The sensitivity of ultrasound screening examination in detecting heterotopic ossification following spinal cord injury.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To analyze the role of sonography in detecting heterotopic ossification (HO) following spinal cord injury (SCI). SETTING: Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Ruhr University Bochum, Germany. METHODS: Between January 2003 and December 2013, 217 patients with HO of the hips met the inclusion criteria and were included in the final analyses. The diagnosis of HO was carried out in all cases using our hospital protocol. Primary outcome measure was to calculate the sensitivity of ultrasound screening examination in detecting HO following SCI. RESULTS: The diagnosis of HO was confirmed in 217 patients after a mean interval of 64.8 days (range from 8 to 295; s.d.=40.4) via computerized tomography or magnetic resonance imaging scan. In 193 out of 217 patients, suspicious HO signs were noted in the ultrasound screening examination (sensitivity=88.9%). CONCLUSIONS: The use of ultrasound for screening for HO in SCI patients is reliable and has a high sensitivity.

Ankylosing spondylitis does not increase the risk of neurogenic heterotopic ossification in patients with a spinal cord injury: a retrospective cohort study.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: The present study was performed to analyze the impact of ankylosing spondylitis (AS) in developing heterotopic ossification (HO) in patients following spinal cord injury. SETTING: Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany. MATERIALS AND METHODS: Between January 2003 and December 2015, 67 patients with AS and SCI were included in the study. The control group consisted of 141 patients with SCI and without AS. The definitive diagnosis of HO was made via magnetic resonance imaging or computed tomography. Primary outcome measure was to analyze the impact of AS on the development of HO. RESULTS: Fifteen out of 67 AS patients (22.4%) had a diagnosed HO. In the control group, 28 of 141 patients (19.9%) suffered from HO. Patients with AS had no significant higher risk for HO development compared with patients without AS (RR=1.16; 95% CI=0.65-2.09). However, patients with a complete neurological deficit had a twofold higher risk for HO development (RR=2.55; 95% CI=1.26-5.16). CONCLUSIONS: AS does not increase the risk for HO development in patients with spinal cord injury.

In-hospital outcomes following single-dose radiation therapy in the treatment of heterotopic ossification of the hip following spinal cord injury-an analysis of 444 cases.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: The objective of the study was to analyse the efficacy of single-dose radiation therapy in the treatment of heterotopic ossification (HO) following spinal cord injury (SCI). SETTING: Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany. METHODS: Patients who were treated for HO around the hips following SCI at our institution between January 2003 and December 2013 were included in this retrospective cohort study. A total of 444 HO cases around the hip were treated with single-dose radiation therapy after a mean time interval of 4.9 days (0-97 days; s.d.=8.1) after HO diagnosis. Primary outcome measures were the number of HO relapses and the occurrence of adverse side effects related to the radiation therapy. RESULTS: After a mean time interval of 63.2 days (8-295 days; s.d.=39.6) subsequent to SCI HO occurred in 207 male (84.8%) and 37 female (15.2%) patients with a mean age of 46.4 years (18-81 years, s.d.=18.2). In 200 patients both hips were affected, whereas the remaining 44 HO occurred unilateral. None of the patients suffered primary side effects due to the radiation therapy. However, in 13 out of 244 patients (5.3%), HO relapse occurred. After repeated single-dose radiotherapy, one patient suffered joint ankylosis and therefore required surgical resection. CONCLUSION: Our results present that single-dose radiation therapy is a safe option in the treatment for spinal cord-injured patients suffering from HOs of the hips.

Heterotopic ossification of the shoulder joint following spinal cord injury: an analysis of 21 cases after single-dose radiation therapy.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: Heterotopic ossification (HO) affecting the hips is a common complaint of patients suffering traumatic spinal cord injury. However, the incidence of HO of the shoulder is considerably rare. In this context, we report on our results of 13 patients with a total of 21 cases of shoulder HO and single-dose radiation therapy. SETTING: Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany. METHODS: The study group consists of 12 male and 1 female patient with a mean age of 55.5 years (range from 24 to 81 years; s.d.=14.5). Primary outcome measures were defined as the number of HO relapses and the number of side or adverse effects in relation to the radiation therapy. RESULTS: At the time of latest follow-up during hospitalization, the mean shoulder flexion was 92.1° while mean abduction was 94.5°. The average external rotation was 26.4°. No HO recurrence occurred and none of the patients suffered any adverse effects related to radiation therapy. CONCLUSIONS: In conclusion, single-dose radiation therapy in the treatment of shoulder HO due to spinal cord injury is an effective and reliable method, although the risk of secondary side effects related to the radiation therapy remain unknown.

