Carsten Neumann

Surgical management of symptomatic spinal metastases : Postoperative outcome and quality of life

STUDY DESIGN Eighty-six surgical interventions in 76 consecutive patients with symptomatic spinal metastases were reviewed retrospectively. OBJECTIVES To evaluate the postoperative outcome and quality of life of patients surgically treated for symptomatic spinal metastases. SUMMARY OF BACKGROUND DATA The standard surgical treatment for patients with symptomatic spinal metastases is anterior spinal cord decompression with stabilization. However, because therapy is only palliative, satisfactory quality of life and high patient acceptance are essential. METHODS The medical records of all patients were reviewed retrospectively. Furthermore, all surviving patients or the next of kin of deceased patients were interviewed by telephone, and the family doctors or the care-providing physicians of external institutions were contacted. RESULTS First-choice surgical treatment was anterior spinal cord decompression with stabilization. Postoperative mean survival was 13.1 months, and mean time at home after spinal surgery was 11.1 months. Neurologic improvement with regard to Frankel classification was observed in 58% of the patients, and 93% were able to walk postoperatively. Pain relief was noted in 89%. Overall, 67% of the patients achieved moderate or good general health as shown by the Karnofsky Index, and 80% were satisfied or very satisfied with the surgical intervention. Moreover, 19% of the surgical interventions were associated with complications, local tumor recurrence developed in 22% of the patients, and paraplegia ultimately developed in 18% of patients. CONCLUSIONS Surgical management of symptomatic spinal metastases, in particular anterior decompression, is of benefit in most metastatic lesions in terms of satisfactory postoperative outcome and quality of life. However, in patients with melanoma or lung carcinoma, the authors advocate spinal surgery only in very exceptional cases.

Thoracic spondylitis from a mycotic (Streptococcus pneumoniae) aortic aneurysm: a case report.

Study Design. We report on a 54-year-old man with chronic lower back pain after recent streptococcus pneumoniae pulmonary infection, resulting in a mycotic aortic aneurysm and spondylodiscitis of the eighth vertebrae 6 months later. Successful surgical treatment and recurrence-free survival after 4 years are described. Summary of Background Data. Osteomyelitis by Streptococcus pneumoniae of the spine combined with contained rupture of a mycotic aortic aneurysm into lung and spine has not been reported to date. Mycotic aneurysms with pulmonary fistulas are reported to carry a mortality rate of up to 100%. Few cases have been reported with different operative and conservative strategies. Methods. The mycotic aortic aneurysm was excised using extracorporeal circulation and replaced by a Dacron graft. The spondylitic section of the eighth thoracic vertebrae was radically resected, and a tricortical bone block from the iliac crest was inserted into the defect. To keep compartments separated, collagen sponges with antibiotic supplementation were used. A triple antibiotic therapy (Metronidazol 3 × 0.5 g/day, Cefotaxim 3 × 2 g/day, and Flucloxacillin 3 × 2 g/day) was prescribed for 6 weeks and changed to Clindamycin for 1 year thereafter. Results. The patient made a good recovery and is free of recurrence 4 years after surgery. Conclusions. Lower back pain might be a projected pain. Particularly in older patients or in the presence of comorbidities resulting in an immunocompromised status, an aggressive workup may be indicated. Radical resection of inflammatory tissues, sparse use of implant material, and prolonged administration of antibiotics proved a successful strategy in this patient.

Medical communication from emergency scenes using a notepad computer.

We have developed a communication system in which data are transferred from the scene of an emergency in the form of an electronic record on a notepad computer by means of a satellite link (MODACOM). The data are received at the dispatch centre and transferred to the admitting hospital automatically. In a prospective study of 53 emergencies the technical suitability of the system was investigated. First-sight information could be fed into the computer in 15 s and transmitted within 3 min of arrival on the scene. For 16 patients with life-threatening conditions, the admitting hospital was notified on average after 13.6 min (SD 6.0), whereas by conventional VHF radio it took 35.5 min (SD 8.9). In addition, more precise information about the patients condition was received at the hospital.

