A morphometric cadaver study of the anterior lumbar epidural space.

INTRODUCTION: Free disc fragments end often up in the concavity of the anterior epidural space. This space consists of two compartments. The discrepancy between the impressive magnetic resonance imaging findings, clinical symptoms in patients and the problem of treatment options led us to the anatomical determination of anterior epidural space volumes. MATERIALS AND METHODS: For the first time, the left and right anterior epidural volume between the peridural membrane and the posterior concavity of the lumbar vertebral bodies L3-S1 were determined for each segment. A CT scan and a polyester resin injection were used for the in vitro measurements. RESULTS: The volumes determined in human cadavers using this method ranged from 0.23 ccm for L3 to 0.34 ccm for L5. The CT concavity volume determination showed this increase in volume from cranial to caudal, as well. CONCLUSION: This volume is large enough to hold average-sized slipped discs without causing neurological deficits. A better understanding of the anterior epidural space may allow a better distinction of patient treatment options.

[Effectiveness and safety of a homeopathic drug combination in the treatment of chronic low back pain. A double-blind, randomized, placebo-controlled clinical trial]. / Wirksamkeit und Sicherheit eines homöopathischen Komplexpräparates bei chronischen Rückschmerzen. Doppelblinde, randomisierte, placebokontrollierte, klinische Studie.

BACKGROUND: The homeopathic drug combination Lymphdiaral Basistropfen is established in the treatment of edema and swellings. This is the first time the effectiveness and safety was investigated in the treatment of chronic low back pain. METHODS: The study is a randomized, double-blind, placebo-controlled trial. From December 2003 to May 2007 248 patients aged 18 to 75 years were screened, 228 were randomized, 221 started therapy, in 192 the progress was measured (103 verum vs. 89 placebo), 137 completed the study (72 verum vs. 65 placebo). They received 10 drops of verum or placebo solution three times daily for 105 days additionally to an inpatient complex naturopathic treatment. RESULTS: The hannover functional ability questionnaire score (primary outcome measure) tends to increase in the intention-to-treat-analysis (verum: 6.6 vs. placebo: 3.4; p = 0.11) and increases significantly in the per-protocol-analysis (verum: 9.4 vs. placebo: 4.1; p = 0.029). The treatment was well tolerated (92.9% vs. 95.4%). The incidence of adverse reactions and serious adverse reactions was similar in both treatment groups. CONCLUSIONS: This first randomized, double-blind, placebo-controlled trial shows, that the homeopathic drug combination can improve the treatment of chronic low back pain.

An international expert survey on acupuncture in randomized controlled trials for low back pain and a validation of the low back pain acupuncture score.

BACKGROUND: Acupuncture is a promising treatment approach in patients with chronic low back pain (cLBP) but little is known about the quality of acupuncture in randomized controlled trials (RCT) of acupuncture cLBP. - OBJECTIVE: To determine how international experts (IES) rate the quality of acupuncture in RCTs of cLBP; independent international validation of the Low Back Pain Acupuncture Score (LBPAS). METHODOLOGY: Fifteen experts from 9 different countries outside China were surveyed (IES). They were asked to read anonymized excerpts of 24 RCTs of cLBP and answer a three-item questionnaire on how the method of acupuncture conformed to 1) Chinese textbook standards, 2) the expert?s personally preferred style, and 3) how acupuncture is performed in the expert?s country. Likert scale rating, calculation of the mode for each answer, and Spearman?s rank correlation coefficient between all three answers and the LBPAS were calculated. RESULTS: On comparison with Chinese textbook standards (question 1), 6 RCTs received a good rating, 8 trials a fair and 10 trials a poor or very poor rating. 5 of the 6 trials rated good, received at least a good rating also in question 2 or 3. We found a high correlation of 0.85 (p<0.0001) between the IES and LBPAS ratings for question 1 and question 2, and a correlation of 0.66 (p<0.0001) for question 3. CONCLUSION: The international expert survey (IES) revealed that only 6 out of 24 (25%) RCTs of acupuncture for cLBP were rated "good" in respect to Chinese textbook acupuncture standards. There were only small differences in how the acupuncture quality was rated in comparison to Chinese textbook acupuncture, personally preferred and local styles of acupuncture. The rating showed a high correlation with the Low Back Pain Acupuncture Score LBPAS.

[Does osteoporosis lead to reduction the primary stability of cementless hip cups?]. / Führt Osteoporose zu einer Reduktion der Primärstabilität zementfreier Hüftpfannen?

