Jürgen Krämer

The Long-term Clinical Sequelae of Incidental Durotomy in Lumbar Disc Surgery

Study Design. A retrospective, long-term follow-up study. Objectives. To find out whether incidental durotomy in lumbar disc surgery is associated with long-term sequelae. Summary of Background Data. Incidental durotomy is a frequent complication during spinal surgery. Little is known about the clinical long-term outcome. Methods. The study population comprised 1,280 patients who underwent standard discectomy of a lumbar disc herniation. A total of 41 patients with incidental durotomies (Group A) were compared with a control group (n = 41) (Group B) matched for age, sex, spinal level, and duration of follow-up. After a mean follow-up period of 10.2 years (Group A) or 10.3 years (Group B), the patients reported complaints, headache, and low back or leg pain. The patients’ activity was assessed by means of a questionnaire concerning hindrance in daily activities, the Tegner score for general activities in daily life, and the Hannover Functional Ability Questionnaire for Measuring Back Pain-Related Functional Limitations (FFbH–R). The frequency of reoperation and the intake of analgesics were included. Furthermore, the patients’ inability to work, change of profession, and retirement were registered. Results. Patients with incidental durotomy had a poorer outcome after surgery. The Tegner score was significantly decreased for the group with dural tears. Furthermore, significant more patients with incidental durotomy complained about headaches after surgery. A strong tendency for worse outcome in Group A was shown in regard to reported complaints and daily activity. The patients with incidental durotomy had a tendency to more reoperations, a longer duration of inability to work, more back-pain, and functional limitations related to back-pain (FFbH-R). Conclusion. Our study revealed that incidental durotomy in lumbar disc surgery was associated with long-term clinical sequelae. We therefore conclude that dural tears bring about poor clinical outcome at the long-term follow-up.

Percutaneous lumbar discectomy in the treatment of lumbar discitis

Lumbar disc infection, either after surgical discectomy or caused by haematogenous spread from other infection sources, is a severe complication. Specific antibiotic treatment has to be started as soon as possible to obtain satisfactory results in conservative treatment or operative fusion. The aim of this study was to analyse 16 cases of lumbar disc infection, treated with percutaneous lumbar discectomy (PLD) to obtain adequate amounts of tissue for histological examination and microbial culture. Between 1990 and 1994, 26 patients with vertebral osteomyelitis were treated. Sixteen patients, with an average age of 41.4 years (range 14–59 years), underwent a diagnostic PLD. Eight of them showed only moderate changes on computed tomograms (CT scans) and magnetic resonance (MR) images in the initial stages of the disease. The other eight showed more or less extensive osteolytic lesions of one or both vertebral bodies adjacent to the involved disc. The histology results showed non-specific discitis in nine patients and tuberculosis in one. In two patients an open biopsy had been performed, which showed non-specific discitis. Microbiological analysis revealed specific infection in 45% of the patients. These patients received a specific antibiotic treatment after antibiogram for an average of 33 days. Only three patients were treated surgically, with evacuation of the disc space and interbody fusion; the whole group received a spondylitis brace. All patients obtained satisfactory clinical results at the last follow-up regarding pain, mobility and spontaneous fusion of the involved disc space. In conclusion, PLD is a very helpful minimally invasive procedure in conservative treatment of lumbar discitis.

Lumbar micro disc surgery with and without autologous fat graft

Abstract Epidural scarring is one of the possible complications after lumbar disc surgery. Perineural scar tissue has been considered responsible for recurrent neurological symptoms in patients operated on for disc herniation and leads to a high rate of unsatisfactory results. In addition, postoperative scars may increase the technical difficulty and risk of subsequent procedures. Various materials have been used in animal studies to try to affect the degree of epidural scar tissue with controversial results. In particular, free fat transplantation has been described to reduce the degree of intraspinal scar tissue. We therefore performed a prospective, double-blind, randomized study comparing clinical and social factors of patients being operated on for the first time for lumbar disc herniation. A total of 92 patients received an implantation of autologous fat graft, 94 did not. After a median of 24.2 months after their surgery, an objective examinator compared various clinical parameters and the social situation of patients in both groups without knowing the operation method used. We found no significant differences between the fat-graft group and the control group regarding either the clinical outcome or the social aspects.

