[Pilot study on pain response patterns in chronic low back pain. The influence of pain response patterns on quality of life, pain intensity and disability]. / Schmerzverarbeitungspattern bei chronischen Rückenschmerzen Pilotstudie. Der Einfluss von "Avoidance-Endurance"-Modell-Pattern auf die Lebensqualität, Schmerzintensität und Beeinträchtigung.

BACKGROUND: The variables pain intensity (SI), disability (DS) and quality of life (QoL) belong to a set of primary patient-based outcomes in chronic low back pain (CLBP). The avoidance-endurance model (AEM) assumes three maladaptive and one adaptive pain response pattern. The purpose of this study was to study the level and course of the outcomes with regard to the four AEM patterns. PATIENTS AND METHODS: A total of 52 CLBP inpatients were investigated at 2 points in time: during the first days after admission and 6 months after the acute exacerbation of pain. Differences between AEM patterns were analyzed with repeated measurement analyses of variance. RESULTS: Groups differences were found for SI (F((3, 48))=2.82, p<0.05), general (F((3, 48))=6.78, p<0.05) and health-related QoL (F((3, 48))=5.99, p <0.05). In contrast, for the variable disability only a significant time effect was found. CONCLUSION: The results show differences in the level and process of SI, DS and QoL between the subgroups. An AEM-based classification of subgroups is also reasonable for CLPB patients.

[In vitro effects of diclofenac and selective cyclooxygenase-2 inhibitors on prostaglandin release from inflamed bursa subacromialis tissue in patients with subacromial syndrome]. / Effekte von Diclofenac und selektiven Cyclooxygenase-(COX-)2-Inhibitoren auf die Prostaglandinfreisetzung aus entzündetem Bursa-subacromialis-Gewebe von Patienten mit Subakromialsyndrom in vitro.

BACKGROUND: To compare the in vitro effects of selective COX-2 inhibitors (L-745,337, NS-398 and DFU) and of COX-unspecific diclofenac on release of PGE(2 )and 6-keto-PGF(1alpha) from inflamed bursa subacromialis tissue (IBST) obtained from a total of 35 patients with shoulder impingement syndrome (SIS). PATIENTS AND METHODS: Bursal specimens were incubated in the presence of drugs (0.01-1000 microM) for 20 min and 16 h. RESULTS: After 20 min 10 microM diclofenac significantly inhibited formation of PGE(2) and 6-keto-PGF(1alpha), whereas L-745,337 and NS-398 (10-1000 microM) induced significant inhibition only at concentrations > or =100 microM. In contrast to equimolar diclofenac, DFU (0.01-10 microM) induced no inhibition of bursal PGE(2) release but a dose-dependent, although statistically not significant inhibition after 16 h. The inhibitory potency of diclofenac (0.01-10 microM) was even more increased during long-term incubation showing greater inhibition than DFU at all concentrations studied. CONCLUSION: The data suggest that in IBST in SIS in vitro the majority of PG is generated via the COX-1 pathway.

[Surgical treatment of spinal stenosis]. / Operative Therapie des engen Spinalkanals.

Surgical treatment of lumbar spinal stenosis is aimed at decompressing the structures of the spinal canal. Several surgical techniques have been described over the last few years. This article gives a survey of the surgical procedures used for the treatment of spinal stenosis. When comparing and discussing indications and current surgical techniques used for spinal stenosis, one can describe some general tendencies: if the symptoms are severe or disabling and do not respond to appropriate conservative treatment, or if the patient is not able to cope with the pain any longer and views his or her quality of life as unacceptable, surgery is indicated. If the symptoms are mainly radicular, (microsurgical) decompression should be performed. If back pain is the main problem combined with preoperative evidence of segmental instability, spondylolisthesis, or scoliosis, one should consider spinal fusion in addition to an appropriate decompression. Further investigations are necessary to exactly find out the appropriate indications for a fusion and to answer the question of whether spinal instrumentation should be used.

[History of the treatment of spinal diseases]. / Geschichte der Behandlung von Wirbelsäulenerkrankungen.

Identification and treatment of spinal disorders have been described for thousands of years. Nevertheless, systematic operative treatment was more or less impossible until about 200 years ago. During the second half of the last century, spinal surgery developed rapidly due to several technical improvements. This article summarizes the main aspects of the historical development of spinal surgery.

