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•The TUG test and the 6WT are feasible to apply in ambulatory patients with spinal cord affection.•The objective measurement of functional impairment resembled the functional status of four patients in this pilot study.•The TUG test and the 6WT may detect and quantify functional decline and/or improvement resulting from spinal cord affection.•Modern smartphone app-based technology may help to accurately quantify impairment, which is key for decision-making and evaluating the efficacy of interventions.

The 6-minute walking test (6WT) and the Timed Up and Go (TUG) test are two of the most commonly applied standardized measures of objective functional impairment that help support clinical decision-making for patients undergoing surgery for degenerative lumbar disorders. This study correlates smartphone-app-based 6WT and TUG results to evaluate their responsiveness.In a prospective study, 49 consecutive patients were assessed preoperatively and 6 weeks postoperatively using the 6WT, the TUG test, and commonly used patient-reported outcome measures. Raw values and standardized z-scores of both objective tests were correlated. An external criterion for treatment success was created based on the Zurich Claudication Questionnaire patient satisfaction subscale. Internal and external responsiveness for both functional tests was evaluated.The mean preoperative 6WT results improved from 401 m (SD 129 m), z-score -1.65 (SD 1.6) to 495 m (SD 129 m), z-score -0.71 (SD 1.6, p0.001). The mean preoperative TUG test results improved from 10.44 seconds (SD 4.37, z-score: -3.22) to 8.47 seconds (SD 3.38, z-score: -1.93, p0.001). The 6WT showed a strong negative correlation with TUG test results (r = -66, 95% CI 0.76-0.53, p0.001). The 6WT showed higher internal responsiveness (standardized responsive mean = 0.86) compared to the TUG test (standardized responsive mean = 0.67). Evaluation of external responsiveness revealed that the 6WT was capable of differentiating between patients who were satisfied and those who were unsatisfied with their treatment results (area under the curve = 0.70), whereas this was not evident for the TUG test ( area under the curve = 0.53).Both tests adequately quantified functional impairment in surgical candidates with degenerative lumbar disorders. The 6WT demonstrated better internal and external responsiveness compared with the TUG test. Clinical trial registration no.: NCT03977961 (clinicaltrials.gov).AUC = area under the curve; COMI = Core Outcome Measures Index; DLDs = degenerative lumbar disorders; LDH = lumbar disc herniation; LSS = lumbar spinal stenosis; PROM = patient-reported outcome measure; ROC = receiver operating characteristic; SRM = standardized responsive mean; TUG = Timed Up and Go; VAS = visual analog scale; 6WD = 6-minute walking distance; 6WT = 6-minute walking test; ZCQ = Zurich Claudication Questionnaire.

The worldwide spread of smartphone usage enables new possibilities for longitudinal monitoring of objective functional impairment (OFI) in patients undergoing surgery for lumbar degenerative disc disease (DDD).Three patients, undergoing elective surgery for lumbar DDD, self-assessed OFI using a recently validated 6-min walking test (6WT) smartphone application. Results are presented as raw 6-min walking distance (6WD) as well as in reference to age- and sex-specific healthy population reference values using standardized z-scores (number of standard deviations). In parallel, patient-reported outcome measures (PROMs), including numeric rating scale (NRS) leg-pain and Core Outcome Measures Index (COMI) were obtained before (pre) and 6 weeks (6 W) as well as 3 months (3 M) after surgery. Descriptive analyses were used to compare PROMs with repeated 6WT measurements over time. The feasibility and benefits of the longitudinal OFI measurements using the 6WT app are discussed.One patient presented a favorable outcome, reflected by a clinically meaningful improvement in PROMs. Correspondingly, the 6WT distance gradually improved above the normal population values ((pre 399 m (z-score - 1.96) vs. 6 W 494 m (- 0.85) vs. 3 M 557 m (- 0.1)). One patient experienced initial improvement at 6 W, followed by a decline in 6WD at 3 M which promoted further interventions with subsequent recovery ((358 m (z-score - 3.29) vs 440 m (- 2.2) vs 431 m (- 2.32) vs 471 m (- 1.78)). The last patient showed a lack of improvement in PROMs as well as in OFI (360 m (z-score 0.0) vs 401 m (0.30) vs 345 m (- 0.11)) resulting in secondary surgery.The longitudinal assessment of OFI using the 6WT app was feasible and provided the physician with a detailed history of patients' postoperative walking capacity complementing commonly used PROMs.

It is generally believed that radiological signs of lumbar degenerative disc disease (DDD) are associated with increased pain and functional impairment as well as lower health-related quality of life (HRQoL). Our aim was to assess the association of the Modic and Pfirrmann grading scales with established outcome questionnaires and the timed-up-and-go (TUG) test. METHODS: In a prospective two-center study with patients scheduled for lumbar spine surgery, visual analogue scale (VAS) for back and leg pain, Roland-Morris Disability Index, Oswestry Disability Index and HRQoL, as determined by the Short-Form (SF)-12 and the Euro-Qol, were recorded. Functional mobility was measured with the TUG test. Modic type (MOD) and Pfirrmann grade (PFI) of the affected lumbar segment were assessed with preoperative imaging. Uni- and multivariate logistic regression analysis was performed to estimate the effect size of the relationship between clinical and radiological findings. RESULTS: Two hundred eighty-four patients (mean age 58.5, 119 (42 %) females) were enrolled. None of the radiological grading scales were significantly associated with any of the subjective or objective clinical tests. There was a tendency for higher VAS back pain (3.48 vs. 4.14, p = 0.096) and lower SF-12 physical component scale (31.2 vs. 29.4, p = 0.065) in patients with high PFI (4-5) as compared to patients with low PFI (0-3). In the multivariate analysis, patients with MOD changes of the vertebral endplates were 100 % as likely as patients without changes to show an impaired TUG test performance (odds ratio (OR) 1.00, 95 % confidence interval (CI) 0.56-1.80, p = 0.982). Patients with high PFI were 145 % as likely as those with low PFI to show an impaired TUG test performance (OR 1.45, 95 % CI 0.79-2.66, p = 0.230). CONCLUSIONS: There was no association between established outcome questionnaires of symptom severity and two widely used radiological classifications in patients undergoing surgery for lumbar DDD

