P. Eysel

Degenerative lumbar spinal stenosis. Long-term results after undercutting decompression compared with decompressive laminectomy alone or with instrumented fusion.

Abstract The aim of the study was to evaluate the long-term outcome of various surgical procedures for lumbar spinal stenosis. Operations were performed on 117 consecutive patients for lumbar spinal stenosis between 1987 and 1992. Pre- and intraoperative data were recorded in a standardized manner. Three treatment groups were distinguished: group I consisting of 39 patients submitted to undercutting decompression; group II, 51 patients, submitted to laminectomy and foraminal decompression alone; and group III, 27 patients, who underwent foraminal decompression and laminectomy with instrumented fusion. Eight years (5–10 years) after surgery a questionnaire was mailed to the patients containing the outcome scales according to Greenough and Fraser [6] and Turner et al. [22] together with questions about residual pain, necessity of treatment and satisfaction with the operative outcome. A total of 72 questionnaires (61.6%) gave enough information for analysis. After a mean follow-up of 8 years, walking capacity had increased significantly in all groups (P<0.001). Compared to preoperative values, pain had decreased significantly in all groups (P<0.01). In group I 36% had good-to-excellent outcomes, and 30.8% and 23.8% in groups II and III (P>0.05). Forty percent of group I patients were unsatisfied with the result, compared to 38.4% and 33.3% in the other groups (P>0.05). Overall, 25 of 72 patients (34.7%) had severe constant back and/or leg pain requiring daily administration of analgesics. We conclude that the long-term outcome of decompressive surgery of the lumbar spinal canal, without and with instrumented fusion, is less favourable than was previously reported.

Outcome after palliative posterior surgery for metastatic disease of the spine--evaluation of 106 consecutive patients after decompression and stabilisation with the Cotrel-Dubousset instrumentation.

Abstract From 1987 to 1996, 106 consecutive patients with metastatic disease of the spine who underwent palliative decompression from a dorsal approach and subsequent stabilisation with Cotrel-Dubousset instrumentation (CDI) were followed prospectively, and independent of the surgeons. Parameters evaluated were neurological function, perioperative complications, survival and rehabilitation. Following the Frankel system for the assessment of neurological disorder, 33 patients had a major deficit (grade A, B or C), 23 a minor deficit (grade D) and 50 no deficit. If there was no neurological dysfunction, the only patients who underwent operation were those graded as class IV according to Harrington. Our surgical strategy combined posterior decompression of the spinal cord followed by CD stabilisation without bone grafting. Of 56 patients who had a neurological deficit preoperatively, 35 enjoyed complete or partial recovery within the first 3 months after the operation. Of the 50 patients without neurological dysfunction, 3 developed an incomplete transient paresis. The rate of survival was 72% (76 of 106) ¶at 6 months and 50% (53 of 106) at 12 months. At 12 months 42 of the 53 patients who were alive were still able to walk. All but 13 patients were able to return home. Overall survival time was 19.2 months, with 5 patients still alive. Six patients required re-operation for tumour recurrence at the same or at a new level. The results of this study show that neurological function, pain level and mobility can be enhanced by decompression and stabilisation through a posterior approach.

Decompression/stabilization of the metastatic spine. Cotrel-Dubousset-Instrumentation in 50 patients.

50 patients with metastatic disease of the spine underwent dorsal decompression and stabilization with the Cotrel-Dubousset-Instrumentation from 1987 to 1991. Indications for surgical treatment were neurologic deficit, spinal instability, and/or pain resistant to medical or radiation treatment. No external orthotics were used postoperatively. Pain was relieved dramatically in 45 patients. Among 25 patients suffering from neurologic deficit preoperatively, 13 improved, 15 remained unchanged, whereas 2 developed an incomplete, transient paraplegia. 15 (7) patients were alive after 1 (2) years. Postoperative complications were frequent, but there were only 2 failures of the stabilization device requiring reoperation.

Gait analysis in idiopathic scoliosis before and after surgery: a comparison of the pre- and postoperative muscle activation pattern

Abstract In a prospective experimental study the level gait activity scores of the iliocostalis lumborum, glutaeus medius, tensor fasciae latae, vastus lateralis and peronaeus longus muscles of both body sides were examined by computerized electromyography in 23 patients with idiopathic scoliosis before and after CD instrumentation. The pre- and postoperative findings were examined as to asymmetric patterns in muscle requisition during gait and the respective changes induced by the spinal correction. These results were compared with the corresponding results obtained in healthy subjects in two independent sessions with identical experimental conditions. A muscle activity asymmetry coefficient was defined to quantify the degree of left/right muscle activation asymmetry observed. Postoperatively a statistically significant reduction (P < 0.05) of a preoperatively strongly increased activity was found in the lumbar muscles of the convex side of double major scolioses as well as in the glutaeus medius and tensor fascia lata muscles of the concave side of thoracic curvatures. Both the casuistic and statistical analysis of the results of our study support the hypothesis that activity asymmetries observed in the paravertebral musculature in idiopathic scoliosis patients are the result of the scoliotic body deformities, with consequent asymmetries in the biomechanical force patterns of body postures and body motions, rather than an aetiological factor of scoliotic curvatures.