The roles of serum alkaline and bone alkaline phosphatase levels in predicting heterotopic ossification following spinal cord injury.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To analyze the usefulness of serum alkaline phosphatase (AP) and bone alkaline phosphatase (BAP), as well as C-reactive protein (CRP) levels in predicting heterotopic ossification (HO). SETTING: Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Ruhr University Bochum, Germany. METHODS: Between January 2003 and December 2013, 87 patients with HO around the hips met the inclusion criteria and were included in the study. Alkaline phosphatase, CRP and BAP were assessed and interpreted at the time of HO diagnosis and after radiation therapy in all patients. RESULTS: At the time of HO diagnosis, 49 out of 87 patients (49.4%) had elevated alkaline phosphatase levels and 39 out of 87 patients (44.8%) had elevated BAP levels. Elevated CRP values were found in 67 patients (77.0%). Within 3 days after single-dose radiation therapy, elevated AP levels persisted in 38 patients (43.7%) and elevated BAP levels in 28 patients (32.2%). CONCLUSIONS: The results obtained show that the determination of CRP, AP and BAP levels may not be considered a reliable screening method for early HO detection, subsequent to spinal cord injury.

[Exoskeletons for rehabilitation of patients with spinal cord injuries. Options and limitations]. / Exoskelette in der Rehabilitation Querschnittgelähmter. Möglichkeiten und Grenzen.

BACKGROUND: Mobile exoskeletons are increasingly being applied in the course of rehabilitation and provision of medical aids to patients with spinal cord injuries. OBJECTIVES AND METHODS: This article gives a description of the currently available exoskeletal systems and the clinical application including scientific and medical evidence, to derive recommendations regarding clinical practice of the various exoskeletons in the rehabilitation of patients with spinal cord injuries. RESULTS: The different systems represent a useful adjunct to the therapeutic regimen depending on the medical objectives. Posture-controlled exoskeletons in particular enable mobilization of patients with neurological gait disorders via direct motion support. In addition the neurologically controlled exoskeleton HAL® leads to functional improvements in patients with residual muscular functions in the chronic phase of spinal cord injury in terms of improved walking abilities subsequent to training. However, beneficial effects on bone density, bladder function and perfusion are conceivable but not yet adequately supported by evidence. Positive effects on spasticity and neuropathic pain are currently based only on case series or small clinical trials. CONCLUSION: Although exoskeletons are not yet an established tool in the treatment of spinal cord injuries, the systems will play a more important role in rehabilitation of patients with spinal cord injuries in the future. Neurologically controlled exoskeletons show beneficial effects in the treatment of acute and chronic spinal cord injuries and might therefore evolve to be a useful alternative to conventional locomotion training.

Surgical extraction after thrombosis around the Avalon dual lumen cannula.

The use of a dual lumen cannula (DLC) for venovenous extracorporeal membrane oxygenation (ECMO) has several advantages and reports of complications are rare. We present a case of thrombosis around and inside the Avalon Elite™ bicaval DLC (Avalon Laboratories, Rancho Dominguez, CA, US), for which simple removal by retraction was impossible. A 30-year-old man had experienced an unstable C6/7 fracture with spinal contusion and haematoma in the spinal canal with incomplete neurological paraplegia and thoracic trauma. He developed acute respiratory failure due to posttraumatic systemic inflammatory response syndrome and venovenous extracorporeal membrane oxygenation (ECMO) support was indicated. The cannulation was performed with an Avalon Elite™ cannula (31Fr) in the right jugular vein under fluoroscopy. After 18 days of ECMO therapy, despite the continuous administration of heparin (400iu/h), ECMO was discontinued because of the formation of a massive thrombus in the oxygenator. At that time, the patient's haemodynamic and respiratory parameters were stable, and we were able to induce a rapid weaning from ECMO. The surgical removal of the cannula became necessary and was performed using a small neck incision without complications. We report this case to emphasise that any resistance encountered during an attempt to extract the Avalon Elite™ cannula may cause serious complications. In such cases, surgical removal must be considered.