Although most patients with a mild traumatic brain injury (mTBI) recover within days to weeks, some experience persistent physical, cognitive and emotional symptoms, often described as post-concussion syndrome (PCS). The optimal recovery time including return-to-work (RTW) after mTBI is unclear. In this single-centre parallel-group trial, patients assigned three days (3D-group) or seven days (7D-group) sick leave were compared with a comprehensive neuropsychological test battery including the Post-Concussion Symptom Scale (PCSS) within one week, after three and 12 months post-injury. The influence of the effective time until RTW on post-concussional symptoms and cognitive performance was analysed. The 3D-group rated significantly higher mean scores in some PCSS symptoms, tended to fulfil diagnosis criteria of PCS more often and showed better cognitive performance in several neuropsychological test scores than the 7D-group at all three time-points of follow-up. Overall, patients returned to work 11.35 d post-injury, thus distinctly above both recommended sick leaves. There was a trend for longer sick leave in patients randomized into the 3D-group. Further analyses revealed that the group with an absolute RTW within one week showed lower symptom severity in fatigue at 3 and 12 months, less PCS and faster performance in fine motor speed at 12 months than the group with an absolute RTW after one week. Our data underline the heterogeneity of mTBI and show that acute and sub-acute symptoms are not prognostic factors for neuropsychological outcome at one year. Later, ability to work seems to be prognostic for long-term occurrence of PCS.

Zerebrale arteriovenöse Malformationen (AVM) sind kongenitale oder im frühen Entwicklungsalter entstehende vaskuläre Pathologien, bei welchen es zu direkten Gefässverbindungen zwischen Arterien und Venen ohne zwischengeschaltetem Kapillarbett und z.T. weiteren, komplizierenden Fehlbildungen kommt. Am häufigsten offenbaren sich AVM durch intrakranielle Blutungen in der 2. bis 4. Lebensdekade. Bei epileptischen Anfällen oder fokal-neurologischen Defiziten stellt die AVM besonders beim jungen Erwachsenen eine wichtige Differenzialdiagnose dar. Als kausale Therapie wird bei symptomatischen AVM in der Regel eine Ausschaltung durch chirurgische, endovaskuläre und radiotherapeutische Massnahmen, oder einer Kombination aus diesen empfohlen. Bei inzidentellen Befunden ist die Indikation zur Behandlung sorgfältig und stets individuell zu stellen. Dieser Übersichtsartikel gibt einen Überblick über aktuelle Empfehlungen zum Management von AVM beim erwachsenen Patienten.

Intradurale spinale Tumoren werden in extra- und intramedulläre Tumoren unterteilt. Die häufigsten intradural-extramedullären Tumoren sind Meningeome und Neurinome, bei den intradural-intramedullären Tumoren überwiegen Ependymome und Astrozytome. Unabhängig von deren Ursprung manifestieren sich spinale Tumoren oft mit progressiven lokalen oder radikulären Schmerzen und neurologischen Defiziten. Die Therapie der Wahl bei den meisten intraduralen Tumoren ist eine möglichst komplette chirurgische Resektion. Bei ausgeprägtem infiltrativem Wachstum im intramedullären Bereich muss jedoch randständig Tumor belassen werden, um nicht zusätzlich bleibende neurologische Defizite zu riskieren. Grundsätzlich ist insbesondere beim Auftreten neurologischer Ausfälle eine möglichst rasche chirurgische Intervention indiziert, da die Prognose von der Schwere und der Dauer der vorbestehenden Defizite abhängt. Im Folgenden werden die klinische Präsentation und die massgebenden Therapieoptionen intraduraler spinaler Neoplasien praxisnah besprochen.

Intrazerebrale Blutungen (ICB) sind für 10-17% aller Schlaganfälle verantwortlich und gehen mit einer hohen Mortalität und Morbidität einher. Von den primären ICB sind über 50% mit einer arteriellen Hypertonie und bis 30% mit einer zerebralen Amyloidose assoziiert. Da mehrere Studien bei Patienten mit supratentoriellen ICB keinen Benefit einer chirurgischen Hämatomevakuation zeigten, ist meist eine primär konservative Therapie indiziert. Bei Patienten mit neurologischen Defiziten und infratentoriellen ICB hingegen kann eine neurochirurgische Evakuation die Prognose deutlich verbessern. Moderne Therapieregime und aktuelle Forschungsbemühungen zielen auf eine frühe Hämostase, ein verbessertes intensivmedizinisches Management und weniger auf invasive chirurgische Interventionen ab, um eine Reduktion sekundärer Gehirnschäden zu erreichen. Im Folgenden wird ein Überblick über die klinische Präsentation, Diagnostik sowie die zur Verfügung stehenden Therapieoptionen gegeben.

Meningeome sind häufige intrakranielle Tumoren, die durch die Entartung von Zellen der Arachnoidea mater entstehen. Klinisch manifestieren sie sich in Form von Kopfschmerzen, fokalen oder generalisierten Krampfanfällen oder kompressionsbedingten neurologischen Ausfällen. Über 90% der in der Regel langsam wachsenden Meningeome sind benigne. Bei den meisten symptomatischen Patienten wird die Tumorresektion in kurativer oder zumindest symptomlindernder Intention angestrebt. Bei subtotaler Resektion besteht die Möglichkeit einer adjuvanten Bestrahlung. Eine stereotaktische Radiotherapie kann jedoch auch als Ersttherapie bei Patienten erfolgen, die sich durch hohes Alter oder Tumoren in eloquenten oder chirurgisch schlecht erreichbaren Arealen nicht für eine neuro-chirurgische Operation qualifizieren. Bei nicht resezierbaren Tumoren oder falls alle vorherigen Therapien keinen Erfolg gebracht haben, kann eine Hormon- oder Chemotherapie in Erwägung gezogen werden.