Verification of the position of pedicle screws in lumbar spinal fusion

Medial or lateral pedicle screw penetration with the potential to affect neural structures in a well-known and frequent problem associated with posterior spinal fusion. We evaluated the placement of pedicle screws (n = 141) in 36 patients following posterior lumbar spinal fusion with Socon or Kluger instrumentation via a lateral transpedicular approach. The examination was based on CT and MR images performed after removal of the instrumentation, on average 1 year after implantation. We found seven pedicle screws with lateral cortical penetration of the pedicle and five screws with medial cortical penetration of the pedicle (8.5% pedicle penetration overall). No severe radicular complications accompanied these pedicle penetrations. The mean insertion angles of the pedicle screws at the L4 level were 22.6° and 23.1° for the left and the right side, respectively. At the L5 level the mean insertion angle was 20.5° on the left side and 21.5° on the right, and at the S1 level the mean angle was 16.2° on the left and 15.2° on the right. The results of this study indicate that the lateral transpedicular approach is a safe procedure for pedicle screw insertion.

Efficacy and safety of acupuncture for chronic pain caused by gonarthrosis: A study protocol of an ongoing multi-centre randomised controlled clinical trial [ISRCTN27450856]

BackgroundControlled clinical trials produced contradictory results with respect to a specific analgesic effect of acupuncture. There is a lack of large multi-centre acupuncture trials. The German Acupuncture Trial represents the largest multi-centre study of acupuncture in the treatment of chronic pain caused by gonarthrosis up to now.Methods900 patients will be randomised to three treatment arms. One group receives verum acupuncture, the second sham acupuncture, and the third conservative standard therapy. The trial protocol is described with eligibility criteria, detailed information on the treatment definition, blinding, endpoints, safety evaluation, statistical methods, sample size determination, monitoring, legal aspects, and the current status of the trial.DiscussionA critical discussion is given regarding the considerations about standardisation of the acupuncture treatment, the choice of the control group, and the blinding of patients and observers.

Bandscheibenvorfall und Trauma

ZusammenfassungDie gutachterliche Beurteilung eines ursächlichen Zusammenhangs zwischen Bandscheibenvorfall und Trauma ist schwierig. Zu berücksichtigen ist der individuelle Vorschaden und das traumatische Ereignis, das zur typischen Beschwerdesymptomatik führte. Angesichts der weiten Verbreitung degenerativer Wirbelsäulenveränderungen mit der Volkskrankheit “Rückenschmerz” kommt es bei der Begutachtung des Vorschadens auf die Erheblichkeit an.Bei der Beurteilung des traumatischen Ereignisses sind zielgerichtete und bewusste Bewegungsabläufe von unvorhergesehenen und plötzlichen Einwirkungen auf die Wirbelsäule zu differenzieren. Nur wenn die TRIAS: adäquates Trauma, vorherige Beschwerdefreiheit und sofortiges Einsetzen der Beschwerden erfüllt ist, kann ein Unfallzusammenhang des Bandscheibenvorfalls anerkannt werden.AbstractIt is difficult to find medical evidence of a correlation between a lumbar disk disease and trauma. One should consider whether the individual degeneration of lumbar disks or the trauma lead to the typical complaints. Disk disease in the population are very common. Therefore the relevance of the individual affection before trauma has to be considered.Spinal trauma with its sudden, incidental onset needs to be differentiated from purposeful and conscious movements. An intervertebral disk disease can be classified as accident related only in cases involving adequate trauma, with no previous complains, and a sudden onset of pain.

[Effective pain relief facilitates exercise therapy : Results of a multicenter study with controlled-release oxycodone in patients with movement pain].

BACKGROUND The efficacy and tolerability of oral controlled-release oxycodone in the therapy of musculoskeletal pain were analyzed in this observational study. PATIENTS AND METHODS A total of 843 patients with severe to most severe pain in the musculoskeletal system were treated with controlled-released oxycodone for 4 weeks or up to a maximum of 6 months. Severity of pain, impairment in quality of life, and mobility associated with the pain were assessed before and during therapy with controlled-release oxycodone by a numerical rating scale (NRS 0-10). RESULTS Pain intensity fell by an average of 65% within the first 4 weeks. Physical therapy was practicable in many patients only after implementation of a therapy regime with controlled-release oxycodone. Quality of life improved significantly under therapy with oxycodone, and the impairment of different aspects of life decreased by 50%. CONCLUSION The therapy of pain of the musculoskeletal system with controlled-release oxycodone is efficient. An effective pain relief makes physical therapy practicable, reduces the impairment in different parts of life, and increases quality of life.

