Ralph Kayser

Analysis of IL-17 + cells in facet joints of patients with spondyloarthritis suggests that the innate immune pathway might be of greater relevance than the Th17-mediated adaptive immune response

IntroductionIn this study, we analysed the number of IL-17+ cells in facet joints, in the peripheral blood (PB) and synovial fluid (SF) of spondyloarthritis (SpA) patients and compared these results with those of patients with other rheumatic diseases and controls.MethodsImmunohistochemical analysis of IL-17+ cells was performed in facet joints of 33 ankylosing spondylitis (AS) patients and compared with data from 20 osteoarthritis (OA) patients. The frequency of IL-17+CD4+ T cells in PB and SF of SpA patients (PB n = 30, SF n = 11), rheumatoid arthritis (RA) patients (PB n = 14, SF n = 7), OA patients (PB n = 10) and healthy controls (PB n = 12) was analysed after stimulation with Staphylococcus aureus Enterotoxin B and phorbol 12-myristate 13-acetate/ionomycin and quantified by flow cytometry.ResultsIn AS facet joints, the frequency of IL-17-secreting cells was significantly higher than in samples obtained from OA patients (P < 0.001), with a slight predominance of IL-17+ cells among the mononuclear cells (61.5% ± 14.9%) compared to cells with polysegmental nuclei. Immunofluorescence microscopy revealed that the majority of IL-17+ cells were myeloperoxidase-positive (35.84 ± 13.06/high-power field (HPF) and CD15+ neutrophils (24.25 ± 10.36/HPF), while CD3+ T cells (0.51 ± 0.49/HPF) and AA-1+ mast cells (2.28 ± 1.96/HPF) were less often IL-17-positive. The frequency of IL-17+CD4+ T cells in the PB and SF of SpA patients did not differ significantly compared to RA patients, OA patients or healthy controls.ConclusionsOur data suggest an important role for IL-17 in the inflammatory processes in AS. However, the innate immune pathway might be of greater relevance than the Th17-mediated adaptive immune response.

Ultrasonographic imaging of fractures of the clavicle in newborn infants

Fractures of the clavicle in the neonate are usually diagnosed by clinical examination and confirmed by plain radiography. Exposure of newborn infants to irradiation should be avoided if possible. Following the clinical examination of 2978 neonates, 15 had suspected fractures of the clavicle. All were confirmed by ultrasound. In combination with clinical examination, ultrasound is a satisfactory alternative to radiological assessment for the diagnosis of fractures of the clavicle in newborn children.

Loads on a telemeterized vertebral body replacement measured in two patients.

Study Design. The loads acting on a vertebral body replacement (VBR) were measured in vivo. Objective. To measure the implant loads for different activities within the first 6 months after surgery. Summary of Background Data. Mathematical models exist for predicting spinal loads for various activities. The intradiscal pressure has been measured in vivo for many activities. Loads on internal spinal fixation devices have been measured in 10 patients. However, only little information exists regarding the loads acting on a VBR. Methods. Telemeterized VBRs were implanted into 2 patients with a fractured L1 vertebral body. The implant allows the in vivo measurement of 3 force and 3 moment components acting on the implant. For several activities, implant loads were measured in the first 6 months after surgery. Results. One month after surgery, the resultant force during standing was about 270 N in 1 patient and 300 N in the other. When the patients were lying in relaxed positions, resultant forces were less than 30% of the values during standing. In one patient, implant loads were slightly lower during sitting than during standing whereas in the other patient higher loads were measured during sitting. In both patients, flexion of the upper body and walking upstairs caused implant loads, which were more than twice as high as those during standing. Force direction varied only slightly for forces higher than 100 N. Conclusion. High forces may act on a VBR especially in the first postoperative month. Flexion of the upper body and going upstairs cause high implant loads and should be avoided in the first few months after stabilizing the spine.