Das Kraniopharyngeom (KP) ist ein seltener dysontogenetischer Tumor, der seinen Ursprung entweder von versprengten Ductus-craniopharyngeus-Inseln nimmt oder sich metaplastisch von adenohypophysaren Parenchymzellen herleitet. Trotz Klassifizierung als WHO-Klasse-I-Tumor kann sich das histologisch benigne KP hierbei zuweilen sehr aggressiv verhalten. Das KP wird meist vor dem 20. Lebensjahr manifest. Patienten klagen oft uber Kopfschmerzen, je nach Lokalisation kann auch ein Chiasmasyndrom auftreten. Eine begleitende Hypophysenvorderlappeninsuffizienz manifestiert sich bei Kindern in der Regel in Form einer Wachstumsverzogerung. Zusatzlich kann bei Kompression des Hypophysenhinterlappens ein Diabetes insipidus oder bei Infiltration des Hypothalamus eine Adipositas auftreten. Therapeutisch kommt sowohl die radikale chirurgische Entfernung als auch die Teilresektion mit adjuvanter Radiotherapie zum Einsatz, bei zystischen Tumoren evtl. auch eine stereotaktische Zystendrainage mit erganzender Bestrahlung. Die Prognose hangt massgebend von der fruhzeitigen Diagnosestellung ab. ABSTRACT: The craniopharyngioma is a rare dysontogenetic tumour that originates from either scattered cells of the craniopharyngeal duct or from metaplastically mutated anterior pituitary parenchyma cells. Despite being classified as a WHO-Class-I tumour, the histologically benign craniopharyngioma may display an aggressive behaviour. Like other congenital tumours, it usually becomes manifest within the first two decades of life. Patients typically complain of headache and a chiasma syndrome with bitemporal hemianopsy may develop depending on tumour localisation. In children, anterior pituitary insufficiency often manifests as growth restriction. Additionally, diabetes insipidus and other hormonal disturbances may develop. Therapeutically either radical total removal or subtotal resection in combination with postoperative radiation is recommended. In cystic tumors, stereotactic cyst drainage and adjuvant radiation may be a possible alternative. The prognosis is best in patients who are diagnosed early.

Background: An enhanced fracture healing response has been reported in patients with traumatic brain injury (TBI). This has been attributed to circulating humoral factors that are thought to be proteins produced and released by the injured brain. However, these factors remain unknown. The aim of this study was to identify osteogenic factors in serum and cerebrospinal fluid (CSF) from TBI patients. This was carried out using in vitro proliferation assays with the human foetal osteoblastic 1.19 cell line (hFOB) combined with a novel proteomic approach. Methods: Serum was collected from brain-injured (n = 12) and non-brain-injured (n = 9) patients with a comorbid femur shaft fracture. Similarly, CSF was obtained from TBI (n = 7) and non-TBI (n = 9) patients. The osteoinductive potential of these samples was determined by measuring the in vitro proliferation rate of hFOB cells. Highly osteogenic serum and CSF samples of TBI patients were chosen for protein analysis and were compared to those of non-brain-injured patients. A new hFOB cell-based method was used to enrich the proteins in these samples, which had a functional affinity for these osteoprogenitor cells. These enriched protein fractions were mapped using two-dimensional gel electrophoresis and protein imaging methods displaying serum and CSF proteins of brain-injured and control subjects that had an affinity for human osteoprogenitor cells. Results: Serum and CSF derived from brain-injured patients demonstrated a greater osteoinductive potential (P Language: en

Das Leitsymptom der aneurysmatischen Subarachnoidalblutung (aSAB) ist der so genannte «Vernichtungskopfschmerz», welcher von Nackensteifigkeit, Bewusstseinsstörungen sowie vegetativen Symptomen begleitet sein kann. Bei klinischer Verdachtsdiagnose wird initial eine native Computertomographie (CT) durchgeführt. Die Lokalisation und Morphologie des Aneurysmas wird mit Hilfe einer CT-Angiographie und/oder konventionellen Panangiographie dargestellt. Bis zur definitiven Aneurysmaausschaltung mittels mikrochirurgischen Clippings oder endovaskulären Coilings sollte eine Nachblutung unbedingt verhindert werden. Die post-operative Phase ist insbesondere bei Patienten mit höhergradiger aSAB mit dem Auftreten krankheitsspezifischer Komplikationen (zerebrale Vasospasmen, intrakranielle Hypertension, Krampfanfälle, Hydrozephalus) und konsekutiv erhöhtem Risiko für sekundäre Hirnschäden geprägt. Zusätzlich präsentieren viele Patienten systemische Komplikationen wie z.B. Elektrolytstörungen und kardiale Dysfunktionen. Durch rechtzeitiges Erkennen der zerebralen und systemischen Komplikationen können entsprechende Gegenmassnahmen getroffen werden, um den klinisch-funktionellen Outcome zu verbessern.

Das Krankheitsbild Pott's puffy-Tumor beschreibt eine lokale Stirnbeinosteomyelitis, die meist durch einen äusseren Infekt mit konsekutiver sub­periostaler Abszedierung entsteht. Die klinische Manifestation entsteht schleichend und die sichtbare Erhebung ist oftmals indolent. Die Symptome sind vor allem Folgen komplizierender Sekundärmorbiditäten. Wir präsentieren einen komplizierten Verlauf mit intrakranieller Ausbreitung der initialen Sinusitis.

The management of patients with aneurysmal subarachnoid hemorrhage (SAH) requires a fundamental knowledge of the disease, its therapeutic options and possible complications. The preoperative goal is to prevent rebleeding by controlling blood pressure and treating pain and anxiety as well as stabilizing cardiopulmonary functions. An acute hydrocephalus has to be treated immediately. Microsurgical clipping or endovascular coiling are the therapeutic options available. The postoperative goal aims at securing cardiopulmonary functions as well as recognizing and treating cerebral (cerebral vasospasm, hydrocephalus, epilepsy) and systemic complications (electrolyte disorder, cardiac dysfunction). This article provides an overview about the pre-, peri- and postoperative management of patients with SAH.

Metal implants are essential therapeutic tools for the treatment of bone fractures and joint replacements. The metals and metal alloys used in contemporary orthopedic and trauma surgery are well tolerated by the majority of patients. However, complications resulting from inflammatory and immune reactions to metal implants have been well documented. This review briefly discusses the different mechanisms of metal implant corrosion in the human body, which lead to the release of significant levels of metal ions into the peri-implant tissues and the systemic blood circulation. Additionally, this article reviews the effects of the released ions on bone metabolism and the immune system and discusses their involvement in the pathophysiological mechanisms of aseptic loosening and metal hypersensitivity in patients with metal implants.

