[Adjuvant systemic antibiotic therapy for surgically treated spondylodiscitis]. / Die adjuvante systemische Antibiotikatherapie der operativ versorgten Spondylodiszitis.

Recognised methods for the treatment of spondylodiscitis in correspondence to the immobilisation are systemic antibiotic therapy. However, the available data for recommendations of specific antibiotic therapy are very heterogeneous. The aim of this study was to focus on the adjuvant antibiotic therapy in surgical treated cases of spondylodiscitis and to reach a guideline regarding its application in patients' spondylodiscitis. Between 01.10.1998 and 31.12.2011 276 inpatient cases of spondylodiscitis were surgically treated, documented and included in the study. The study involved medical history, germ status, localisation and extent of spondylodiscitis and antibiotic treatment. Between 01.01.2012 and 31.12.2013 a further 20 cases of spondylodiscitis were treated according to a standardised treatment regimen of antibiotic therapy and included in the study. The age distribution shows a marked prominence of 60 to 80 year-olds, with a leading localisation of spondylodiscitis in the lumbar spine with 55 % followed by the thoracic spine (33 %) and the cervical spine (12 %). A constant observation during the study periods was the delayed diagnosis of more than 1 month of spondylodiscitis, so that about 60 % of the patients were not receiving any treatment for their disease at the time of hospitalisation. The aetiology of spondylodiscitis is very heterogeneous and remained unknown in 34 % of cases. However, diabetes mellitus appeared as a disease favouring the occurrence of spondylodiscitis since it was concomitant with almost 50 % of patients with spondylodiscitis. The bacterial spectrum is limited in our area to staphylococci, with a predominance of Staphylococcus aureus. At least about 10 % of the germs are multi-drug resistant. In 45 % of cases, pathogen detection was unsuccessful. Clindamycin is the most commonly used antibiotic in the treatment of spondylodiscitis and is used in 26.8 % in combinations with other antibiotics. The antibiotic therapy is administered for at least for 3 months. The significant decrease in inflammatory markers in the course of treatment shows the positive response of patients to therapy. The recommendations for antibiotic treatment of spondylodiscitis are very heterogeneous, so our goal is to standardise the therapy without reducing the quality and effectiveness of treatment. The results show that the calculated antibiotic therapy (CAT) with clindamycin is reasonable in the treatment of spondylodiscitis especially with the predominance of Staphylococcus aureus as pathogen. In addition, suitable antibiotic therapy should be administered in correspondence to a culture and sensitivity testing and should be maintained for at least 12 weeks, even when a reduction of inflammatory markers by 50 % after 2 weeks has already been achieved. It is noteworthy to point out the high probability of coexistence of spondylodiscitis with diabetes mellitus, so that spondylodiscitis should always be considered in diabetic patients with back pain and increased levels of inflammatory markers. A significant reduction in the very long time until reaching a definitive diagnosis should be achieved.

Artificial disc versus spinal fusion in the treatment of cervical spine degenerations in tetraplegics: a comparison of clinical results.

STUDY DESIGN: Comparative prospective study. OBJECTIVES: To determine functionality of the cervical spine when using ProDisc C in comparison with the conventional method of treatment (decompression and fusion) in paraplegics. SETTING: Spinal Cord Injury Centre in Germany. METHODS: Two homogeneous groups were studied. The patients were treated with ventral decompression and either had a fusion with an iliac bone graft and plate (group 1) or had received a disc replacement (group 2). Pre- and postoperatively, the subjective scores of SF 36 and Neck Disability Score were determined. Also, objective data of the Spinal Cord Independence Measure (SCIM) III and mobility of the cervical spine, using the neutral-0-method, were evaluated. Prosthesis implementation and union or fusion were monitored by X-rays. Complications and alterations of the neurology were recorded according to the American Spinal Injury Association Score. RESULTS: Neurological remissions of the radicular syndrome that caused the operation were observed. In one case, the dislocation of the prosthesis necessitated an alternative treatment. Mobility of the cervical spine after 6 months was higher in group 2. Both groups showed signs of improvement in the Neck Disability Score and in SF 36. None of the two groups had changes in their SCIM score. One case in group 2 showed ventral blocking; all cases of group 1 fused successfully. CONCLUSION: Usage of prostheses results in improved total mobility of the cervical spine in comparison with the outcomes of a fusion. This study also confirmed these results in tetraplegics.

Protein-Z-deficiency as a rare case of unexpected perioperative bleeding in a patient with spinal cord injury.

STUDY DESIGN: Case report describing the management of repeated perioperative bleeding probably due to Protein-Z-deficiency in a post-traumatic paraplegic patient. OBJECTIVES: To describe the difficulty in diagnosing this rare form of hypocoagulability and the monitoring and substitution concept during three elective surgical interventions. SETTING: Spinal Cord Injury Center, Bergmannstrost, Halle, Germany. CASE REPORT: A 19-year-old male suffering from a post-traumatic paraplegia sub Th8 (ASIA-A) since childhood had experienced two life-threatening intraoperative bleeding incidents before finally Protein-Z-deficiency as the underlying coagulation disorder was diagnosed. After substitution of 2000 IE PPSB (Beriplex P/N) a repeatedly postponed implantation of a sphincter-externus (Brindley-) stimulator could be performed without bleeding complications, and this was also true for two additional urological interventions 1 year later. Protein-Z levels were monitored before, during and after the operations. The preoperative application of between 1000 and 2000 IE PPSB was safe and sufficient to raise the patients' plasma Protein-Z level to almost normal and so prevent excessive intraoperative blood loss. CONCLUSION: In case of repeated bleeding tendency of unknown origin it is mandatory to look for rare causes of hypocoagulability such as Protein-Z-deficiency. We developed a substitution concept using a plasma concentrate with guaranteed Protein-Z amount (PPSB) allowing the safe performance of elective surgical interventions.