Five-year results from chemonucleolysis with chymopapain or collagenase: a prospective randomized study.

STUDY DESIGN: A 5-year clinical follow-up assessment of a prospective randomized study of chemonucleolysis using chymopapain (4000 IU) or collagenase (400 ABC units) was performed. SUMMARY OF BACKGROUND DATA: Intradiscal therapy can be performed for patients with contained discs by chemonucleolysis, percutaneous discectomy, or laser ablation. The oldest intradiscal therapy is chemonucleolysis with chymopapain. OBJECTIVE: The purpose of this study was to compare prospectively the efficacy of chymopapain and collagenase for intradiscal injection. METHODS: In this study, 100 patients with indication for intradiscal therapy were prospectively randomized to treatment with either chymopapain or collagenase. All the injections were performed by the double-needle technique with the patient under general anesthesia. The mean age of the patients was 35.5 years in the chymopapain group and 38 years in the collagenase group. An equal number of injections was performed at L4-L5 and L5-S1. RESULTS: After 5 years, good and excellent results were observed in 72% of the chymopapain group and 52% of the collagenase group when the surgically treated and lost patients were graded as poor. Using a scale of 0 (no pain) to 10 (intractable pain), the pain level dropped from 8.5 to 0.7 in the chymopapain group and from 8.6 to 0.9 in the collagenase group. Microdiscectomy at the injected level was required for 23 patients (14 in the collagenase group and 9 in the chymopapain group). CONCLUSIONS: After 5 years, no deterioration had occurred, as compared with the 1-year follow-up assessment. Chymopapain has proved to be safe, with one minor anaphylactic reaction, and effective even over the long term. Collagenase may need further study and cannot be recommended at this time.

Surgical or conservative treatment for chronic rotator cuff calcifying tendinitis--a matched-pair analysis of 100 patients.

Conservative or operative treatment for rotator cuff calcifying tendinitis was investigated in 100 patients in a matched-pair analysis. They were examined clinically and ultrasonographically 35-60 months after the initial visit. The mean Patte score was 91.8 for the patients who underwent surgical treatment and 81 for the ones who received conservative therapy (p < 0.004), while the age-related Constant-score was 103.4 and 95, respectively. Ultrasonography showed 28% calcifications in the surgical group, 18% newly formed and 10% that did not resolve after surgery. In the conservatively treated group, 33% calcifications were seen, of which 67% resolved. The number of rotator cuff ruptures was significantly higher in the conservative group. In the surgical group, 2% of partial tears and in the conservative group 5% of partial and 4% of complete cuff ruptures were found. Conservative treatment for calcifying tendinitis leads to less favourable pain results in the long term than surgical treatment. Surgery shortens the painful period and may reduce the number of future rotator cuff ruptures. Finally, the subjective functional outcome is significantly better after surgery.

Local anaesthetic injection with and without corticosteroids for subacromial impingement syndrome.

Fifty patients with impingement syndrome refractory to long-term conservative treatment were randomized to three treatment groups. All patients received an injection of 10 ml 0.5% bupivacaine, in group 1 without corticosteroid, in group 2 with crystalline corticosteroid and in group 3 with lipoid corticosteroid. Treatment in group 1 had to be stopped because of inefficacy. In groups 2 and 3 favorable results were achieved in 19 out of 40 patients.

Load-sharing characteristics of stabilized lumbar spine segments.

STUDY DESIGN: Load sharing in stabilized spinal segments was evaluated using sequential injury and stabilization with a posterior instrumentation system under an in vitro flexibility protocol. OBJECTIVE: To analyze the partitioning of applied loads between anatomic and implanted structures of lumbar functional spinal units stabilized with a posterior instrumentation system. To identify surgical indications for which the risk of fixator breakage in vivo is high. SUMMARY OF BACKGROUND DATA: Relatively few groups have experimentally measured the in vitro and in vivo forces and/or moments supported by posterior instrumentation systems, and no analysis, of the load sharing in these systems has been performed. This information will provide novel insight into implant fatigue life, and the degree to which the spinal anatomy is shielded from the applied load and will allow the verification of mathematical models for new injury scenarios. METHODS: Specimen kinematics were determined using an optoelectronic tracking system. Intradiscal pressure and the forces and moments supported by the implants were measured using, respectively, a needle-mounted pressure sensor and strain gauges mounted on the spinal implants. RESULTS: A large majority of the applied moments were supported by an equal and opposite force pair between the intervertebral disc and fixator rods in flexion and extension and an equal and opposite force pair between the left and right fixator rods in lateral bending. Torsional moments were shared approximately equally between the posterior elements, intervertebral disc, an equal and opposite shear force pair in the transverse plane between the right and left fixators and internal fixator moments. CONCLUSIONS: When posterior instrumentation devices are used to stabilize severe anterior column injuries, they are at risk of fracture secondary to reversed bending moments.