Does spinal cord injury influence the mortality rate in patients with necrotizing fasciitis?

STUDY DESIGN: Retrospective chart review. OBJECTIVES: This study was performed to compare the outcome, especially the mortality rate, in patients with and without spinal cord injury (SCI) and necrotizing fasciitis (NF). SETTING: Division of Spinal Cord Injury and Department of Plastic and Hand Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany. METHODS: Twenty-five patients with SCI and thirty patients without SCI treated with NF were included in the study. Mean length of hospital stay, mean age, mean laboratory risk indicator for necrotizing fasciitis (LRINEC) score, mean number of surgical debridements, co-morbidity factors and mortality rate were compared between both groups. RESULTS: There were no differences for the mean LRINEC score (P=0.07), mean number of surgical debridements (P=0.18) and co-morbidities (odds ratio=2.32; 95% confidence interval =0.78-6.92) between both groups. Patients with SCI were significantly younger than patients without SCI (P=0.02). Patients without SCI had a higher mortality risk rate (n=9) than patients with SCI (n=2) (relative risk=1.71; 95% confidence interval =1.13-2.6). CONCLUSIONS: In conclusion, SCI patients have a lower mortality rate than patients without SCI. Age may influence the mortality rate. Nevertheless, we believe that further unknown risk factors might influence the mortality, especially in patients with SCI.

[Aspiration pneumonia after spinal cord injury. Placement of PEG tubes as effective prevention]. / Aspirationspneumonie nach HWS-Verletzung. Präventiver Effekt von PEG-Sonden.

BACKGROUND: Pulmonary infections are dreaded complications in acute spinal cord injuries. The prevention of pneumonia is essential for reducing mortality and the period of hospitalization. Swallowing disorders occur frequently in patients with cervical cord injuries and are accompanied by aspiration with a high risk of pneumonia. PATIENTS AND METHODS: In this study the identification and analysis of patients with newly acquired cervical cord injuries were carried out with respect to respiratory complications, treatment and prevention. RESULTS: A total of 27 patients with a cervical cord injury (tetraplegia) were identified. Of these 20 patients (74%) were identified with a swallowing disorder and a high risk of aspiration. Of these patients 11 (PEG group) received a percutaneous feeding tube (PEG tube), 9 patients (non-PEG group) with diagnosed dysphagia were treated without PEG tube. A total of 6 patients in the non-PEG group (67%) acquired pneumonia compared to 3 patients (27%) in the PEG group. CONCLUSION: A swallowing disorder is a major risk factor for a pulmonary infection after a cervical cord injury. An early placement of a PEG tube has a preventive effect with respect to aspiration pneumonia in patients with dysphagia.

Pressure sores significantly increase the risk of developing a Fournier's gangrene in patients with spinal cord injury.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: The aim of our study was to evaluate the mortality rate and further specific risk factors for Fournier's gangrene in patients with spinal cord injury (SCI). SETTING: Division of Spinal Cord Injury, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany. METHODS: All patients with a SCI and a Fournier's gangrene treated in our hospital were enrolled in this study. Following parameters were taken form patients medical records: age, type of SCI, cause of Fournier's gangrene, number of surgical debridements, length of hospital and intensive care unit stay, co morbidity factors and mortality rate. In addition, laboratory parameter including the laboratory risk indicator for necrotizing fasciitis (LRINEC) score and microbiological findings were analyzed. Clinical diagnosis was made via histological examination. RESULTS: A total of 16 male patients (15 paraplegic and one tetraplegic) were included in the study. In 81% of all cases, the origin of Fournier's gangrene was a pressure sore. The median LRINEC score on admission was 6.5. In the vast majority of cases, a polybacterial infection was found. No patient died during the hospital stay. The mean number of surgical debridements before soft tissue closure was 1.9 and after a mean time interval of 39.1 days wound closure was performed in all patients. CONCLUSIONS: Pressure sores significantly increase the risk of developing Fournier's gangrene in patients with SCI. We reported the results of our patients to increase awareness among physicians and training staff working with patients with a SCI in order to expedite the diagnosis.

[Spine fractures in patients with ankylosing spondylitis: an analysis of 129 fractures after surgical treatment]. / Wirbelsäulenfraktur bei ankylosierender Spondylitis : Eine Analyse von 129 Frakturen nach operativer Versorgung.