There is increasing evidence that titanium ions are released from orthopedic implants by biocorrosion. The aim of this study was to investigate titanium uptake by human T-lymphocytes and its effects on phenotype and proliferation. Freshly isolated human nonadherent peripheral blood mononuclear cells (NA-PBMC), were exposed to TiCl4 [Ti(IV)]. Bioavailability and distribution of Ti(IV) in T-lymphocytes was determined by energy-filtered electron microscopy (EFTEM). The effects of Ti(IV) challenge on nonactivated and PHA-activated cells were assessed by flow cytometric analysis of surface markers, RANK-L production, and proliferation assays. EFTEM colocalized Ti(IV) with phosphorus in the nucleus, ribosomes, cytoplasmic membranes, and the surface membrane of T-lymphocytes. Ti(IV) increased significantly the expression of CD69, CCR4, and RANK-L in a concentration-dependent manner. Titanium enters T-lymphocytes through a currently unknown mechanism and binds to phosphorus-rich cell structures. Titanium influences phenotype and function of T-lymphocytes, resulting in activation of a CD69+ and CCR4+ T-lymphocyte population and secretion of RANK-L. These results strongly suggest the involvement of titanium ions challenged T-lymphocytes in the complex pathophysiological mechanisms of aseptic loosening of orthopedic implants.

Die Ursache ischämischer Hirninfarkte bei jungen Patienten (

Im klinischen Alltag besteht ein wesentlicher Teil der ärztlichen Tätigkeit darin, Patienten über medizinische Diagnosen und insbesondere über das Vorgehen operativer Eingriffe zu informieren. In diesen Gesprächen wird das Krankheitsbild, der Ablauf im Spital vor und nach der Operation sowie das Vorgehen während der Operation erklärt. Aus rechtlicher Sicht muss von ärztlicher Seite während des Gesprächs auf alle möglichen Risiken des Eingriffs hingewiesen werden. Um die Informationsvermittlung zu optimieren, werden während des Gesprächs Hilfsmittel wie Zeichnungen, Bilder, Röntgenbilder und Modelle verwendet. Nach einer rein mündlichen Aufklärung wird jedoch nur ein geringer Prozentsatz der Informationen vom Patienten aufgenommen. Damit die Patienten besser und frühzeitig über medizinische Details und interne Abläufe vor einer geplanten Operation informiert werden können, haben wir ein webbasiertes Informationsportal mit einer Kombination aus Bild, Text, Ton und Video über chirurgische Eingriffe entwickelt. Durch den Einsatz dieses Patienten-Informationssystems in der Aufklärungskaskade kann die Patientenzufriedenheit wesentlich verbessert werden. Zusätzlich kann der Einsatz des webbasierten multimedialen Informationsportals für das ärztliche Personal zu einer wesentlichen Zeitersparnis führen.

Bei bis zu 10% der Patienten mit «Low Back Pain» kommt es zu chronischen Kreuzschmerzen, welche per definitionem über einen Zeitraum von mindestens drei Monaten bestehen. Dieses Krankheitsbild hat gravierende Auswirkungen auf die psycho-soziale und physische Integrität der betroffenen Personen. Schmerzsyndrome der Lendenwirbelsäule verursachen jährlich direkte und indirekte Kosten von 150–250 Milliarden Schweizer Franken. Trotz intensiver Behandlung bleiben einige Patienten symptomatisch. Daraus resultiert eine beschwerdebedingte funktionelle Unterbelastung, welche zu einer Verminderung der Leistungsfähigkeit und einer verstärkten Inaktivität führt – der Beginn eines Teufelskreislaufs. Ein multimodales Behandlungskonzept mit physio- und psychotherapeutischer Behandlung, welches von einer gezielten medikamentösen Therapie unterstützt wird, verbessert die körperlichen Funktionen und bewirkt eine deutliche Beschwerdereduktion. Bei länger andauernder Therapieresistenz ist es sinnvoll, frühzeitig minimal-invasive oder invasive Therapieoptionen in Erwägung zu ziehen.

Background: Scientific evidence is mounting for an association between traumatic brain injury and enhanced osteogenesis. The aim of this study was to correlate the in vitro osteoinductive potential of serum with the features of fracture-healing and the extent of brain damage in patients with severe traumatic brain injury and bone fracture. Methods: Patients with a long-bone fracture and a traumatic brain injury (seventeen patients) or without a brain injury (twenty-four patients) were recruited. The Glasgow Coma Scale score was determined on admission. Radiographs of the fracture were made before surgery, at six weeks, and at three, six, and twelve months after surgery. The time to union was estimated clinically and radiographically, and the callus ratio to shaft diameter was calculated. Serum samples were collected at six, twenty-four, seventy-two, and 168 hours after injury, and their osteogenic potential was determined by measurement of the in vitro proliferation rate of the human fetal osteoblastic cell line hFOB1.19. Results: Patients with a traumatic brain injury had a twofold shorter time to union (p = 0.01), a 37% to 50% increased callus ratio (p < 0.01), and their sera induced a higher proliferation rate in hFOB cells (p < 0.05). A linear relationship was revealed between hFOB cell proliferation rates and the amount of callus formed (p < 0.05). The Glasgow Coma Scale score was correlated with the callus ratio on both radiographic projections (p < 0.05), time to union (p = 0.04), and the proliferation rate of hFOB cells at six hours after injury (p = 0.03). Conclusions: Patients with a severe brain injury release unknown humoral factors into the blood circulation that enhance and accelerate fracture-healing.

Most metals in contact with biological systems undergo corrosion by an electrochemical process. This study investigated whether human osteoclasts (OC) are able to grow on stainless steel (SS) and directly corrode the metal alloy leading to the formation of corresponding metal ions, which may cause inflammatory reactions and activate the immune system. Scanning electron microscopy analysis demonstrated long-term viable OC cultures and evident resorption features on the surface of SS discs on which OC were cultured for 21 days. The findings were confirmed by atomic emission spectrometry investigations showing significantly increased levels of chromium, nickel, and manganese in the supernatant of OC cultures. Furthermore, significant levels of pro-inflammatory cytokines IL-1beta, IL-6, and TNF-alpha, which are considered to be major mediators of osteolysis, were revealed in the same cultures by cytometric bead array analysis. Within the present study, it was shown that human osteoclast precursors are able to grow and differentiate towards mature OC on SS. The mature cells are able to directly corrode the metal surface and release corresponding metal ions, which induce the secretion of pro-inflammatory cytokines that are known to enhance osteoclast differentiation, activation, and survival. Enhanced corrosion and the subsequently released metal ions may therefore result in enhanced osteolytic lesions in the peri-prosthetic bone, contributing to the aseptic loosening of the implant.