Bilateral Madelung's deformity without signs of dyschondrosteosis within five generations in a European family--case report and review of the literature.

The paper presents a European family showing bilateral Madelung's deformity within five consecutive generations. Females as well as males are affected alternately indicating autosomal dominant inheritance. Despite of a body height within the lower normal range in two patients the diagnosis of dyschondrosteosis could not be clearly established as further hints for dwarfism are missing. The etiology of Madelung's deformity may be difficult to establish. There seems to be the possibility of an inheritance independent from the complete syndroma of dyschondrosteosis. Therefore the genetic counselling will always be difficult and has to regard the wide variety of symptoms ranging from little pain and cosmetic disturbance to moderate pain and functional impairment.

[A prospective double blind study of cervical nerve infiltration with isotonic saline and local anaesthetic]. / Isotone Kochsalzlösung gegen Lokalanästhetika. Prospektiv randomisierte Doppelblindstudie bei zervikalen Spinalnervenanalgesie.

PURPOSE OF THE STUDY: Aim of this investigation was the examination of the therapeutic effect of cervical nerve infiltration with mepivacaine in comparison to local applications of isotonic sodium chlorid solution in a prospective randomised double blind study. METHODS: 57 patients with cervicocephalgia or cervicobrachialgia were injected daily with mepivacaine ( n=28) or physiological sodium chlorid solution ( n=29). The success was judged through the blinded patients and blinded therapists first after three days of treatment. If no improvement occurred a single injection of mepivacaine and triamcinolonacetonid was given. This injection could be repeated if required. At the end of the inpatient treatment, after a mean of 14 days, the patients assessed the treatment according to a scale of 1-4 (painfree - no improvement). RESULTS: The average therapeutic effect, in the subjective appraisal of 1-4 by the patients, was 2.15 in the mepivacaine-group and 2.54 in the sodium chlorid - group. In the mepivacaine-group no pain (note 1) was achieved two times and 21 times a clear improvement (note 2), while in the sodium chlorid - group 18 times a clear improvement was achieved and never freedom of pain ( p<0,038). In the mepivacaine-group twice a steroidinjection was required, while in the sodium chlorid - group this was necessary in 16 cases ( p<0,01). CONCLUSION: Cervical injections with mepivacaine improve the subjective pain perception in cervicocephalgia and cervicobrachialgia significantly better than isotonic sodium chlorid - solution in short term results and can therefore be prefered. After an inpatient treatment good and excellent subjective results could be achieved in a high percentage.

The correlation between magnetic resonance imaging and the operative and clinical findings after lumbar microdiscectomy.

Fifty-four consecutive patients were studied prospectively with magnetic resonance imaging before microdiscectomy, and the findings correlated with clinical symptoms before and after operation. A sequestrated fragment was found in 59% of cases, a subligamentous disc sequestration in 25% and a disc protrusion in 16%. The levels operated on were L4/5-36%, L5/S1-62.5%, and one at L3/4; 71% were laterally placed, 10% lay intraforaminal and 10% medial. The diameter of the protrusion was 4 mm to 13 mm for the craniocaudal extension, and 5 mm to 18 mm for the anteroposterior extension. No correlation could be found between a neurological deficit and the size of the prolapse. A positive correlation was present between the increasing degree of canal obstruction and the degree of disc degeneration determined by imaging for extrusions, subligamentous disc sequestrations and free sequestrations. Nerve root inflammation and enlargement was seen in 36% of the images, corresponding to an operative finding of 32%. Magnetic resonance imaging is a helpful pre-operative diagnostic investigation which shows structural changes in the disc and the correct localisation and size of the disc sequestration, but there was no correlation between the imaging findings and the clinical symptoms.