INTRODUCTION: The ankylosing spondylitis (AS) is a systemic rheumatic disease, which affects the skeleton, joints and internal organs. Attributed to the augmented rigidity of the spine and the concomitant impairment of compensatory mechanism minor force might cause spine fractures. Multilevel stabilization and dorsoventral instrumentation is a well - established procedure. This study was to evaluate the surgical outcome of 119 patients with AS associated spine fractures. METHODS: From 07/96 to 01/10, 119 patients with 129 spine fractures due to AS were treated in our department. Data were collected retrospectively. In all patients the operative treatment of the fracture was either performed by ventral and/or dorsal spondylodesis. RESULTS: The median age was 67 years (37-95). There were 51 cervical, 55 thoracic and 23 lumbar spine fractures. On initial presentation no fractures in 18 patients (15%) and stable fractures in 15 patients (13%) were detected, which further secondarily dislocated. Thus, in 28% of the patients the injury was assessed falsely. 47% of the fractures were preceded by a trivial trauma in domestic surrounding. 61 patients (51%) developed either an incomplete or a complete paraplegia. In 32 patients ventral instrumentation, in 82 patients dorsal and in 15 patients dorsoventral instrumentation were performed. 14% developed postoperative wound infection an in 15% revision surgery due to implant loosening or insufficient stabilization was required. CONCLUSION: Early diagnostic of AS associated spine fractures using conventional radiographs and computed tomography scans is important for the detection and adequate treatment. A great amount of spine fractures are obviously either under diagnosed or underestimated, initially. A secondary dislocation of the fracture might result in severe neurological complications up to paraplegia.

[Treatment of heterotopic ossification after spinal cord injury - clinical outcome after single-dose radiation therapy]. / Therapie der heterotopen Ossifikation bei frischem Rückenmarkstrauma - Klinisches Outcome nach einmaliger Radiatio.

INTRODUCTION: Heterotopic ossification (HO) is a common and serious complication after spinal cord injury, with an incidence of 5-50 %. Single-dose radiation therapy with 7 Gy is an established procedure for HO prophylaxis after total hip replacement. The aim of our study was to determine the clinical outcome after single-dose radiation therapy in the prophylaxis of HO in paraplegic patients. PATIENTS AND METHODS: Between January 2006 and July 2009, 75 paraplegic patients with heterotopic ossification were treated in our hospital. On the basis of the defined inclusion and exclusion criteria, 62 patients were included in our study, whereas 55 patients participated in our follow-up examination. All patients received a bi-weekly ultrasound of the hip for an attempt at early diagnosis of the condition. In case of an ultrasound suspicion of HO, a computed tomography (CT) or magnetic resonance imaging (MRI) of the hip was performed. After confirmation of HO, a single-dose radiation therapy with 7 Gy was performed. In group A, the patients were irradiated with an electrode voltage of 15 MeV (36 patients) and in group B with 6 MeV (26 patients). All patients were assessed with a standardised questionnaire with a mean follow-up of 30.6 months (range 6-78 months). RESULTS: The mean interval time between the initial spinal injury and HO development was 58,2 days (range 14-125). 69,4 % of all patients revealed a Brooker grade I, 27.4 % grade II and 3.2 % a grade III. No cases of Brooker grade IV (ankylosis) occurred. No patient showed side-effects after radiation therapy. However, in group A one patient (3,2 %) and in group B three patients (12.5 %) developed HO relapse. Those patients were treated again with a single-dose radiation therapy with 7 Gy and 15 MeV and, afterwards, they were free of complaints. Deep vein thrombosis was confirmed in 11 patients (32.3 %) in group A and in 8 patients (33.3 %) in group B. CONCLUSIONS: Single-dose radiation therapy with 7 Gy in the treatment of heterotopic ossification is an effective option. A higher electrode voltage improves the effectiveness of the irradiation and the clinical outcome. Essential for the outcome is the early detection and treatment of HO with single-dose radiation therapy. Randomised, prospective studies should be undertaken in order to confirm these findings.

[Vertebral fractures in patients with ankylosing spondylitis: a retrospective analysis of 66 patients]. / Wirbelfrakturen bei patienten mit spondylitis ankylosans: eine retrospektive analyse von 66 patienten.