Die lumbale Spinalkanalstenose (SKS) ist als Einengung des Spinalkanals mitsamt neuralen und vaskulären Strukturen durch das umgebende Knochen- und Weichteilgewebe definiert. Bei Patienten über 65 Jahren gehört die SKS zu den häufigsten Ursachen von Kreuzschmerzen, mit oder ohne Schmerzausstrahlung in die Beine. Die Prävalenz wird aufgrund der steigenden Lebenserwartung zunehmen. Leitsymptom ist die Claudicatio spinalis, mit lumboglutealen oder ischialgieformen Schmerzen, die beim Gehen auftreten und zu einer Einschränkung der Gehstrecke führen. Die typische Symptomkonstellation von Claudicatio spinalis mit subjektiver Beinschwäche führt zur Verdachtsdiagnose. Das bildgebende Verfahren der Wahl zur Diagnosestellung ist heutzutage die Magnetresonanztomographie. Eine konservative Therapie ist initial in den meisten Fällen ausreichend. Die Operationsindikation ist gegeben, wenn die Schmerzen und die Einschränkung der Gehstrecke nicht mehr toleriert werden. Eine zusätzliche Fusion muss bei degenerativer Spondylolisthese und anderen pathomorphologischen Veränderungen, die zu einer Instabilität führen, in Betracht gezogen werden. Konservative und operative Behandlungsziele beinhalten primär neben der Schmerzlinderung die Verbesserung der körperlichen Funktionalität, Mobilität und allgemeinen Lebensqualität.

Primary objective: The aetiology of the increased osteogenesis associated with severe traumatic brain injury (TBI) remains incompletely understood. The purpose of this article is to review the available evidence regarding the release of osteogenic humoral factors after TBI.Research design: This study is presented in the form of a literature review.Methods and procedures: To obtain suitable references, Pubmedwas searched using keywords ‘heterotopic ossification’, ‘brain’, ‘trauma’, ‘injury’, ‘aetiology’.Main outcomes and results: Evidence from both clinical and laboratory investigations points to centrally released osteogenic factor(s) that enter the systemic circulation following TBI.Conclusions: Further investigation into the identification of these putative osteogenic factor(s), using human tissues and new techniques, is indicated to better understand this phenomenon.

Das isolierte Schädel-Hirn-Trauma (SHT) ist ein Hauptrisikofaktor für Morbidität und Mortalität nach einem Unfallereignis. Die Prognose ist sowohl von der primären, also der direkten Schädigung als auch von der sekundären Schädigung (posttraumatische Blutung, Ödem etc.), abhängig. Das in diesem Artikel beschriebene leichte SHT ist eine traumatisch bedingte, reversible Schädigung des Gehirns ohne morphologisch fassbare Veränderung, welches einem GCS von 13–15 zugeordnet wird. Gleich zu Beginn der Aufnahmeuntersuchung sollten Risikofaktoren für intrakranielle Pathologien identifiziert werden. Hierzu richtet sich die durchzuführende Diagnostik nach dem Schweregrad der Verletzungen. Besonders im Bereich der SHT ist dies nur ungenügend mit der herkömmlichen Nativradiologie zu gewährleisten. Im Folgenden werden praxisnah sowohl Algorithmen zum Vorgehen bei leichten SHT als auch der sinnvolle Einsatz einer frühen CT-Diagnostik besprochen.

The Guillain-Barre syndrome (GBS) is a reactive, self-limited, autoimmune disease frequently triggered by a preceding bacterial or viral infection. In its typical form, GBS presents with a gait disturbance and clinical features of pain, weakness and areflexia. A careful history, physical examination and routine laboratory tests are necessary to make the clinical diagnosis and to exclude other disorders that cause a similar presentation. GBS following surgery is rare and may either be secondary to anaesthesia or due to metabolic changes induced by the surgical procedure itself (e.g. gastrectomy, thymectomy, and transplantation). Diagnosis of GBS under these circumstances is often delayed, which may lead to an increase in morbidity. In this article, we present the first described case of a patient who developed GBS after surgical fixation of multiple pelvic injuries and a fracture of the fourth lumbar vertebral body sustained in a motorcycle accident.

Spinal cordectomy has been described as an effective treatment option in paraplegic patients for the treatment of syringomyelia to manage spasticity, pain and ascending neurological dysfunction. The objective of this study was to investigate the long-term health-related quality of life (HRQoL) after cordectomy in patients with intractable symptoms caused by syringomyelia. Seventeen patients underwent spinal cordectomy for syringomyelia between February 2000 and July 2009. The etiology of syringomyelia was traumatic in 16 patients and spinal ependymoma in one patient. The mean follow-up was 3.8 years (range, 0.9–10.3). The HRQoL was assessed pre- and postoperatively using the EuroQol (EQ; degree of discomfort: 1 = none, 2 = moderate and 3 = extreme) and the short-form SF-36 quality of life score (SF-36). All patients underwent a telephone interview. The mean pre- and postoperative EuroQol-levels for mobility were 1.8 and 1.5; for self-care, 1.9 and 1.5; for usual activities, 2.1 and 1.5; for pain/discomfort, 2.3 and 2.0; and for anxiety/depression, 1.7 and 1.5, respectively. The mean overall EQ visual analogue scale improved postoperatively from 42 points (range, 15–80) to 67 points (range, 10–95) (p = 0.006). The component summary measure for mental health (SF-36) significantly improved postoperatively (p = 0.01). A telephone interview revealed a high subjective patient satisfactory (94.1%) in terms of postoperative sequelae. Following the intervention, 58.8% of all patients were employed full or part-time. Spinal cordectomy may increase the quality of life and can be considered as an ultimo ratio therapy in a selective group of patients with intractable symptoms caused by syringomyelia.