A comparison of conservative and delayed surgical treatment of anterior cruciate ligament ruptures. A matched pair analysis.

A series of 60 matched and paired patients with complete rupture of the anterior cruciate ligament (ACL) was studied; 30 were treated conservatively, even though operation was recommended, and 30 were operated on within 35 months (range 18 to 48 months) after the ACL rupture. The average age was 34 years in each group. They were assessed 39 months after arthroscopy or reconstruction. At follow up, no patient had flexion of less than 100 degrees, 13 of the reconstructed knees had an extension deficit, but in only one was this more than 10 degrees. Thirty-six percent of the reconstructed and 14% of the conservatively treated patients graded their sports activity as unlimited, while 13% of the ACL reconstructions and 21% of those treated conservatively were severely limited. The Lysholm, Cincinnati and OAK scores were significantly better in the reconstructions. The anterior drawer sign was positive in 24% of the ACL reconstructions and in 81% of the conservatively treated patients; 19% had a positive pivot shift after reconstruction compared to 75% of those treated conservatively. Even though there was a considerable number of patients with a decreased range of motion after ACL reconstruction because of the slow regime of postoperative mobilisation used, the results of operation are significantly better than after conservative treatment even when ACL reconstruction was carried out late after injury.

Antiinflammatory effect of tepoxalin: blood and synovial tissue studied in patients with knee arthrosis.

Our aim was to determine the amounts of eicosanoids in blood and synovial tissue of patients with knee arthrosis and to examine the effects of 2 doses of tepoxalin (50 mg twice, 200 mg twice), administered p.o. for 3.5 days. Concentrations of leukotriene B4 (LTB4, LTC4, and thromboxane B2 (TXB2) were measured in blood before and after oral administration of tepoxalin and release of prostaglandin E2 (PGE2), 6-keto-PGF1alpha, and LTC4 was measured in incubation media of synovial tissue, taken at surgery from patients treated with tepoxalin. Radioimmunoassay (RIA) was used to determine the levels of the eicosanoids. LT and TXB2 release was reduced by tepoxalin in both doses used. Under these conditions, PGE2, 6-keto-PGF1alpha, and LTC4 release from synovial tissue was detectable only after stimulation with calcium ionophore A23187. Washed synovial tissue, in which tepoxalin concentrations should be reduced, released higher amounts of all eicosanoids measured than directly incubated synovial tissue did. Pain after tepoxalin administration was significantly reduced. Relevant drug concentrations were detected in plasma and synovial fluid. Tepoxalin was well tolerated and had no marked adverse effects. At 400 mg, tepoxalin is a dual inhibitor of cyclooxygenase (CO) and 5-lipoxygenase (5-LO) in blood and synovial tissue.

[Intermediate-term follow-up of surgically managed tendinosis calcarea (calcifying subacromion syndrome--SAS) of the shoulder joint]. / Mittelfristige Nachuntersuchungsergebnisse der operativ versorgten Tendinosis calcarea (kalzifizierendes Subakromialsyndrom-SAS) des Schultergelenkes.

PURPOSE: Investigation of clinical und ultrasonographical results after operatively treated calcifying tendinitis. METHODS: 131 patients with calcifying tendinitis were treated by surgical decompression and, if necessary and possible, calcific deposit removal. 93% of these patients were clinically and ultrasonographically examined after an average time of 4 years and 5 months. RESULTS: Pain rating on a visual analogue scale 0-no pain to 10-maximum pain was 8.7 before surgery and 1.4 at follow-up. 88% of the patients rated the operation excellent or good. The Constant Score results corresponded to the average results of a normal population (100.3). At the time of examination in 16.4% of the cases new calcific deposits could be discovered. CONCLUSION: According to the clinical results operative treatment shows good and excellent results in a high degree even after unsuccessful non-operative therapy.

[Injection treatment of non-radicular lumbalgia]. / Injektionsbehandlung bei nicht-radikulären Lumbalgien.