Spondylodiscitis in Childhood: Results of a Long-term Study

Study Design. Retrospective study to gather long-term data clinical, paraclinical, and radiographic data on nonoperatively managed cases of childhood spondylodiscitis. Objectives. To analyze and assess the clinical, laboratory, and radiologic findings in children with spondylodiscitis and to document the efficacy of conservative treatment based on the long-term clinical, functional, and radiologic outcomes of these patients. Summary of Background Data. Childhood spondylodiscitis is an extremely rare entity that often presents an nonspecific clinical picture. Treatment strategies are mainly conservative. Assessment of the clinical and radiologic outcomes of these patients is essential for prognosis and for justification of nonoperative management. Methods. According to our hospital records, 25 children (17 girls and 8 boys) with a mean age of 6.1 years (range: 2 months–12 years) were hospitalized for spondylodiscitis between 1968 and 1988. Parameters related to the duration of symptoms, clinical manifestations, diagnostic workup, and course of treatment were reviewed. Twenty of the patients (75%) returned for clinical and radiologic follow-up at least 10 years after discharge (range 10–23 years). Results. All of the patients presented with uncharacteristic signs and symptoms. Laboratory markers of inflammation were only moderately elevated. On average, the diagnosis of spondylodiscitis was established after a delay of 14 weeks (range 2 days–60 weeks). All levels of the spine were affected, whereby the thoracic and lumbar spine were preferential sites. The radiographic studies revealed destruction of adjacent vertebral bodies in 12 cases (48%). The remaining 13 patients (52%) had isolated disc involvement without radiographically detectable bone destruction. An abscess was detected by computed tomography in only 1 case. At the time of follow-up, 16 patients (80%) were asymptomatic and had unrestricted spinal mobility. Four patients (20%) had restricted spinal mobility with local kyphosis, which could be documented objectively on radiograph film. In 12 cases (60%), healing was accompanied by fibrous ankylosis and high-grade narrowing of the intervertebral disc space, as was demonstrated radiologically. Eight patients (40%) exhibited fusion of the vertebrae (4 partial, 4 complete). Four patients (20%) had residual defects. Conclusions. Our study shows that the course of childhood spondylodiscitis is generally benign. Segmental orbony ankylosis may occur during the healing process but normally does not lead to serious functional deficits. Neurologic deficits were not observed in any of our patients. Conservative management must be intensive, but the results are good. Biopsy is not required except in the few cases where diagnostic uncertainty prevails.

Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging

Objectives: The aim of this study was to determine whether ultrasound can correctly visualise partial ruptures of the proximal Achilles tendon. Method: This was a prospective study in which all chronic Achilles tendon injury patients seen at three centres in Germany from 1998 to 2003 were screened. All patients with clinical and/or sonographic signs of abnormalities in the region of the proximal third of the Achilles tendon and tendomuscular junction were included in the analysis. Each of these cases was evaluated by ultrasound following an assessment protocol. Patients with ambiguous ultrasound findings and/or clinical signs were additionally assessed by magnetic resonance imaging (MRI). Results: Sonomorphologic changes suggestive of an abnormality in the proximal third of the Achilles tendon were detected in 13 out of 320 patients (4.2%) with recurring Achilles tendon complaints. Thirteen patients had clinical signs but no sonographic changes in the tendon. The sonographic diagnosis was correct in 19 cases. In six of the 26 cases studied, MRI was needed to establish the correct diagnosis of partial intratendinous rupture of the proximal Achilles tendon. Sensitivity was 0.5, specificity was 0.81, and the overall agreement of the ultrasound examination was 61.5%. All patients were asymptomatic at follow up at a mean of 14 months (range 12–17 months) after surgery. Conclusions: Ultrasound is a useful tool for evaluation of proximal Achilles tendon complaints. However, ultrasound is not sufficiently reliable for diagnosis of all pathologies, especially partial ruptures of the Achilles tendon. Thus, the definitive diagnosis must be established by MRI.

Immunohistochemical analysis of osteoblasts in zygapophyseal joints of patients with ankylosing spondylitis reveal repair mechanisms similar to osteoarthritis.