Value of 3D Reconstructions of CT Scans for Calcaneal Fracture Assessment

Background: The interpretation of CT scans for the evaluation of calcaneal fractures is difficult. Three-dimensional (3D) reconstruction (volume rendering technique [VRT]) has been valuable in the evaluation of irregularly shaped bones. However, their value for the analysis of calcaneal fractures is still debated. Therefore, the objective of this study was to assess the effect of additional use of 3D CTs in calcaneal fractures. Methods: In a prospective multicenter study, the CT data set of 5 different fractures was presented to 57 evaluators. First, the participating surgeons were asked to assess the fractures on the basis of axial, coronal, and sagittal reconstructions using a multiple-choice questionnaire. Second, 3D reconstructions (VRT) were presented. The CT scans were validated by the intraoperative findings and the results were compared to the model solution of 3 foot and ankle surgeons. Intra- and interrater reliabilities were calculated. Results: The proportion of intraobserver agreement was 82%, with Cohen kappa of κ = 0.748 (P < .001). Interrater agreement varied between 0.772 (P = .006) for the assessment of concomitant fractures and 0.987 (P < .001) for the suggested approach. The evaluation of several items improved after presentation of the 3D CTs (Cochrane Q test, P < .001). The benefit of 3D imaging was higher in inexperienced surgeons and complex fractures (Friedman test P < .001). Conclusion: The evaluation of CT scans of calcaneal fractures was improved by the additional use of 3D images (VRT). Level of Evidence: Level II, prospective comparative study.

Spinal fracture reduction with a minimal-invasive transpedicular Schanz Screw system: clinical and radiological one-year follow-up.

INTRODUCTION Surgical management of thoracolumbar trauma involves correction of posttraumatic deformity and placement of transpedicular instrumentation. The aim of this prospective cohort study was to generate first results reflecting the clinical and radiological outcome of patients treated with percutaneous dorsal instrumentation for fractures of the thoracic and lumbar spine with the use of a transpedicular new Schanz Screw system (USS Fracture MIS, DePuy Synthes). METHODS A total of 26 patients with fractures of the thoracic and lumbar spine were operatively treated with bi-segmental dorsal instrumentation between January and December 2012. Radiological data acquisition was performed pre- and postoperatively, after six weeks, three, six, and twelve months. The radiological parameter of interest was the bi-segmental kyphotic end plate angle (Cobb angle). The Chronic Disability Index (CDI), the Oswestry Disability Index (ODI), and the Spine Tango Core Outcome Measurement Index (COMI) were applied to investigate the clinical outcome. RESULTS The clinical follow-up was completed by 22 patients (84.6%), and the radiological follow-up by 21 (80.8%) patients. Our patient population had a mean age of 47.4 ± 4.1 years. Twelve patients received dorsal instrumentation, and 14 patients were treated with an additional ventral reconstruction. Intraoperative reduction was 11.5 ± 1.5° among all patients (p < 0.01). A considerable amount of the operative correction was lost after six weeks with a loss of reduction of 4.6 ± 1.4° (p < 0.01). At one year follow-up, the measured loss of reduction was significant in comparison to the postoperative state, 6.9 ± 1.3° among all patients, 8.7 ± 2.1° after dorsal and 4.9 ± 1.1° after dorsoventral stabilisation (all p < 0.01). Moreover, all patients had minimal to moderate disability with a CDI of 1.8 ± 0.4 (0 - 7), and an ODI of 15.6 ± 3.6 (0 - 60). CONCLUSION The new transpedicular Schanz screw system can deliver a correction and stabilization of thoracic and lumbar spine fractures. Patients report minimal to moderate disability as a result of their severe injury one year after trauma. We advocate the use of the transpedicular Schanz screw system to correct posttraumatic kyphotic deformity, with secondary anterior fusion in our treatment strategy of thoracolumbar incomplete burst fractures in patients without a neurologic deficit.

Post-traumatic fulminant paradoxical fat embolism syndrome in conjunction with asymptomatic atrial septal defect: a case report and review of the literature

IntroductionFat embolism syndrome with respiratory failure after intramedullary nailing of a femur fracture is a rare but serious complication in trauma patients.Case presentationWe present the case of a 20-year-old Caucasian man who experienced paradoxical cerebral fat embolism syndrome with fulminant progression after intramedullary nailing of a femur fracture, in conjunction with a clinically asymptomatic atrial septal defect in a high position resulting in a right-to-left shunt.ConclusionFat embolism syndrome may occur as a fulminant complication following femoral fracture repair in the presence of a concomitant atrial septal defect with right-to-left shunt. Thus, in patients with cardiac right-to-left shunts, femurs should not be nailed intramedullary, not even in cases of isolated injuries.

Operative Versorgung einer Acetabulumfraktur in der Schwangerschaft

ZusammenfassungWir berichten über eine Patientin, die sich, in der 23.Woche schwanger, im Rahmen eines Verkehrsunfalls eine Acetabulumfraktur zuzog, die 6 Tage nach Trauma operativ versorgt wurde; 1 1/2 Jahre nach dem Unfall ist die Mutter klinisch beschwerdefrei, das Kind entwickelte sich unauffällig und es besteht keinerlei Anhalt für eine Schädigung.Aufgrund dieses Falls sowie der entsprechenden Literatur sehen wir die operative Versorgung einer Acetabulumfraktur in der Schwangerschaft bei bestehender Indikation als die Methode der Wahl an, da sie für die Mutter zweifellos die beste Behandlung darstellt und gleichzeitig für Mutter und Kind mit nur minimalem Risiko einhergeht.AbstractWe report about a case of a pregnant women in the 23rd gestation week who sustained an isolated acetabular fracture in a car accident. The fracture was treated surgically by open reduction and internal fixation 6 days after trauma.The outcome for the mother and the baby was excellent; both could be followed up for 1.5 years.The baby did not suffer from any disease related to the diagnostic or surgical procedures.We conclude from this case and from reviewing the literature that the operative fixation of an acetabular fracture during pregnancy is the appropriate treatment with minimal risk for the unborn child and best outcome for the mother.