PURPOSE: Retrospective analysis of vertebral fractures in patients with ankylosing spondylitis (AS) for the evaluation of associations with mortality, concurrent neurological deficits, and other complications. MATERIALS AND METHODS: Image analysis (conventional radiographs, CT, MRI) was applied to all patients with AS admitted between 1997 and 2007 due to vertebral fractures to determine fracture location and classification. Patient characteristics, trauma mechanism, neurological symptoms, and other complications were documented. RESULTS: 66 patients (54 male, age 64 +/- 11 years) were enrolled in the study. 74 % of patients suffered from minor trauma. 51 % and 56 % had cervicothoracic and thoracolumbar fractures, respectively, while 8 % had multi-level fractures. 63 % of patients suffered combined vertebrodiscal fractures. 70 % revealed neurological symptoms, significantly correlating with spinal stenosis (p = 0.024; Odds ratio 4.265) and hyperlordosis (p = 0.014; OR 4.806). 68 % developed complications with non-combined fractures (p = .042; OR 4.954) and paravertebral hematomas (p = .009; OR 16.969) representing independent risk factors. The female gender (p = 0.005; OR 15.617) and conservative therapy (p = 0.040; OR.094) exerted significant influence on the mortality rate. CONCLUSION: Vertebral fractures frequently occur in patients with AS after minor trauma and often lead to neurological symptoms, which in turn are associated with spinal stenosis and hyperlordosis. Paravertebral hematomas and non-combined fractures are accompanied by higher incidences of other complications. The female gender entails a higher mortality rate.

[The spontaneous spinal epidural haematoma]. / Das spontane spinale epidurale Hämatom.

Spontaneous spinal epidural haematoma (SSEH) is a rare and serious condition. Four cases of SSEH are presented in this paper, three of which were in the cervical segment while one involved the entire spine. In two of these four cases the diagnosis was not made until late in the course, and persisting neurological deficits resulted; one case was diagnosed early and the neurological outcome was good; and in one the decompression achieved was inadequate, owing to intraoperative complications. Laminectomy was performed in all four cases for the purpose of decompression of the spinal cord but at different intervals after the onset of symptoms and with different neurological outcomes. The prognosis of SSEH depends heavily on the time that elapses between the onset of symptoms and the surgical treatment. The diagnostic procedure of choice is MRI.

[The dorsal spondylodesis of rotationally unstable thoracic fractures. Is additional ventral stabilization necessary?]. / Dorsale Spondylodese rotationsinstabiler Frakturen der Brustwirbelsäule. Bedarf sie einer ventralen Gegenstabilisierung?

METHODS: A total of 60 patients with solely dorsally reconstructed type C fractures of the thoracic spine admitted between January 2000 and December 2003 were retrospectively evaluated. Stability was determined by measuring kyphosis of the vertebral body, the operated segments and of lateral bending on the basis of plain films and computed tomography immediately postoperatively and after 2 and 19 months. RESULTS: There were 48% C2, 38% C1 and 13% C3 fractures. Of the injuries, 28% were caused by motorbike accidents, 25% by car accidents, 23% by falling from a height, 13% by suicidal jumps, 3% by ski accidents and 3% for other reasons. A total of 92% of the patients had severe thoracic trauma as attendant injuries, 42% further vertebral fractures, 35% a head injury, 30% an extremity fracture, 15% a clavicle fracture, 8% an abdominal trauma and 7% a fractured pelvis. At 19+/-12 months postoperatively, the angle of the operated segments increased by 4.7 degrees +/-4.0 degrees and that of lateral bending of the operated segments by 0.7 degrees +/-1.8 degrees compared to the immediate postoperative values. CONCLUSION: In spite of the high instability of the injured spine, the collective examined had no relevant postoperative loss of correction and no increase in lateral bending. Therefore, a solely dorsal reconstruction is sufficient, reasonable and economical.

[Early rehabilitation care in the hospital--definition and indication. Results of the expert group "Early Rehabilitation Care in the Hospital"]. / Frührehabilitation im Krankenhaus--Definition und Indikation. Ein Ergebnisbericht der Methodengruppe "Frührehabilitation im Krankenhaus".