Purpose. To compare early functional outcomes, complications, and mortality in elderly patients treated with the less costly, cemented Thompson prosthesis or the cemented bipolar prosthesis in order to identify factors affecting outcomes. Methods. Records of 303 patients with femoral neck fractures treated with the cemented Thompson monoblock prosthesis (n=206) or the cemented bipolar prosthesis (n=97) were reviewed. The choice of prosthesis was solely determined by surgeon's preference. Data relating to patient demographics, clinical and residential status, mobility, mental function, mortality, and complications during hospitalisation and rehabilitation were collected. Results. After adjusting for confounding variables, independent postoperative indoor mobility was associated with preoperative indoor mobility (p=0.002) and mental function (p=0.001), whereas postoperative outdoor mobility was associated with preoperative outdoor mobility (p=0.003), daily living activity (p=0.02), and mental function (p=0.02). Mortality within 6 months was only associated with poor mental function (p=0.009). At 6-month follow-up, there was no significant difference between the 2 types of prosthesis in terms of functional outcomes, mortality and complication rates. Conclusion. In elderly patients with limited mobility, treatment with the bipolar prosthesis was not associated with better short-term outcomes than those receiving the Thompson prosthesis.

An enhanced fracture healing response has been reported in patients with traumatic brain injury (TBI). This has been attributed to circulating humoral factors that are thought to be proteins produced and released by the injured brain. However, these factors remain unknown. The aim of this study was to identify osteogenic factors in serum and cerebrospinal fluid (CSF) from TBI patients. This was carried out using in vitro proliferation assays with the human foetal osteoblastic 1.19 cell line (hFOB) combined with a novel proteomic approach.Serum was collected from brain-injured (n = 12) and non-brain-injured (n = 9) patients with a comorbid femur shaft fracture. Similarly, CSF was obtained from TBI (n = 7) and non-TBI (n = 9) patients. The osteoinductive potential of these samples was determined by measuring the in vitro proliferation rate of hFOB cells. Highly osteogenic serum and CSF samples of TBI patients were chosen for protein analysis and were compared to those of non-brain-injured patients. A new hFOB cell-based method was used to enrich the proteins in these samples, which had a functional affinity for these osteoprogenitor cells. These enriched protein fractions were mapped using two-dimensional gel electrophoresis and protein imaging methods displaying serum and CSF proteins of brain-injured and control subjects that had an affinity for human osteoprogenitor cells.Serum and CSF derived from brain-injured patients demonstrated a greater osteoinductive potential (P0.05) than their non-brain-injured counterparts. Clear-cut differences in the pattern of proteins in two-dimensional gels were detected between TBI and control patients. Fourteen proteins were exclusively present in the serum of TBI patients, while other proteins were either up- or downregulated in samples collected from TBI patients (P0.05).Osteoinductive factors are present in the serum and CSF of brain-injured patients. These may include one or more of those proteins identified as having an affinity for osteoprogenitor cells that are either exclusively present or up- or downregulated in the serum and CSF of brain-injured patients.

In the current climate of increasing awareness, patients are demanding more knowledge about forthcoming operations. The patient information accounts for a considerable part of the physician’s daily clinical routine. Unfortunately, only a small percentage of the information is understood by the patient after solely verbal elucidation. To optimise information delivery, different auxiliary materials are used. In a prospective study, 52 consecutive stationary patients, scheduled for an elective lumbar disc operation were asked to use a web-based audiovisual patient information system. A combination of pictures, text, tone and video about the planned surgical intervention is installed on a tablet personal computer presented the day before surgery. All patients were asked to complete a questionnaire. Eighty-four percent of all participants found that the audiovisual patient information system lead to a better understanding of the forthcoming operation. Eighty-two percent found that the information system was a very helpful preparation before the pre-surgical interview with the surgeon. Ninety percent of all participants considered it meaningful to provide this kind of preoperative education also to patients planned to undergo other surgical interventions. Eighty-four percent were altogether “very content” with the audiovisual patient information system and 86% would recommend the system to others. This new approach of patient information had a positive impact on patient education as is evident from high satisfaction scores. Because patient satisfaction with the informed consent process and understanding of the presented information improved substantially, the audiovisual patient information system clearly benefits both surgeons and patients.

Osteopetrosis (OP) is a rare heterogeneous group of inherited skeletal dysplasias characterised by osteoclast dysfunction, impaired bone resorption and poor bone remodelling. Three groups can be categorised on the basis of clinical findings. These include neurological symptoms, haematological abnormalities and renal tubular acidosis in the first group. Increased bone density, osteomyelitis and frequent fractures are the clinical findings in the second group, and the third group have normal life expectancy but may develop cranial nerve compression and osteomyelitis. Fractures in patients with OP are common and require appropriate pre-, peri- and postoperative management. The long bones are most frequently affected, fractures of the femoral neck and proximal (upper third) shaft being particularly common. This case report proposes possible operative fracture treatment in a patient with OP and highlights the potential perioperative pitfalls in this rare surgical population.

There is increasing evidence that titanium ions are released from orthopedic implants by biocorrosion. The aim of this study was to investigate titanium uptake by human T-lymphocytes and its effects on phenotype and proliferation. Freshly isolated human nonadherent peripheral blood mononuclear cells (NA-PBMC), were exposed to TiCl4 [Ti(IV)]. Bioavailability and distribution of Ti(IV) in T-lymphocytes was determined by energy-filtered electron microscopy (EFTEM). The effects of Ti(IV) challenge on nonactivated and PHA-activated cells were assessed by flow cytometric analysis of surface markers, RANK-L production, and proliferation assays. EFTEM colocalized Ti(IV) with phosphorus in the nucleus, ribosomes, cytoplasmic membranes, and the surface membrane of T-lymphocytes. Ti(IV) increased significantly the expression of CD69, CCR4, and RANK-L in a concentration-dependent manner. Titanium enters T-lymphocytes through a currently unknown mechanism and binds to phosphorus-rich cell structures. Titanium influences phenotype and function of T-lymphocytes, resulting in activation of a CD69+ and CCR4+ T-lymphocyte population and secretion of RANK-L. These results strongly suggest the involvement of titanium ions challenged T-lymphocytes in the complex pathophysiological mechanisms of aseptic loosening of orthopedic implants.