Sagittal static imbalance in myelomeningocele patients: improvement in sitting ability by partial and total gibbus resection.

Abstract The progression of kyphosis in myelomeningocele is independent of skeletal growth and requires early operative correction and stabilization to prevent a loss of sitting ability. In severe cases, only vertebrectomy makes it possible to achieve correction, stability and skin-closure without tension. In 14 patients with myelomeningocele gibbus, kyphectomy was performed, removing two vertebral bodies on average. The average kyphosis angle decreased from 128° to 81°, enabling most of the patients to participate again in social life by restoring wheelchair mobility. Nevertheless, a significantly higher complication rate was found compared to other correctional operations, lengthening the average hospital stay to 41 days. Special problems arose from trophic disorders of the skin and soft tissue and from the dystrophic muscles below the level of neural malfunction. In three cases, kyphosis reappeared cranial to the fused segments, requiring ventral stabilization. With respect to increasing kyphosis angle, an early intervention should be aimed at. A secondary operation can be necessary, if surgery is performed without taking care of the growth potential.

Metastatic instability at the proximal end of the femur

A retrospective study was performed of the surgical treatment of metastatic lesions of the proximal femur in 50 patients. In 25 consecutive cases a megaprosthesis was implanted; compound plate osteosynthesis was performed in another 25 consecutive patients. Indications for surgical treatment were pathological fractures or, for prophylactic treatment, lesions of the femoral cortex exceeding 2.5 cm in diameter or affecting half the diameter of the bone or more. In all patients capable of walking preoperatively mobility was regained. Immediate full weight-bearing stability was obtained in all patients. Group analysis showed that the functional rating of the hip joint was unchanged, i.e., good or excellent, in all patients with compound osteosynthesis, compared to only 68% in the endoprosthesis group. Pain relief was excellent or good in 84% and 88% respectively. Dislocation of the tumor prosthesis occurred in 3 patients. Closed reduction was possible in 2 cases. Local recurrence was higher in the patients undergoing plate osteosynthesis, as was the frequency of tumor-related implant failure. Postoperative survival averaged 14.7 months and 12.1 months respectively.

Development of scoliosis in myelomeningocele: differences in the history caused by idiopathic pattern

The natural history of scoliosis in the literature concerning the idiopathic and neuromuscular scoliosis in myelomeningocelet patients (MMC) are compared to our own results in 12 patients with MMC and 89 patients operated because of an idiopathic scoliosis. According to known experiences the natural history of scoliosis in MMC is progression even after the end of growth. The chance of developing a scoliosis increases with the patients, age and the level of the lesion. The higher the level of paralysis the more common is a spinal deformity. In literature the progression rate of MMC scoliosis is 2,5–3,5° per year, with the idiopathic pattern 0,5–0,65° per year after end of growth. Our own results of surgically treated patients show a rate of progression of 6,2° per year in MMC. The surgical treatment must start before a severe spinal deformity has developed because of the higher rate of operative complications.