[Protein-z-deficiency as a rare case of perioperative bleeding]. / Protein-Z-Mangel als seltene Ursache unklarer perioperativer Blutungen.

Protein Z is a vitamin-K-dependent plasma glycoprotein synthesized by the liver, showing great structural similarity to other vitamin-K-dependent coagulation factors such as factors II, IX, X and protein C and S. Protein Z seems to assist haemostasis by binding thrombin and promoting its association with phospholipid surfaces, and it downregulates coagulation by forming a complex with the plasma protein-Z-dependent protease inhibitor, which inhibits activated factor Xa. Studies in patients with a bleeding tendency of unknown origin during and after surgery displayed diminished protein-Z-concentrations in about 50 % of the patients with recurrent bleeding. We report about a 19 year old patient, who suffers from a posttraumatic paraplegia subTh 8 since childhood. In 1998 a correction operation in order to reduce scoliosis with restrictive ventilatory defects had to be stopped before successful spondylodesis because of massive bleeding. After a second intraoperative bleeding incident and exclusion of other more frequent thrombocytic or plasmatic causes of hypocoagulability protein-Z-deficiency finally was diagnosed. Under substitution of protein-Z using PPSB (Beriplex P/N) a repeatedly postponed implantation of a sphincter-externus (Brindley-) stimulator could be performed without bleeding complications in 2001, and this was also true for two other urological interventions in 2002. This report about repeated life-threatening intraoperative bleeding in a patient with protein-Z-deficiency, which could be successfully counteracted using selected plasma concentrates with guaranteed protein-Z-amounts, underlines the importance of protein-Z-assessment in some rare cases of bleeding tendency of "unknown origin" and documents the preventive plasma Protein-Z-levels achieved with the substitution of PPSB.

Endoprosthesis in paraplegics with periarticular ossification of the hip.

STUDY DESIGN: Clinical study. OBJECTIVES: To evaluate indications of hip endoprosthesis in periarticular ossifications. SETTING: A Spinal Cord Injury Centre in Germany. METHODS: Clinical examination, X-ray control. RESULTS: Surgery of periarticular ossification (paraosteoarthropathy, POA) either involves simple resection of the ossification or removal of the hip. The latter has an impact on the sitting posture with concomitant increased pressure sore risk. Nevertheless the hip is biomechanically important in paraplegics. We are investigating the outcome of total hip replacement (THR) in patients with ankylosis due to periarticular ossification. Six hip replacement cases seen in follow-up of up to 24 months showed no loosening, with good mobility of the joint. We follow a strict perioperative POA prophylaxis, which resulted in each case reporting only a slight recurrence (Brooker 1-2) without any loss of functional mobility. CONCLUSION: In ankylotic hips with mobility/social/hygenic problems we favour a hip replacement in cases with osteoarthritis or high risk of osteoporotic fracture. A replacement of the joint should be preferred to a Girdlestone operation.

The role of plasma transglutaminase (F XIII) in wound healing of complicated pressure sores after spinal cord injury.

STUDY DESIGN: A case report. OBJECTIVES: To demonstrate stimulating action of F XIII in wound healing of complicated pressure sores. SETTING: A Spinal Cord Injury Center in Germany. METHODS: Clinical exam, clinical and photographic wound control, biochemical serum monitoring. RESULTS: Recurrent pressure sores in plegic patients are common complications requiring long-standing conservative or operative therapy. Additional risk factors such as diabetes increase the complication rate for surgery. Surgery itself may be difficult in recurrent pressure sores due to limited remaining soft tissues. We report the case and treatment of a 47-year-old patient with long-standing and recurrent ulcers and complications after flap surgery. As a final option we added plasma transglutaminase (factor XIII) to our treatment scheme which changed the course of the disease dramatically and we achieved complete and rapid healing. CONCLUSION: Our experience suggests that F XIII has a positive role in treating pressure sores as shown already in several other surgical fields. Its use is giving the surgeon an additional tool in complicated cases.

[Unusual site of heterotopic ossification in the area of a laparotomy scar]. / Ungewöhnliche Lokalisation einer heterotopen Ossifikation im Bereich einer Laparotomienarbe.

We report on a patient with spinal cord injury and an unusual localization of heterotopic ossification (HO) in the area of a laparotomy scar, with a large quantity of foreign bodies from residual suture material. This makes it obvious that extraskeletal cells can differentiate for osteogenesis. However, neither the mechanism of the induction process of HO nor the stimulating agents are precisely known. It must be stressed, however, that the occurrence of HO can be influenced by foreign bodies in the presence of favourable microenvironmental conditions.