Albrecht Waschke

Degenerative lumbar spinal stenosis in older people: current treatment options.

BACKGROUND Degenerative lumbar spinal stenosis is increasingly being diagnosed in persons over age 65. In 2011, 55 793 older people with this condition were treated as inpatients in German hospitals. Among physicians, there is much uncertainty about the appropriate treatment strategy. METHOD Selective literature review. RESULTS Lumbar spinal stenosis in older people is characterized by spinal claudication and neurological deficits. A precise clinical history and physical examination and ancillary radiological studies are the necessary prerequisites for treatment. Magnetic resonance imaging is the radiological study of choice. Conservative treatment consists of physiotherapy, drugs, and local injections; various surgical treatments can be considered, depending on the severity of the problem. The main purpose of surgery is to decompress the spinal canal. If the lumbar spine is demonstrably unstable, an instrumented fusion should be performed in addition. There is, however, only moderately good evidence supporting the superiority of surgery over conservative treatment. In a prospective study, the complication rate of purely decompressive surgery was found to be 18%. The utility of the current operative techniques cannot be definitively assessed, because they are applied to a wide variety of patients in different stages of the disease and at different degrees of severity, and the reported results are thus not comparable from one trial to another. CONCLUSION No evidence-based recommendation on the diagnosis and treatment of lumbar spinal stenosis in older people can be formulated at present because of the lack of pertinent randomized trials.

Anterior Cervical Intercorporal Fusion in Patients With Osteoporotic or Tumorous Fractures Using a Cement Augmented Cervical Plate System: First Results of a Prospective Single-center Study

Study Design: Prospective observational clinical study. Objective: The aim of this study is to evaluate the technical feasibility and the safety of additional cement augmentation of anterior cervical implants in patients with poor bone quality because of osteoporosis or tumor infiltration. Summary of Background Data: With an increasing number of elderly patients in spinal surgery the problem of implant dislocation after cervical instrumentation will become a more and more important problem. Whereas in the thoracolumbar area cement augmented screws have become widely accepted to ensure a rigid fixation in patients with reduced bone quality there are no data concerning an additional intravertebral cement augmentation after cervical plating. Methods: Nine patients (4 males, 5 females, mean age 62.8 y) with newly diagnosed fractures of 1 or 2 cervical vertebrae because of tumor infiltration (6 cases) or osteoporosis (3 cases) were included in our study. A standard 1-level or 2-level cervical corpectomy with vertebral body replacement by an in situ expandable titanium cage and additional anterior plating was carried out. After this, additional cement augmentation was performed as a vertebroplasty of the anterior two thirds of the cranial and caudal adjacent vertebra by a new anterior hole. The cement should enclose the screws and stabilize the endplates of the adjacent vertebrae. Follow-up comprised clinical examinations, SF-36 questionnaire and visual analog scale 3, 6, and 12 months after surgery. Cervical spine radiographs were obtained 3 and 6 months after surgery and computed tomography scans 6 and 12 months after surgery. Results: The median follow-up was 10 months with a range of 4–18 months. There was no intraoperative cement leakage into the spinal canal. The visual analog scale decreased from 8.2 to 4.2 at 6 months, physical and mental component summaries of SF-36 increased significantly from 27.7 to 36.1 and 31.5 to 48.6 at 6 months, respectively. Loosening of screws or plates was not detected throughout the whole observation period. There was 1 subsidence of a titanium cage into an adjacent vertebra without any clinical consequences. There was no adjacent fracture during the follow-up period and other surgical interventions or revisions were not necessary in any patient. Conclusions: In patients with severe osteoporosis or in patients with advanced tumor disease, excellent surgical, clinical, and radiologic results are possible following our method. In our opinion, a second-step posterior approach can be avoided by this technique.