Objective. New bone formation of the spine is a typical feature of ankylosing spondylitis (AS). It is unknown whether new bone formation is part of a physiological repair process or a unique pathological entity of the disease. Methods. We analyzed zygapophyseal joints from patients with AS and osteoarthritis (OA) undergoing spinal surgery for rigid hyperkyphosis (AS) or radiculopathy caused by severe OA. In 17 patients with AS, 11 with OA, and 5 controls we performed immunohistochemical analysis of osteoprotegerin (OPG), nuclear factor-κB ligand (RANKL), and osteocalcin (OC) expression in osteoblasts and determined the trabecular thickness in AS and OA patients and controls. Osteoclasts were detected by tartrate-resistant alkaline phosphatase (TRAP) staining. Results. Trabecular thickness was significantly lower in patients with AS compared to OA (p = 0.01). The absolute number of CD56+ osteoblasts (p < 0.001) and OC+ (p = 0.002), OPG+ (p = 0.003), and RANKL+ osteoblasts (p = 0.03) in AS patients was also significantly lower than in OA patients. The percentages of OC+, OPG+, and RANKL+ osteoblasts did not differ between AS and OA (p > 0.05 in all cases). In controls, the percentages of OPG+ (p = 0.013) and OC+ (p = 0.034) but not RANKL+ (p > 0.05) osteoblasts were significantly lower compared to AS patients. The frequency of TRAP+ osteoclasts in AS patients was significantly lower compared to OA (p < 0.001), but higher compared to controls. Conclusion. Immunohistochemical analysis of zygapophyseal joints suggested that osteoblast activity is similar in AS and OA, indicating that new bone formation is possibly a physiological function of repair in both diseases.

Complications and safety aspects of kyphoplasty for osteoporotic vertebral fractures: a prospective follow-up study in 102 consecutive patients.

BackgroundKyphoplasty represents an established minimal-invasive method for correction and augmentation of osteoporotic vertebral fractures. Reliable data on perioperative and postoperative complications are lacking in the literature. The present study was designed to evaluate the incidence and patterns of perioperative complications in order to determine the safety of this procedure for patients undergoing kyphoplasty.Patients and MethodsWe prospectively enrolled 102 consecutive patients (82 women and 20 men; mean age 69) with 135 operatively treated fractured vertebrae who underwent a kyphoplasty between January 2004 to June 2006. Clinical and radiological follow-up was performed for up 6 months after surgery.ResultsPreoperative pain levels, as determined by the visual analogous scale (VAS) were 7.5 +/- 1.3. Postoperative pain levels were significantly reduced at day 1 after surgery (VAS 2.3 +/- 2.2) and at 6-month follow-up (VAS 1.4 +/- 0.9). Fresh vertebral fractures at adjacent levels were detected radiographically in 8 patients within 6 months. Two patients had a loss of reduction with subsequent sintering of the operated vertebrae and secondary spinal stenosis. Accidental cement extravasation was detected in 7 patients in the intraoperative radiographs. One patient developed a postoperative infected spondylitis at the operated level, which was treated by anterior corporectomy and 360 degrees fusion. Another patient developed a superficial wound infection which required surgical revision. Postoperative bleeding resulting in a subcutaneous haematoma evacuation was seen in one patient.ConclusionThe data from the present study imply that percutaneous kyphoplasty can be associated with severe intra- and postoperative complications. This minimal-invasive surgical procedure should therefore be performed exclusively by spine surgeons who have the capability of managing perioperative complications.

Management of spine injuries in polytraumatized patients

ZusammenfassungDie Wirbelsäulenverletzung im Rahmen eines Polytraumas stellt eine besondere fachliche Herausforderung hinsichtlich der Diagnostik und der Einordnung sowohl ins therapeutische Gesamtkonzept als auch betreffend der Versorgungsschritte an der verletzten Wirbelsäule dar. Die 1. Phase der Diagnostik und Therapie folgt den Empfehlungen des ATLS®-Protokolls unter Beachtung einer potentiell vorliegenden Wirbelsäulenverletzung. Für die Weiterbehandlung wurde das Konzept des „damage control“ auf die verletzte Wirbelsäule im Rahmen des heute etablierten Algorithmus der Versorgung des polytraumatisierten Patienten in definierten Phasen angepasst. Diese etablierten Kriterien hinsichtlich des Zeitpunktes und der Art der operativen Versorgung von Wirbelsäulenverletzungen bei polytraumatisierten Patienten sollen nachfolgend vorgestellt und diskutiert werden.AbstractThe management of spine injuries in polytraumatized patients remains a great challenge for the diagnostic procedures and institution of appropriate treatment by integrating spinal trauma treatment into the whole treatment concept as well as following the treatment steps for the injured spine itself. The established concept of “damage control” and criteria regarding the optimal time and manner for operative treatment of the injured spine in the polytrauma setting is presented and discussed.