Pediatric Cervical Spine Injuries: A Rare But Challenging Entity.

Background: Injuries to the cervical spine in pediatric patients are uncommon. A missed injury can have devastating consequences in this age group. Because of the lack of routine in diagnosis and management of pediatric cervical spine injuries (PCSI), each of these cases represents a logistic and personal challenge. Methods: By means of clinical cases, we demonstrate key points in diagnostics and treatment of pediatric spine injuries. We highlight typical pediatric injury patterns and more adult-like injuries. Results: The most common cause of injury is blunt trauma. There is an age-related pattern of injuries in pediatric patients. Children under the age of 8 frequently sustain ligamentous injuries in the upper cervical spine. After the age of 8, the biomechanics of the cervical spine are similar to adults, and therefore, bony injuries of the subaxial cervical spine are most likely to occur. Clinical presentation of PCSI is heterogeneous. Younger children can neither interpret nor communicate neurological abnormalities, which make timely and accurate diagnosis difficult. Plain radiographs are often misinterpreted. We find different types of injuries at different locations, because of different biomechanical properties of the immature spine. We outline that initial management is crucial for long-term outcome. Conclusions: Knowledge of biomechanical properties and radiographic presentation of the immature spine can improve the awareness for PCSI. Diagnosis and management of pediatric patients after neck trauma can be demanding. Level of Evidence: Level IV.

Telemedizin zur Verbesserung der Patientenversorgung in der Unfallchirurgie

ZusammenfassungDie steigende Komplexität der Leistungsprozesse in der Medizin erfordert einen schnelleren und konsistenteren Informationsfluss, gerade zwischen entfernt gelegenen Versorgungseinrichtungen. Das Regensburger Modell, eine Realisation „schlanker“ Telemedizin aus dem Low-cost-Bereich unter Verwendung PC-basierter Videokonferenzsysteme, zeigt die Nutzung moderner Telekommunikation speziell im unfallchirurgischen Umfeld. Bei 203 prospektiv evaluierten Telekonsilen wurden zwischen 15 Teilnehmern insgesamt 697 Bilder per Videokonferenz verschickt. In 95% des traumatologischen Krankenguts wurde das Befundmaterial qualitativ als mindestens ausreichend beurteilt. In einer projektbegleitenden Evaluation konnten die Effizienz dieser Systeme sowie auch deren Nutzen gezeigt werden. Einsparungen an Transportkosten in einer Höhe bis zu 4400 DM pro Fall konnten erzielt werden. Durch einen schnelleren Informationsfluss resultierten Qualitätsverbesserungen für alle Beteiligten. Auf dem Boden dieser Überlegungen entsteht in Regensburg eine weiterführende Kommunikationsplattform als abgeschlossenes medizinisches Netzwerk für die Region Ostbayern.AbstractThe increasing complexity of performance processes in medicine requires a quicker and more consistent flow of information, especially between health care sites that are far distant from each other. The Regensburg model, a realisation of lean telemedicine from the low-cost domain using PC-based standard videoconferencing systems, shows the use of modern telecommunications specifically in trauma surgery. In 203 prospectively evaluated teleconsultations with 15 persons taking part, a total of 6597 images were transmitted via videoconferencing. In 95% of the trauma cases concerned the material transmitted was judged to be at least sufficient. In an evaluation parallel to the project the efficacy of these systems and their benefit were clearly demonstrated. ¶Savings of up to 4400 DM per case were achieved on transportation costs. The faster flow of information resulted in qualitative improvements for all parties concerned, and some considerable costs of health care were avoided or lowered. Based on these thoughts, a new communication platform will be established in Regensburg as a closed medical intranet for the administrative region of eastern Bavaria.

The regensburg protocol for spinal metastases

Metastases to the vertebrae are a common problem in the practice of a spine surgeon. Therapeutic intervention can alleviate pain, preserve or improve neurologic function, achieve mechanical stability, optimize local tumor control, and improve quality of life. Treatment options available for metastatic spine tumors include radiation therapy, chemotherapy and surgery. This article is focused on the decision making for spine surgeons and shows the protocol to treat spinal metastases at the University Hospital of Regensburg, Germany.