Multifocal Glioblastoma Multiforme in the Posterior Fossa Mimicking Cerebral Metastases: Case Presentation and Review of the Current Literature

OBJECTIVE In general, glioblastomas multiforme (GBM) arise in the supratentorial region, but in less than 4% of cases they also occur in the posterior fossa, particularly in the cerebellum. Furthermore, a minority of malignant gliomas are multifocal. We report on an unusual case with infratentorial multifocal lesions, suspicious for metastases, which turned out to be a multifocal GBM of the posterior fossa. PATIENT AND METHOD A 69-year-old woman presented with recurring episodes of vertigo, headache, and progressive weight loss. Three multifocal cerebellar and brainstem lesions highly suspicious for metastases were identified by magnetic resonance imaging (MRI). Workup for malignancy elsewhere in the body was negative. RESULTS The patient underwent craniotomy with successful resection of the tumor in the cerebellar vermis with an excellent outcome and uneventful postsurgical course. Histopathology of the tumor revealed features consistent with the diagnosis of GBM and ruled out metastatic lesions. Workup for molecular genetics characterized this tumor as a primary GBM. The patient initially responded to treatment with radiation therapy and temozolomide but died after 10 months with a tumor relapse. CONCLUSION We discuss the unusual aspects of multifocal primary GBMs in the posterior fossa. Although rare, they should be considered in the differential diagnosis of cerebellar tumors, which stresses the importance of a surgical treatment to establish a histological diagnosis because there are no reliable radiographic criteria for distinguishing multifocal infratentorial gliomas from multiple metastases and other tumor entities. The differentiation between a primary and secondary cerebellar GBM did not lead to any change of the treatment strategy in this case.

Cement augmented anterior odontoid screw fixation is biomechanically advantageous in osteoporotic patients with Anderson Type II fractures.

Study Design: A biomechanical human cadaveric study. Objective: The authors tested a cannulated and perforated lag screw and compared in situ polymethylmethacrylate (PMMA) augmentation against nonaugmentation for fixation of osteoporotic type II odontoid fractures. Summary of Background Data: Osteoporosis has been identified as a strong predictor for pseudarthrosis after screw fixation of type II odontoid fractures with cut-out through the anterior wall of C2 as the most frequent mode of implant failure. The concept of PMMA augmentation of the proximal screw shank could serve as a useful supplement in this context. Methods: A total of 18 fresh-frozen human cadaveric C2 vertebrae were harvested (median 86.5 y; range, 69–98 y). Reduced bone quality was verified by quantitative computed tomography. Type II odontoid fractures were created and repaired with a cannulated lag screw, which has perforations in the proximal screw shank. Additional PMMA augmentation was carried out for 9 specimens. The position of the screw and cement distribution were evaluated by computed tomography. Values for maximum force to failure, energy to failure, and stiffness were statistically compared between cement augmented and nonaugmented screws. Results: Cement distribution in the C2 vertebral body was circumferential around the screw shank without leakage into the spinal canal or into the fracture gap in all 9 specimens. The cement augmented screws showed a 2.4 times higher maximum force to failure (363±94 N, P<0.001), a 2.7 times higher energy to failure (1300±698 mJ, P<0.001), and a 1.76 times higher stiffness (90±35 N/mm, P=0.031) in comparison with the nonaugmented screws. Conclusions: Cement augmentation for fixation of osteoporotic type II odontoid fractures showed biomechanical advantages. It was also shown that cement augmentation of the newly developed screw is technically easy and safe under in vitro conditions. The technique might be useful with regard to the surgical treatment of elderly patients with osteoporotic odontoid fractures.

[Intramedullary tuberculoma--rare differential diagnosis of paraplegia].

Eine 30-jährige Patientin aus Äthiopien stellte sich mit seit 14 Tagen andauernden, lokalisierten Rückenschmerzen und progredienter Paraparese der Beine vor. Gleichzeitig hatte sie Fieber sowie unproduktiven Husten. Was steckte dahinter?Eine 30-jahrige Patientin aus Athiopien stellte sich mit seit 14 Tagen andauernden, lokalisierten Ruckenschmerzen und progredienter Paraparese der Beine vor. Gleichzeitig hatte sie Fieber sowie unproduktiven Husten. Was steckte dahinter?

Spontaneous Involution of a Presumably Rathke's Cleft Cyst in a Patient with Slight Subclinical Hypopituitarism: A Case Report and Review of the Literature

Rathke cleft cyst is described as benign intrasellar cyst. They are mostly small and asymptomatic; they may become large enough to cause symptoms by compression of intrasellar or suprasellar structures. We report on a case of spontaneous regression of a symptomatic RCC with subsequent recovery of preexisting endocrine dysfunction and resolution of headaches. A 60-year-old man complained about headaches. Laboratory investigation revealed a partial hypopituitarism with a slight central hypothyroidism without need for substitution. An MRI study showed a cystic, T2-hyperintense, sellar lesion compatible with a RCC. At one year follow-up, the patient had no complaints and the hormone work-up revealed a regression of the previous slight hypopituitarism. The MRI study showed a complete regression of the cystic lesion and a normal sized and shaped pituitary gland. The spontaneous regression of cystic sellar lesions is rare. The exact mechanism of the possible spontaneous involution of RCC is until now not well understood. However, spontaneous regression is possible and justifies the conservative therapy with regular clinical and radiological follow-up for asymptomatic patients or patients with symptoms not caused by the mass effect of these lesions.