Die Versorgung von Wirbelsäulenverletzungen beim Polytrauma

ZusammenfassungDie Wirbelsäulenverletzung im Rahmen eines Polytraumas stellt eine besondere fachliche Herausforderung hinsichtlich der Diagnostik und der Einordnung sowohl ins therapeutische Gesamtkonzept als auch betreffend der Versorgungsschritte an der verletzten Wirbelsäule dar. Die 1. Phase der Diagnostik und Therapie folgt den Empfehlungen des ATLS®-Protokolls unter Beachtung einer potentiell vorliegenden Wirbelsäulenverletzung. Für die Weiterbehandlung wurde das Konzept des „damage control“ auf die verletzte Wirbelsäule im Rahmen des heute etablierten Algorithmus der Versorgung des polytraumatisierten Patienten in definierten Phasen angepasst. Diese etablierten Kriterien hinsichtlich des Zeitpunktes und der Art der operativen Versorgung von Wirbelsäulenverletzungen bei polytraumatisierten Patienten sollen nachfolgend vorgestellt und diskutiert werden.AbstractThe management of spine injuries in polytraumatized patients remains a great challenge for the diagnostic procedures and institution of appropriate treatment by integrating spinal trauma treatment into the whole treatment concept as well as following the treatment steps for the injured spine itself. The established concept of “damage control” and criteria regarding the optimal time and manner for operative treatment of the injured spine in the polytrauma setting is presented and discussed.

Kopf- und Gesichtsschmerzsyndrome

ZusammenfassungKopfschmerzen sind eine der häufigsten krankhaften Störungen in Mitteleuropa. Die Klassifikation der International Headache Society ist sehr detailliert, berücksichtigt jedoch Kopf- und Gesichtsschmerzen im Zusammenhang mit funktionellen Störungen des Bewegungssystems nicht ausreichend. Im vorliegenden Beitrag werden zwei manualmedizinische Kopf- und Gesichtsschmerzsyndrome vorgestellt: das orbitotemporale (OTS) und das orofaziale Syndrom (OFS). Weitere manualmedizinische Kopfschmerzsyndrome wie das nasopharyngeale (NPS) und das laryngomediastinale Syndrom (LMS) werden in der nächsten Ausgabe dieser Zeitschrift beschrieben, dann auch mit der differenzialdiagnostischen Abgrenzung zur Migräne, dem Spannungskopfschmerz und den trigeminoautonomen Kopfschmerzen.In diesen Beiträgen werden spezifische manualmedizinische Funktionsstörungen im Zusammenhang mit typischen Beschwerdeschilderungen von Kopfschmerzpatienten herausgearbeitet, sie stellen also den Versuch einer manualmedizinischen Syndrombildung in Bezug auf die Kopf- und Gesichtsschmerzen dar. Der manualmedizinische Untersuchungsgang und die Behandlungssequenz werden syndromspezifisch beschrieben. Auf die Prognose und die Prophylaxe der einzelnen Syndrome wird ebenfalls eingegangen.AbstractHeadaches are one of the most frequent illnesses in Europe. In the classification of the International Headache Society, headache and prosopalgia are not, however, taken sufficiently into account in relation to functional disturbances of the locomotor system. In this article, two manual medical headache and prosopalgia syndromes are introduced: the orbitotemporal syndrome (OTS) and the orofacial syndrome (OFS). In the following issue of this journal, further manual medical headache syndromes like the nasopharyngeal syndrome (NFS) and the laryngomediastinal syndrome (LMS) will be described. The differential diagnosis between migraine, trigeminoautonomal headaches and tension headache is also discussed in detail in these subsequent papers.These contributions try to work out specific manual medical disturbances in connection with typical descriptions of pain and discomfort by patients, and therefore represent an attempt to build manual medical syndromes with respect to headache and prosopalgia. Furthermore, syndrome-specific manual medical investigations and treatment are introduced and discussed. The prognosis and prophylaxis of the individual syndromes are also discussed.