BACKGROUND: Cementless hip cups require adequate primary stability in order to achieve osseointegration. Depending on implant design, a different biomechanical behavior in osteoporotic bone and in bone with normal bone mineral density might be expected. MATERIAL AND METHODS: The micromovement between bone and implant was determined in macerated human hip acetabula with reduced and with normal bone density for two different cementless screwed cups and two different cementless press-fit cups. The bone mineral density was assessed by means of Q-CT and 20 implantations were performed for each acetabulum with reduced and with normal bone density. RESULTS: Screwed cups showed significantly less micromovement than press-fit cups. The average micromovement of all cups, with the exception of the Monoblock cup, remained below the value of 100 µ, the upper limit for successful osseointegration. Values of over 200 µ were measured only for the Monoblock cup and only in some of the tests. There was no significant difference between the micro-movement in acetabula with reduced bone mineral density and with normal bone. CONCLUSION: Impaired osseointegration in osteoporotic bone because of increased micromovement is not to be expected in the investigated cementless hip cups as no relevant differences in micromovement were found between normal and osteoporotic bone stock. On the basis of the good clinical results with the Monoblock cup, the upper limit of 100 µ of micromotion for osseointegation in macerated bone is probably set too low.

[Naturopathic and orthopaedic in-patient treatment of chronic back pain--a comparison study]. / Naturheilkundliche und orthopädische station are Behandlung bei chronischen Rückenschmerzen: Eine Vergleichsstudie.

BACKGROUND: This study compares orthopaedic and naturopathic inpatient treatment concepts for back pain with regards to therapeutic efficacy. PATIENTS AND METHODS: A controlled prospective cohort study is presented. 187 conservatively treated patients of an orthopaedic clinic and 161 patients of a clinic for naturopathy were recruited for the study, if they needed inpatient treatment because of chronic back pain.The results were measured with the Oswestry Score for orthopaedic symptoms as primary endpoint and the SF-36 for life quality before treatment (T0), after 3 (T2) and 6 months (T3), plus the SES for pain intensity and pain quality (T0, T1 = at discharge, T2, T3). Accompanying diseases were documented with anamnesis and catamnesis sheets. The whole collectives were evaluated. Additionally a gender specific analysis was performed. RESULTS: For the main and secondary objectives no differences between the naturopathic and orthopaedic treatment groups (screened patients with back pain for naturopathy 286, 187 for orthopedics, in the study included patients 161 respectively 140 after 2 weeks, 62 respectively 68 after 6 months; mean age 57.1 respectively 54.0 years, female 85.1 respectively 63.6%) could be verified (Oswestry Score at T0: 43.0, 95%-confidence-interval 39.6-45.3; at T2: 40.7, 95%-confidence-interval 37.4-44.0). Only in the subgroup of women, who account for 86% of the naturopathic patients, a difference in the main objective (Oswestry Score) was found (p = 0.014) in favour of naturopathy (T2: 32.6, 95%-confidence-interval 24.9-40.2) compared to orthopedics (T2: 45.1,95%-confidence-interval 41.2-49.1). CONCLUSION: Treatment results of naturopathic, complex" inpatient treatment of chronic back pain are comparable to conventional orthopaedic treatment at all points of time T1 to T3. The study design does not allow the conclusion, that the therapeutical concept can be changed forthetwo groups of patients with the same chance of good therapeutical efficacy. The result of the study is limited in this respect as the therapeutic effect cannot be claimed to be the same if the treatment groups were exchanged. Thus the improvement is only comparable.

[Rupture of the anterior cruciate ligament. Diagnostics and therapy]. / Ruptur des vorderen Kreuzbands. Diagnostik und Therapie.

Rupture of the anterior cruciate ligament (ACL) is the most common ligamentous knee injury. The knee is stabilized by the cruciate ligaments and the collateral ligaments. The ACL originates from the inner surface of the lateral condyle of the femur, runs in an anterior medial direction and inserts at the tibial plateau in the intercondyle area. The most common injury is an indirect knee trauma, typically a joint torsion in sports. Patients often describe a snapping noise followed by hemarthrosis. Concomitant injuries are lesions of the medial collateral ligament, the medial meniscus (unhappy triad) and chondral fractures. The age peak is between 15 and 30 years with a higher incidence in females. The cardinal symptom of the ACL rupture is the giving way phenomenon. The clinical diagnosis is provided by a positive Lachman test, a positive pivot shift test and the anterior drawer test. Fractures can be excluded by X-ray examination. Magnetic resonance imaging (MRI) allows the evaluation of the internal knee structures. ACL repair is carried out by arthroscopically assisted bone-tendon-bone or semitendinosus grafting techniques. Early rehabilitation is important for a good functional outcome.

