management of IHPS at a regional level has important implications and presents opportunities for surgical training.

Cardiac-directed adenylyl cyclase expression improves heart function in murine cardiomyopathy.

BACKGROUND: We tested the hypothesis that increased cardiac myocyte adenylyl cyclase (AC) content increases cardiac function and response to catecholamines in cardiomyopathy. METHODS AND RESULTS: Transgenic mice with cardiac-directed expression of AC type VI (ACVI) were crossbred with mice with cardiomyopathy induced by cardiac-directed Gq expression. Gq mice had dilated left ventricles, reduced heart function, decreased cardiac responsiveness to catecholamine stimulation, and impaired beta-adrenergic receptor (betaAR)-dependent and AC-dependent cAMP production. Gq/AC mice showed improved basal cardiac function in vivo (P=0.01) and ex vivo (P<0.0005). When stimulated through the betaAR, cardiac responsiveness was increased (P=0.02), and cardiac myocytes showed increased cAMP production in response to isoproterenol (P=0.03) and forskolin (P<0.0001). CONCLUSIONS: Increasing myocardial ACVI content in cardiomyopathy restores cAMP-generating capacity and improves cardiac function and responsiveness to betaAR stimulation.