Low back pain is the most expensive condition in industrialized countries. Approximately 65-80% of the population will be afflicted with low back pain at some point during their life. Low back pain has many causes and can originate from any of several pain-sensitive foci, among which are facet joints, sacroiliac joint, muscle and ligaments. Primary care in the acute phase consists of nonsteroidal anti-inflammatory drugs to address the biochemical and inflammatory mediators of pain or skeletal muscle spasmolytics to reduce low back pain symptoms. Injection procedures should be reserved for the patients with low back pain who fail to respond to a directed, conservative treatment trial and have had pain for at least 2 weeks duration. Eliminating sensation from a certain pain source has been proposed as a way to allow an examiner to determine if that joint is responsible for the patient's pain. Injections of local anesthetic into the facet joint or around its nerve supply are clinical methods of eliminating pain from focal areas such as facet joints or myofascial trigger points. When a particular joint is determined to be the source of pain, long-term relief can be sought by directing therapeutic interventions at that joint. The anatomic accessibility of the most common pain sources of low back pain make diagnostic blocks and therapeutic instillation of corticosteroids particularly appealing. If used, their potential benefit for the individual case needs to be carefully weighed. They should be used to facilitate more aggressive conservative care and not as an isolated treatment. Certainly, if response to corticosteroids does not occur after the first injection, no further administration of corticosteroids is indicated.

[Calcifying subacromial syndrome--clinical and ultrasound outcome of non-surgical therapy]. / Kalzifizierendes Subakromialsyndrom--Klinische und sonographische Ergebnisse unter nicht-operativer Therapie.

PURPOSE: The aim of this study is to analyse the mid-term clinical and sonographical results of non-operative therapy of calcifying tendinitis. METHODS: Retrospectively the anamnestical, clinical and sonographical results after various non-operative treatment of patients with calcifying tendinitis were reviewed. For this purpose 159 patients with 178 calcifying deposits in the rotator cuff were evaluated on an average of 60 months after their first examination in our clinic (mean age: 49.2 years; sex ratio: 58% women). RESULTS: During a mean symptomatic period of 49 months, an average of 4.2 different therapeutic modalities were applied. After this time 70% of all patients showed an excellent or good result. With regard to the age-correlated Constant-Score 85% of all patients had more than 81 points, i.e. a good result. The mid-term results on a visual analogous scale from 10 (pain) to 0 (no pain) showed a decrease from 7.7 to 2.2 and this correlated with the shoulder function scores (Constant-/Patte-Score, r -0.8). After an average of 104 months 82% of the hydroxyapatite deposits could not be diagnosed by sonography (7.5 MHz.) anymore. CONCLUSION: In the treatment of calcifying tendinitis the conservative methods achieve good and excellent results in 70%. Patients should be treated with analgetics, subacromial injections, physiotherapy and ice therapy up to a period of twelve months, above all with small deposits and radiologic resorptive stadiums. The results of this study should be compared with any invasive regimen.

Inhibition of eicosanoid release from synovial organ culture by incubation with tepoxalin and its acid metabolite.

The pharmacological profile of a novel dual inhibitor, tepoxalin and of its carboxylic acid metabolite on cyclooxygenase and lipoxygenase pathways was evaluated by in vitro incubation with synovial tissue. Tissue specimens obtained at surgery in rheumatoid arthritis (RA, n = 10) or osteoarthritis (OA, n = 11) patients were incubated. Tepoxalin (10(-7), 10(-6), 10(-5) M) decreased eicosanoid release calculated in % of tyrode control for OA: LTC4 to 71-33%, 6-keto-PGF1a to 37-20%, PGE2 to 29-6%. For RA: LTC4 to 56-22%, 6-keto-PGF1a to 43-22%, PGE2 to 57-32%. Similarly, its metabolite (10(-7), 10(-5)M) decreased release in OA: LTC4 to 99 and 60%, PGE2 to 42 and 20%, 6-keto-PGF1a to 54 and 25%. In RA:LTC4 to 81 and 45%, PGE2 to 61 and 30%, 6-keto-PGF1a to 46 and 18%. Significance (P < 0.05) was achieved for all but 1 group (LTC4 metabolite at 10(-7)M vs tyrode). In summary a marked and dose dependent decrease of LT and PG release was obtained when incubating the dual inhibitor tepoxalin and its active carboxylic acid metabolite with synovial tissue at doses expected to be reached in the joint during therapy.