[Comparison of treatment expenses of naturopathic and orthopedic in-patient treatment]. / Kostenvergleichsuntersuchung zur naturheilkundlichen und konventionellen orthopädischen stationären Behandlung.

BACKGROUND: In health services research comparative studies between orthopaedics and naturopathy are necessary. They allow evidence based decisions between individual therapeutical alternatives as well as decisions on health politics, e.g. concerning allocation of resources. PATIENTS AND METHODS: A controlled prospective cohort study is presented. Conservatively treated patients were recruited for the study, if they needed in-patient treatment because of chronic back pain. The conservative orthopaedic treatment including Minimal invasive Therapy (MIT) was compared to in-patient naturopathic "complex"-treatment. The real costs to the public health insurance system are unknown--relating to both the individual patient and the physician. Hence an approximation was attempted on the basis of the billing of the concerned hospitals, the analysis of extensive patient interviews, randomly selected evaluation of in- and out-patient records, validated by an expert panel. RESULTS: Costs for medication decreased in the post stationary phase after orthopedic and naturopathic treatment. Rehabilitation measures and treatments at a health resort increased after orthopedic treatment, whereas the frequency of specialist consultation decreased in both cohorts indicating the efficacy of the in-patient treatment. Incidence of psychotherapy was highest in the naturopathic group before admission to hospital and decreased afterwards. The gathered data point to a reduction of the total outpatient treatment costs in both cohorts. There were treatment-specific differences when regarding single components. CONCLUSION: Naturopathic complex in-patient treatment is a cost-efficient complement of the conventional orthopedic treatment options.

[Cement-in-cement hip revision with a long-stemmed femoral component]. / Zement-in-Zement-Hüftrevision mit einem zementierten langen Prothesenstiel.

Revision hip surgery often requires individualized techniques and implants. We report on a case of failed femoral revision in an extensively cemented femur with a concomitant proximal and dorsal femoral bone defect. We advocate the clinically effective revision procedure of antegrade drilling of the stable cement mantle and use of a cemented long-stemmed femoral component. This cement-in-cement revision technique is discussed along with the pertinent literature.

[Uncemented arthroplasty of the hip]. / Zementfreie Endoprothetik des Hüftgelenks.

Prognosis of cemented total hip replacement seems to be excellent for elderly patients. In younger age the outcome is less favourable and early revision is more common. Thus, different concepts with better prognosis and preservation of bone stock for possible revisions were needed. After more than 30 years of application with excellent short-term and long-term results, uncemented total hip arthroplasty is nowadays generally regarded as the standard procedure for younger patients. New bone-preserving implants, such as surface replacement or short-stemmed femoral shaft prostheses, have been introduced especially for younger patients. Some of these new procedures are still under development, and the long-term results of new implant concepts have to be evaluated over the next decades. Regarding recently published scientific studies an overview about non-cemented total hip arthroplasty is given and current concepts and developments are presented.

[Back school - an update]. / Rückenschule heute.

AIM: The aim of this paper is to present an update of the Back School concept including recent randomised controlled studies, systematic reviews and guidelines. METHOD: After definition and classification of the origins of the Back School concept, results of randomised controlled studies and systematic reviews within the framework of the Cochrane Collaboration Back Review Group are presented with their consequences with regard to German and International guidelines for the rehabilitation and prevention of low-back pain. RESULTS: The Back School, integrated into a multidisciplinary programme, is effective in the rehabilitation and prevention of recurrent and chronic low-back pain. It is not effective for acute back problems when compared to other treatment modalities. There is moderate evidence suggesting that back schools in an occupational setting reduce pain and improve function and return to work status. CONCLUSION: The classic structure of the Back School with information, back protection exercises and gymnastics can be practiced successfully for chronic low-back pain and in an occupational setting. Insurance companies should consider the low-cost technology. For children, adolescents and for older people with osteoporosis and lumbar spinal stenosis, a special age-orientated design of the Back School is necessary.

[Epidural injection therapy with local anaesthetics versus cortisone in the lumbar spine syndrome: a prospective study]. / Die epidurale Injektionsbehandlung mit Lokalanästhetikum versus Kortison beim chronischen lumbalen Nervenwurzelkompressionssyndrom: eine prospektive Studie.