Epithelioides Hämangioendotheliom der Wirbelsäule

ZusammenfassungHintergrund: Epithelioide Hämangioendotheliome sind seltene vaskuläre Tumoren, die bevorzugt im Bindegewebe, in der Lunge oder in der Leber auftreten. Falldarstellung: Wir präsentieren den Fall einer 58-jährigen Patientin, die mit oberer Einflussstauung, Horner-Syndrom und segmentalen Sensibilitätsstörungen in den Fingern der rechten Hand aufgenommen wurde. Die daraufhin durchgeführten Computertomographie- und Magnetresonanztomographieuntersuchungen der Wirbelsäule zeigten eine tumoröse Raumforderung vom siebten Halswirbelkörper bis zum vierten Brustwirbelkörper. Wegen rascher Tumorprogression mit progredienter oberer Einflussstauung und neurologischen Ausfällen musste die Patientin wiederholt operiert werden. Eine Tumorexstirpation in sano war aufgrund der ausgeprägten Infiltration mit Kompression der oberen Hohlvene nicht möglich, und die Patientin verstarb 4 Wochen nach der zweiten Operation. Die histologischen Untersuchungen ergaben die Diagnose epithelioides Hämangioendotheliom, ausgehend vom ersten Brustwirbelkörper mit Infiltration des Umgebungsgewebes. Schlussfolgerung: Vor allem die Lokalisation des lokal destruierenden epithelioiden Hämangioendothelioms entscheidet über die Prognose. Bei fortgeschrittenem Befall und fehlender chirurgischer Resektabilität in sano muss auch mit infausten Verläufen gerechnet werden. Daher kommt eienr frühen Berücksichtigung des epithelioiden Hämangioendothelioms in der Differentialdiagnose unklarer Knochenläsionen eine entscheidende Bedeutung zu.AbstractBackground: Epithelioid hemangioendotheliomas are rare vascular tumors, mostly originating from soft tissue, lungs or liver. Case Report: A 58-year-old woman was admitted to hospital because of upper congestion. Horners syndrome and segmental sensory disturbance. MRI of the spine showed a spinal mass, reaching from the seventh cervical vertebra to the fourth chest vertebra. Because of worsening of upper congestion and progressive neurological impairment, the patient had to be operated twice. Unfortunately a surgical excision of the infiltrating tumor in sano was not possible and the patient died 4 weeks after the second operation. Histologic examination revealed the diagnosis of infiltrating epithelioid hemangioendothelioma, originating from the first chest vertebra. Conclusion: Prognosis of epithelioid hemangioendothelioma is mainly determinated by its location. In advanced stages of diseases or lack of surgical cure epithelioid hemangioendotheliomas may be fatal. Therefore epithelioid hemangioendotheliomas should be considered early in the differential diagnosis of patients with uncertain bone lesions.

Chronische Insertions- tendopathie am lateralen Epicondylus humeri

ZusammenfassungFragestellung: Seit Beginn der 90er Jahre wurde in der Orthopädischen Universitätsklinik Mainz überprüft, bei welchen Krankheitsbildern die niederenergetische extrakorporale Stoßwellentherapie sinnvoll eingesetzt werden kann. Methode: In einer prospektiv-randomierten Studie wurde die Wirksamkeit der 3maligen Applikation von 1000 vs. 10 Impulsen niedriger Energieflußdichte bei chronischer Epicondylopathia humeri radialis überprüft. Ergebnisse: Sehr gute oder gute Ergebnisse lagen nach einem Follow-up von 12 Monaten bei 26 von 50 Patienten der Behandlungsgruppe vor, aber lediglich bei 3 der Kontrollgruppe. Schlußfolgerungen: Zusammenfassend läßt sich sagen, daß die Methode bei entsprechender restriktiver Indikationsstellung aus der klinischen Erprobung in den Praxisalltag entlassen werden kann.AbstractAim: This review article focuses on a possible pain-alleviating effect of shock-wave application in persistent lateral epicondylopathy of the elbow and compares the effects with data on other non-operative and operative procedures. Methods: Patients who suffered from chronic tennis elbow for more than 12 months and were therefore referred for a surgical procedure were assigned at random to two groups of low-energy shock-wave therapy. Group I received a total of 3000 (3×1000) impulses of 0.08 mJ/mm2, while group II (control group) received a total of 30 (3×10) impulses of 0.08 mJ/mm2. Follow-up examinations were carried out after 3, 6, and 24 and 52 weeks. Results: There was a significant improvement of pain and function in group I, with a good or excellent outcome in 52% of cases compared to 6% in group II at the last evaluation. Conclusion: Extracorporeal shock-wave application has a dose-dependent pain-relieving effect on chronic tendopathy of the lateral elbow.

Anterior spondylosis of the cervical spine causing dyspnea and sleep disturbance

BACKGROUND Cervical osteochondrosis is a rare differential diagnosis leading to dysphagia, inspiratory stridor and obstructive sleep apnea syndrome (OSAS). PATIENTS AND METHODS We report six cases of patients with episodes of neck pain (n=6), pain reflected to the arm (n=1), sleep apnea (n=5), inspiratory stridor (n=3) and/or unclear dysphagia (n=6), who presented between 2000 and 2003 at the Römerwallklinik Mainz and the university hospitals of Mainz and Cologne. None of these patients had symptoms of spinal or radicular compression. All underwent otorhinolaryngological and radiological examination followed by excision of anterior spondylophytes and intervertebral fusion. One patient required immediate tracheotomy due to perforation of the pharyngeal wall associated with severe supraglottic swelling. RESULTS All patients were free of inspiratory stridor postoperatively. Symptoms of dysphagia disappeared in four patients and were reduced in two. Three of five patients were free of apnea. OSAS had improved in two. Neck pain was eliminated in four cases and markedly improved in two cases. CONCLUSIONS In case of symptoms of pharyngeal compression and OSAS, a vertebragenic cause should be considered.