As a result of the continuing development in recent medicine, and improvements of emergency services, an increasing number of patients are surviving serious disease and injury. This has increased the need for rehabilitation, starting already during the acute hospital stay. Early identification and rehabilitation may reduce overall costs and help patients to regain independence earlier. Since the eighties specialized early post-acute rehabilitation units have been increasingly implemented in German hospitals. With book 9 of the German Social Code (SGB IX) coming into effect in July 2001, early post-acute rehabilitation care in hospitals became accepted as a social right. However, the specifics of early rehabilitation care have not been defined. There is a lack of generally accepted indication criteria for early rehabilitation services. Similarly, the aims, objectives and methods need to be specified. It was the objective of a group of interested experts from different fields and backgrounds to achieve an interdisciplinary consensus in terms of conceptual definitions and terminology for all early rehabilitation care services in the acute hospital. The development of the definitions and criteria was achieved by using a modified Delphi-technique. By publishing this paper the group is providing information about its activities and results. Examples of typical cases from the various fields of early rehabilitation care were identified and described. Furthermore, the report points out a number of other problems in the area of early rehabilitation care, which have yet to be solved.

[Thoracic injuries associated with acute traumatic paraplegia of the upper and middle thoracic spine]. / Die Akutbehandlung der traumatischen Brustmarklähmung Wird das Thoraxtrauma übersehen oder unterschätzt?

AIM: The aim of this study was to analyse the number of thoracic injuries associated with acute traumatic paraplegia of the upper and middle thoracic spine and review the early management in respect to treatment standards. METHODS: Using a prospective study protocol, data were sampled and analyzed from 12 December 2000 to 31 March 2002 at a level 1 trauma center. RESULTS: Twenty-two consecutive patients were included in the study. Sixteen suffered severe chest traumata. Lung contusion was diagnosed in 81%, followed by haemopneumothorax (75%) and fracture of the bony chest (75%). Intubation was performed 12 times in all. Chest drainage was performed in 14 patients. The mean duration of artificial ventilation was 20 days (range 2-93) and of intensive care treatment 25 days (range 2-93). Five patients died. CONCLUSIONS: Acute traumatic paraplegia of the upper and middle thoracic spine caused by high energy trauma is highly associated with severe chest trauma. Therefore, respiratory impairment must be kept in mind during the early treatment. If respiratory failure becomes more evident, emergency procedures such as intubation and chest drainage have to be performed. Secondary transfer should be avoided.

[Intramedullary abscess of the spinal cord--a rare pathology. Case report, therapeutic regimen and review of the literature]. / Der intramedulläre Abszess des Rückenmarks--ein seltenes Krankheitsbild. Falldarstellungen, Behandlungskonzept und Literaturübersicht.

Although the presence of an intramedullary abscess of the spinal cord is extremely rare, it is most important to be aware of its existence in the differential diagnosis of neurological diseases. Existing neurological deficits with progressive symptoms of paraplegia should always be regarded as suspect and a differential diagnosis of an intramedullary abscess of the spinal cord should then be included in the therapeutical regimen. A correct diagnosis using MR-tomography followed by an early surgical treatment strategy are essential for the affected patients, simply because an early diagnosis and an immediate operative intervention represent decisive prognostic factors independent from the cause of infection. Surgical intervention must include a decompressive laminectomy, a myelotomy, and also a secure intraoperative abscess drainage. In this analysis two patients will be reported on, both of whom were already showing symptoms of paraplegia at the time they were admitted to hospital. In both cases MR-tomographically an intramedullary nodulary lesion of the spinal cord could be detected. However, due to a complete lack of any acute symptoms of inflammatory reaction in one patient, an intramedullary abscess was not actually diagnosed before surgical treatment was performed. These two cases, together with existing scientific literature, aim to present an overview of the pathogenesis, the clinical symptomatology, the treatment strategy, and the expected therapeutical outcome of an intramedullary abscess formation. It will be shown that by treating this disease as early as possible using adequate therapeutic interventions a functional improvement of the resulting neurological symptoms can be expected.

Adaptationism and the anthropoid postcranium: selection does not govern the length of the radial neck.

The length of the radial neck has been assumed to vary in living and extinct primates in accordance with its role as a moment arm during flexion by the m. biceps brachii. We here use a simple developmental approach to investigate whether or not this trait does, in fact, vary in such a manner. We find, instead, that virtually all variation in radial neck length is explicable as a simple correlate of overall body size, and that there is no evidence to conclude that selection has separately modified radial neck length in response to differing locomotor patterns. Further implications for the interpretation of mammalian skeletal morphology are briefly discussed.