AIM: The prospective randomised double-blind study analyses follow-up data of the therapeutic effects of cortisone versus local anaesthetics using an injection technique close to the nerve root in chronic lumbar spine syndrome. METHODS: 57 patients were included with an MRI-assured clinical diagnosis. The study was performed over a 6-month period to evaluate long-term effects. The level of disability (ODQ), the quantitative and qualitative sensations of pain were separately determined. The t-test was used for interval and relation variables, the chi (2) test for nominal variables and the Mann-Whitney-U-test for ordinal variables. RESULTS: Significant differences in favour of cortisone were not found for the measured parameters at any time. An improvement for all parameters was seen in both groups between the time t0 and the definite times t1 and t2. CONCLUSION: The advantage of a combined injection of local anaesthetics and cortisone versus a injection of local anaesthetics alone in epidural-peridural technique in the inpatient treatment of the chronic lumbar spine root compression syndrome could not be detected.

[Angle of needle position for the epidural-perineural injection at the lumbar spine]. / Einstichwinkel bei der epidural-perineuralen Injektion an der Lendenwirbelsäule.

AIM: The aim of this study was to find the correct angle of the needle position for the epidural perineural injection at the lumbar spine without any help by imaging. METHODS: In 11 human cadaver lumbar spines besides dura, nerve roots and bones all soft tissue had been removed to allow us to look into the anterior lateral epidural spaces between L3 and S1 in different angles with an operation microscope. The area between the dura (medial), facet joint (lateral) and the laminae (cranial and caudal) were photographed and planimetrically measured. This area is called the width of the injection canal. RESULTS: Degenerative lumbar spines show a width of the injection canal of 29.61 mm(2) in L5/S1 with an angle of the needle position of 15 degrees to the midline. The optimal angle position of the needle brought a width of the injection canal in L4/5 only for 7.3 mm(2) and in L3/4 for 3.5 mm(2). In non-degenerative spines the injections canals were much wider. DISCUSSION: The epidural-perineural injection into the anterolateral epidural space only makes sense in the segment L5/S1. Here the L5 nerve root is reached as well as the S1 root - the main causes of sciatica. In upper segments the injection canal is far smaller even at optimal injection angles. In case of nerve root compression at L4 and upwards other epidural injection techniques should be used such as the epidural dorsal loss of resistance technique or the transforaminal technique. CONCLUSION: With some training it is possible to perform epidural-perineural injection for sciatica without the help of imaging.

[Effective pain relief facilitates exercise therapy : Results of a multicenter study with controlled-release oxycodone in patients with movement pain]. / Effektive Schmerzlinderung ermöglicht Bewegungstherapie : Ergebnisse einer Multicenterstudie mit retardiertem Oxycodon bei Patienten mit Bewegungsschmerz.

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

[Registration of intraoperative 3D ultrasound with preoperative MRI data for computer-assisted orthopaedic surgery]. / Registrierung von intraoperativem 3D-Ultraschall mit präoperativen MRT-Daten für die computergestützte orthopädische Chirurgie.

AIM: The trend towards minimally invasive surgery leads to an increasing demand for methods enhancing in situ spatial orientation. Hence, navigation systems are being more and more used for many operations. At the beginning of a navigated surgery the coordinate systems of the patient need to be registered with the navigation system. Our registration method is based on intraoperative freehand ultrasound imaging and overcomes some problems related to landmark-based registration, such as invasiveness, inaccuracy and the time-consumption of the process. After a successful registration, the operation can be conducted safely with the aid of the navigation system which provides enhanced spatial orientation on high-quality preoperative image data (e.g., MRI, CT). Soft tissue is depicted especially well in MRI data. Since imaging of soft tissue close to the joints is of high diagnostic importance, MRI scans are often part of the preoperative routine. These data can also be utilised by a navigation system. In this article we present our first results on the registration of 3D ultrasound and MRI data of the knee. METHODS: 3D ultrasound and T (1)/T (2)-weighted MRI data were acquired from the distal femur and the proximal tibia. The ultrasound volume data were pre-processed to enhance the contrast of bone and surrounding tissue. A dataset combined from T (1)- and T (2)-weighted MRI images was also created. Points of the bone surface corresponding optimally to the bone surface demonstrated in the ultrasound images were extracted from the MRI volume data. For the surface extraction of the femur the T (1)-weighted image data were used, and for the tibia the combined MRI dataset was used. Based on the extracted bone surface, MRI and ultrasound volume data were registered with a surface-volume registration algorithm. RESULTS: Registrations of ultrasound data of both the femur and the tibia were successful. Bone and cartilage was depicted well in the ultrasound data and visual inspection showed the accurate overlay of bone structures in MRI and ultrasound volumes. CONCLUSION: We have demonstrated the feasibility of registering bone structures based on 3D-ultrasound and MRI data. Our method allows for minimally invasive routine surgery of orthopaedic diseases which so far had to be operated conventionally because other methods for navigated surgery are too expensive, inaccurate or time-consuming.