Effektive Schmerzlinderung ermöglicht Bewegungstherapie

BACKGROUND The efficacy and tolerability of oral controlled-release oxycodone in the therapy of musculoskeletal pain were analyzed in this observational study. PATIENTS AND METHODS A total of 843 patients with severe to most severe pain in the musculoskeletal system were treated with controlled-released oxycodone for 4 weeks or up to a maximum of 6 months. Severity of pain, impairment in quality of life, and mobility associated with the pain were assessed before and during therapy with controlled-release oxycodone by a numerical rating scale (NRS 0-10). RESULTS Pain intensity fell by an average of 65% within the first 4 weeks. Physical therapy was practicable in many patients only after implementation of a therapy regime with controlled-release oxycodone. Quality of life improved significantly under therapy with oxycodone, and the impairment of different aspects of life decreased by 50%. CONCLUSION The therapy of pain of the musculoskeletal system with controlled-release oxycodone is efficient. An effective pain relief makes physical therapy practicable, reduces the impairment in different parts of life, and increases quality of life.

Microdiscectomy for lumbar disc herniation

Surgical Principles One-level herniated or sequestrated disc material in the lumbar spinal canal is removed through a 3 cm long incision using a speculum shaped muscle retractor (speculum) and specially angulated microsurgical instruments. The surgical field is illuminated with a headlight if surgery is not performed with a microscope.

Spondylolyse und Spondylolisthese

Das Phänomen des Wirbelgleitens wurde erstmals 1782 von Herbinaux als Hindernis im Geburtskanal beschrieben. Es dauerte jedoch noch fast ein Jahrhundert bis die Wirbelkörperverschiebung von Kilian 1854 als Spondylolisthesis bezeichnet wurde [26]. Der Begriff Spondylolisthese ist hergeleitet aus den griechischen Worten “spondylos” (Wirbelkörper) und “olisthesis” (Gleiten). Robert beschrieb 1855 als Ursache dieses Gleitens eine Schädigung im Bereich der pars interarticularis. Im gleichen Jahr hatte Lambl die Spondylolyse als Defekt der pars interarticularis ohne Wirbelkörperverschiebung beschrieben. Neugebauer zeigte dann 1881, daß die Ventralverschiebung des Wirbelkörpers auf einer Elongation der pars interarticularis beruhen kann [25].Die Spondylolyse ist eine Spaltbildung in der Interartikularportion des Wirbelbogens. In deren Folge kann eine sogenannte Spondylolisthesis – ein Wirbelgleiten – auftreten. Hierbei handelt es sich um das Gleiten eines Wirbelkörpers nach ventral (Abb. 1)Die verbreitetste aktuelle Klassifikation für die Anterolisthesis geht auf Wiltse, Newman und Macnab [42] zurück und unterscheidet eine dysplastische, isthmische, degenerative, traumatische und pathologische Spondylolisthese. Diese Einteilung wurde 1989 durch Wiltse und Rothmann [45] modifiziert und durch eine post-operative Gruppe ergänzt.Fazit: Spondylolyse ist eine Spaltbildung in der Interartikularportion des Wirbelbogens. Sie besteht bei 4,5% der Kinder im Alter bis zu 6 Jahren und bei 6% der Erwachsenen. Bei Leistungssportlern mit wiederholter Lordosierung der Lendenwirbelsäule ist die Rate bis auf 50% erhöht. In Folge einer Spondylolyse kann eine Spondylolisthese auftreten. Die Spondylolisthese ist ein Wirbelgleiten nach ventral.Viele Spondylolysen und Spondylolisthesen bestehen ohne jegliche Beschwerden. Die Notwendigkeit und Art der Behandlung ist vom Alter des Patienten, der Beschwerdesymptomatik und den Auswirkungen auf die Körperstatik abhängig. Bei einer Beschwerdesymptomatik ohne relevante neurologische Ausfälle steht die konservative Therapie, mit Muskelkräftigung und physikalischen Anwendungen sowie ggfs. Ruhigstellung im Gips beziehungsweise Korsett, ganz im Vordergrund. Ausnahmen bilden hier nur weit fortgeschrittene und progrediente Spondylolisthesen. Die operativen Maßnahmen orientieren sich an der Beschwerdeursache.Im Jugendalter steht gewöhnlich die Stabilisierung im Vordergrund. Diese sollte möglichst interkorporell durchgeführt werden. Im Erwachsenenalter, mit vermehrt degenerativen Veränderungen, sind Dekompressionen nervaler Strukturen häufiger notwendig. Aber auch gerade nach Dekompressionen ist häufig eine Stabilisierung mit Durchführung einer Spondylodese indiziert.