Risk Factors for Adjacent Fractures After Cement-Augmented Thoracolumbar Pedicle Screw Instrumentation

ABSTRACT Background: The aim of our study was to identify factors that influence the occurrence of adjacent fractures in patients with cement-augmented pedicle screw instrumentation. Methods: Data were retrospectively collected from medical charts and operative reports for every surgery in which cement-augmented instrumentation was used in our hospital of 4 consecutive years. A total of 93 operations were included and examined for gender, age, T-score, number of fused segments, number of implanted screws, broken screws, loosening of screws, leakage and distribution pattern of cement, pre- and postoperative kyphosis angle, revision surgery and adjacent fractures in follow-up. Categorical data were compared using the χ2 test or by Fishers exact test, as appropriate. Continuous variables conforming to a normal distribution were compared using Students t test. Otherwise the Mann-Whitney U test was applied. A P-value of <.05 was considered statistically significant. A trend was defined as a P < .2. Results: The mean age was 68.1 years with a mean T-score of −3.12. Nineteen adjacent fractures occurred during follow-up and the median follow-up was 12 months (range, 1−27). Patients showed a higher risk for adjacent fractures following revision surgery (P = .016). Most fractures occurred superior to the instrumented level (P = .013) and in the first 12 months. Difference of T-score between the group “no adjacent fracture” and the group “adjacent fracture” was 0.7 (P = .138). Another trends were found in greater age (P = .119) and long instrumentations (P = .199). Conclusions and Clinical Relevance: Revision surgeries are associated with a higher risk of adjacent fractures. In these cases, prophylactic kyphoplasty of the superior vertebra should be considered. This study is a retrospective, nonrandomized cohort/follow-up study. Level of Evidence: 3.

Time course of the response to navigated repetitive transcranial magnetic stimulation at 10 Hz in chronic neuropathic pain

ABSTRACT Objective This prospective study evaluated the time to response and outcomes of navigated repetitive transcranial magnetic stimulation (TMS) at a frequency of 10 Hz in patients with chronic neuropathic pain. Methods This prospective study included patients with unilateral chronic neuropathic pain. All patients received motor cortex stimulation at 10 Hz over nine consecutive days using repetitive TMS. Outcome was evaluated over a six-week follow-up period using the visual analogue scale, the German Pain Questionnaire and time to pain reduction. Results Fifty patients (23 female, 27 male) were recruited. Two patients were excluded from analysis owing to premature discontinuation of treatment and follow-up. 31/48 patients in the cohort suffered from atypical facial pain. The pain duration ranged approximately from six months to 27 years. After six weeks, 28/46 patients reported a significant level of pain relief (P < 0.001). Conclusion Navigated repetitive TMS for chronic pain is a non-invasive modality with demonstrable clinical benefit. In particular, patients with atypical facial pain with a clear clinicoanatomical correlate responded well to high-frequency stimulation. Patients with a mean pain history of less than five years benefited significantly from this treatment, so early treatment with repetitive TMS should be encouraged.

Degenerative Spine Disease

Degenerative spine disease in patients older than 65 years becomes more and more an issue of interest in daily routine. The following chapter resumes pathogenesis and clinical and radiological aspects. We present possible therapeutic approaches including cervical and lumbar pathologies against the background of the actual scientific data.

Hätten Sie hier an eine Tbc gedacht

Eine 30-jährige Patientin aus Äthiopien stellte sich mit seit 14 Tagen andauernden, lokalisierten Rückenschmerzen und progredienter Paraparese der Beine vor. Gleichzeitig hatte sie Fieber sowie unproduktiven Husten. Was steckte dahinter?Eine 30-jahrige Patientin aus Athiopien stellte sich mit seit 14 Tagen andauernden, lokalisierten Ruckenschmerzen und progredienter Paraparese der Beine vor. Gleichzeitig hatte sie Fieber sowie unproduktiven Husten. Was steckte dahinter?