[Definition of shock types]. / Definitionen der Schockformen.

Definitions of shock types. Hypovolaemic shock is a state of insufficient perfusion of vital organs with consecutive imbalance of oxygen supply and demand due to an intravascular volume deficiency with critically impaired cardiac preload. Subtypes are haemorrhagic shock, hypovolaemic shock in the narrow sense, traumatic-haemorrhagic shock and traumatic-hypovolaemic shock. Cardiac shock is caused by a primary critical cardiac pump failure with consecutive inadequate oxygen supply of the organism. Anaphylactic shock is an acute failure of blood volume distribution (distributive shock) and caused by IgE-dependent, type-I-allergic, classical hypersensibility, or a physically, chemically, or osmotically induced IgE-independent anaphylactoid hypersensibility. The septic shock is a sepsis-induced distribution failure of the circulating blood volume in the sense of a distributive shock. The neurogenic shock is a distributive shock induced by generalized and extensive vasodilatation with consecutive hypovolaemia due to an imbalance of sympathetic and parasympathetic regulation of vascular smooth muscles.

[Comparative study of surgically treated shoulder injuries with or without metal implants]. / Vergleichende Untersuchung operativ versorgter Schultereckgelenksverletzungen mit und ohne metallische Implantate.

In 36 patients with acromioclavicular fracture type III, IV and V following the Rockwood classification, different surgical procedures without using metal implants were compared. Augmentation of both, the coracoclavicular and acromioclavicular ligaments was done by Vicryl-threads (5 mm) in 26 cases (group I). Solitary augmentation of coracoclavicular ligaments were done in 6 cases (group II), of acromioclavicular ligaments in 4 cases (group III). Twenty-four patients underwent follow-up regarding clinical, ultrasonic and radiological results after 30 month in average. Dislocations of more than 10 mm we found once in group I and II, three times in group III. Using the Taft score, regarding clinical, ultrasonic and radiological findings, five patients had an excellent, 15 a good five patients a satisfying result and the remaining patient had a poor reconstruction of the acromioclavicular joint. Comparing these results with previous 75 patients who underwent surgical reconstruction of acromioclavicular joint, using metal implants between 1980 and 1985, the results were nearly equal. Although severe complications like migration or fracture of the implant and the necessity for another surgical intervention for explantation were not given in patients who were treated without using metal implants. Solitary augmentation of acromioclavicular ligament showed insufficient results, therefore this therapy should not be recommended anymore.

[Validity of potential support--a pilot study of myocardial infarct patients]. / Zur Validität potentieller Unterstützung--Eine Pilotstudie bei Herzinfarktpatienten.

This investigation examines the validity of potential (anticipated) support as an indicator of social action. A comparison of anticipated support with received support in the past is problematic; other research variants have to be found. A comparison of two samples offers possible validation: asking one sample about the potential support, with regard to a possible crisis, and asking the second sample about actually received crisis support. This study examines received social support in a population of 30 myocardial infarction patients, and anticipated social support among 30 healthy individuals (on the assumption that they would suffer from a cardiac-infarct). The findings suggested that patients self-reported support values are lower than the expected support of the disease-free population. In particular, the healthy individuals expected support from their spouses and grown-up children. On the contrary the patients often name their doctors in this context. In general the findings suggested that the expected support with regard to an imagined crisis is a problematical indicator (validity problem). Alternative explanations are possible; the explanation that results are effects of patients perception bias is less likely.

The use of prontosil for the visualization of carbonic anhydrase bands in polyacrylamide gels. Application to the carbonic anhydrase isozymes of erythrocytes and white skeletal muscle of the rabbit.

Prontosil, a carbonic anhydrase inhibitor of orange-red colour, is used to visualize carbonic anhydrase bands during isoelectric focusing in polyacrylamide gels. 5-60 ng of the sulfonamide Prontosil are added to the 100-200 microliters samples before application to the gels. Bound Prontosil moves into the gel together with carbonic anhydrase and stains the enzyme bands formed there, while unbound Prontosil remains on top of the gels. The method is specific, no proteins other than carbonic anhydrase were observed to be stained, and it requires no special equipment. It was applied to chloroform/ethanol extracts of erythrolysates and white muscle homogenates from rabbits. Densitometric evaluation of the Prontosil-stained bands obtained with these extracts showed that rabbit red cells contain roughly equal amounts of carbonic anhydrase isoenzymes B and C while in rabbit white skeletal muscle isoenzyme C is predominant and little B enzyme occurs. These results confirm previous findings obtained by affinity chromatography of erythrolysates and muscle homogenates.