All metals in contact with a biological system undergo corrosion through an electrochemical redox reaction. This study investigated whether human osteoclasts (OC) are able to grow on titanium and aluminum, and directly corrode the metals leading to the release of corresponding metal ions, which are believed to cause inflammatory reactions and activate osteoclastic differentiation. Scanning electron microscopy analysis demonstrated long-term viable OC cultures on the surface of titanium and aluminum foils. Atomic emission spectrometry investigations showed significantly increased levels of aluminum in the supernatant of OC cultured on aluminum; however, all measurements in the supernatants of cell cultures on titanium were below detection limits. Despite this, confocal microscopy analysis with Newport Green DCF diacetate ester staining depicted intense fluorescence throughout the cytoplasm and nucleolus of OC cultured on titanium foils. Comparable fluorescence intensities were not observed in monocytes and control cells cultured on glass. The present study demonstrated that human osteoclast precursors are able to grow and differentiate toward mature OC on titanium and aluminum. Furthermore, it established that the mature cells are able to directly corrode the metal surface and take up corresponding metal ions, which subsequently may be released and thereby induce the formation of osteolytic lesions in the periprosthetic bone, contributing to the loosening of the implant. © 2010 Wiley Periodicals, Inc. J Biomed Mater Res Part A, 2010.

Background: Patients with a traumatic brain injury (TBI) and bone fractures often show an enhanced fracture healing, as well as an increased incidence of heterotopic ossifications (HO). It has been suggested that unknown osteoinductive factors may be released by the injured brain into the systemic blood circulation and act peripherally on the affected tissues. The aim of this study was to investigate whether serum from TBI patients is osteoinductive. Methods: Sixty-one consecutive patients were classified into four groups: TBI and long-bone fracture (group I, n = 12), isolated severe TBI (group II, n = 21), isolated long-bone fracture (group III, n = 19) and controls (group IV, n = 9). Blood samples were collected at 6, 24, 72 and 168 h post-injury. The osteogenic potential was determined by measuring the in vitro proliferation rate of the human fetal osteoblastic cell line hFOB1.19, and primary human osteoblasts. Additionally, serum induced osteoblastic differentiation was assessed by measuring the mRNA expression of specific osteoblastic markers, including alkaline phosphatase, runt-related transcription factor 2, cathepsin K and serine protease 7. Results: The sera of group I induced a higher mean proliferation rate of primary human osteoblasts at all time points of sampling than group III (P

Polymethyl-methacrylate (PMMA) as part of bone cement is a widely used material in the context of orthopaedic implants and also in cranioplasty. Although PMMA is characterised by excellent biocompatibility with low intrinsic toxicity and inflammatory activation, a minor portion of patients develop allergic reactions. We present the case of a 39-year-old woman with an increasing headache and a corresponding erythema over the parieto-occipital cranioplasty, which was performed 42 days prior using a PMMA compound. A patch test specific for bone cement components confirmed the diagnosis of a PMMA delayed-type hypersensitivity reaction. The prevalence of allergic reactions to bone cement components are known to vary from between 0.6% and 1.6%, however no adequate, pre-interventional diagnostic tool is currently available. Therefore, physicians are required to consider this differential diagnosis even after an extremely delayed onset of symptoms. This case describes the first ever-reported case in the literature of hypersensitivity to bone cement cranioplasty.

January 9, 2009 commemorates the 100-year anniversary of the Swiss surgeon Emil Theodor Kocher's first performance of the surgical removal of a pituitary adenoma by a trans-nasal approach. He was awarded the Nobel Prize in 1909 for his work on the physiology, pathology and surgery of the thyroid gland. He was the first Swiss citizen and the first surgeon to ever receive such an award. He was a pioneer and a world leader in the surgical revolution of the end of the nineteenth century. Over a period of 45 years, Kocher developed a considerable activity in various fields of surgery leading to worldwide acclaim and renown. Kocher's most significant contribution to medicine concerned the thyroid and pituitary gland. Additionally, he developed or modified many surgical instruments. In total, he published 249 articles and books, the majority based on his own experimental studies. His devotion to his patients, his mentoring of students, his service and loyalty to his university hospital was widely recognized and came to epitomize what society wants and needs in its medical practitioners as well as providing example and motivation to young doctors.

BACKGROUND: Severe brain trauma leads to an activation of the immune system. To this date, neither the exact perturbation of the specific immune reaction induced by the traumatic brain injury (TBI), nor the interactions leading to the infiltration of peripheral immune cells into the brain are fully understood. PATIENTS AND METHODS: Serum was collected from 17 patients with TBI and a long bone fracture, 24 patients with an isolated long bone fracture and from healthy individuals. The effect of the serum on normal human monocytes and T-lymphocytes was tested in vitro by assessing proliferation and expression of surface markers, chemokine receptors and cytokines. RESULTS: Serum collected from patients with a TBI and a long bone fracture increased the expression of the chemokine receptor CCR4 in monocytes when compared to patients with an isolated long bone fracture. Extending this comparison to T-lymphocytes, the serum from TBI patients induced lower proliferation rates and decreased expression of the pro-inflammatory cytokine TNF-alpha, while simultaneously increasing the secretion of immune-modulatory cytokines (IL-4, IL-10 and TGF-beta) (p

There is increasing evidence that titanium (Ti(IV)) ions are released from orthopedic implants and play a role in aseptic loosening. This study aimed to investigate whether titanium induces expression of chemokines and cytokines that are important in osteoclastogenesis in human osteoclasts and osteoblasts. Incubation of those cells with 1 muM Ti(IV) significantly upregulated expression of CCL17/TARC and CCL22/MDC, RANK-L, M-CSF and pro-inflammatory cytokines as determined by quantitative real-time PCR and ELISA assays. Additionally, flow cytometry was used to show Ti(IV) related increased expression of CCR4, the cognate receptor for CCL17 and CCL22 in challenged osteoclast precursors. These results strongly suggest that Ti(IV) ions play a role in the recruitment of osteoclast precursors to the bone-implant interface by increasing CCL17 and CCL22 expression and by upregulating their cognate receptor. Moreover the increased expression of RANK-L and M-CSF by osteoblasts together with increased levels of pro-inflammatory cytokines may enhance osteoclast differentiation and activity, and subsequently contribute to the pathomechanism of aseptic loosening.

Most metals in contact with biological systems undergo corrosion by an electrochemical process. This study investigated whether human osteoclasts (OC) are able to grow on stainless steel (SS) and directly corrode the metal alloy leading to the formation of corresponding metal ions, which may cause inflammatory reactions and activate the immune system. Scanning electron microscopy analysis demonstrated long-term viable OC cultures and evident resorption features on the surface of SS discs on which OC were cultured for 21 days. The findings were confirmed by atomic emission spectrometry investigations showing significantly increased levels of chromium, nickel, and manganese in the supernatant of OC cultures. Furthermore, significant levels of pro-inflammatory cytokines IL-1beta, IL-6, and TNF-alpha, which are considered to be major mediators of osteolysis, were revealed in the same cultures by cytometric bead array analysis. Within the present study, it was shown that human osteoclast precursors are able to grow and differentiate towards mature OC on SS. The mature cells are able to directly corrode the metal surface and release corresponding metal ions, which induce the secretion of pro-inflammatory cytokines that are known to enhance osteoclast differentiation, activation, and survival. Enhanced corrosion and the subsequently released metal ions may therefore result in enhanced osteolytic lesions in the peri-prosthetic bone, contributing to the aseptic loosening of the implant.

There is increasing evidence that titanium (Ti) ions are released from orthopedic implants, with concentrations in the range of 1 microM in tissue and blood, and may play a role in aseptic loosening of orthopedic implants. This study investigated whether Ti(IV) ions induce differentiation of monocytic osteoclast precursors into osteo-resorptive multinucleated cells and influence the activation and function of in vitro generated osteoclasts. Human monocytes and in vitro generated osteoclasts were exposed to 1 microM Ti(IV) ions for 10 days. Thereafter, osteoclast differentiation, activation, and function were evaluated. Transcription of specific osteoclastic genes was measured using quantitative reverse transcription polymerase chain reactions, which showed increased expression of tartrate-resistant acid phosphatase (TRAP) in approximately 20% of Ti(IV)-treated monocytes. Detection and quantification of intracellular TRAP activity using ELF97 as a fluorescent substrate revealed a significant increase of TRAP-positive cells in Ti(IV)-treated monocytes. Additionally, as demonstrated on dentin slide cultures, Ti(IV)-treated monocytes became functional bone resorbing cells, significantly increasing their osteo-resorptive activity to similar levels as osteoclasts in vitro. These results suggest that Ti(IV) ions released by biocorrosion from orthopedic implants induce differentiation of monocytes toward mature, functional osteoclasts, which may well contribute the pathomechanism of aseptic loosening.

Earthquakes present a major threat to mankind. Increasing knowledge about geophysical interactions, progressing architectural technology, and improved disaster management algorithms have rendered modern populations less susceptible to earthquakes. Nevertheless, the mass casualties resulting from earthquakes in Great Kanto (Japan), Ancash (Peru), Tangshan (China), Guatemala, Armenia, and Izmit (Turkey) or the recent earthquakes in Bhuj (India), Bam (Iran), Sumatra (Indonesia) and Kashmir (Pakistan) indicate the devastating effect earthquakes can have on both individual and population health. Appropriate preparation and implementation of crisis management algorithms are of utmost importance to ensure a large-scale medical-aid response is readily available following a devastating event. In particular, efficient triage is vital to optimize the use of limited medical resources and to effectively mobilize these resources so as to maximize patient salvage. However, the main priorities of disaster rescue teams are the rescue and provision of emergency care for physical trauma. Furthermore, the establishment of transport evacuation corridors, a feature often neglected, is essential in order to provide the casualties with a chance for survival. The optimal management of victims under such settings is discussed, addressing injuries of the body and psyche by means of simple diagnostic and therapeutic procedures globally applicable and available.

The role of bone morphogenetic proteins (BMPs) in bone healing has been shown in numerous animal models. To date, at least 20 BMPs have been identified, some of which have been shown in vitro to stimulate the process of stem cell differentiation into osteoblasts in human and animal models. Having realized the osteoinductive properties of BMPs and having identified their genetic sequences, recombinant gene technology has been used to produce BMPs for clinical application - most commonly, as alternatives or adjuncts in the treatment of cases in which fracture healing is compromised. BMP-2 and BMP-7 are approved for clinical use in open fractures of long bones, non-unions and spinal fusion. However, despite significant evidence of their potential benefit to bone repair and regeneration in animal and preclinical studies, there is, to date, a dearth of convincing clinical trials. The purpose of this paper is to give a brief overview of BMPs and to critically review the clinical data currently available on the use of BMP-2 and BMP-7 in fracture healing.

Rupture of the pectoralis major muscle is a rare injury that can result in both functional and cosmetic deficiency, with fewer than 150 cases reported in the literature. To date, the injury has been reported exclusively in men and is most common among weight lifters and high-performance athletes. The treatment of partial rupture is conservative, whereas in cases of total rupture surgical repair is advocated, particularly in young active patients. Here, we report the case of a complete proximal tear of the pectoralis major muscle from a seat belt injury sustained in a motor vehicle accident. To the best of our knowledge, this is the first time such a case has been reported in the literature.

Case report.Traumatic atlanto-occipital dislocation (AOD) with a complete medulla/spinal cord transection is rare and believed to be fatal owing to the high level of the spinal cord injury. Clinical outcome is poor. Consequently, relatively few case reports of adult patients surviving this injury appear in the literature. OBJECTIVES AND RESULT: We present the case of a 20-year-old male, who sustained an AOD with a complete medulla/spinal cord transection in a motorcycle accident to discuss the possibility of long-term survival with this condition. The patient underwent occipito-cervical stabilization. With an Injury Severity Score of 75, by definition unsurvivable, the patient is 16 months after the injury, ventilated and fully dependent for all care.Long-term survival following AOD with a complete medulla/spinal cord transection is possible if immediate resuscitation at the scene is available. Nevertheless, it remains questionable whether or not a patient with such a devastating injury and without any prospect of functional recovery should be kept alive under all circumstances.