[Erratum to: Histopathological findings following SARS-CoV-2 infection with and without treatment-Report of three autopsies]. / Erratum zu: Histopathologische Befunde bei therapierter und nichttherapierter SARS-CoV-2-Infektion ­ Bericht über 3 Autopsien.

[This corrects the article DOI: 10.1007/s00194-020-00408-x.].

[Histopathological findings following SARS-CoV-2 infection with and without treatment-Report of three autopsies]. / Histopathologische Befunde bei therapierter und nichttherapierter SARS-CoV-2-Infektion ­ Bericht über 3 Autopsien.

According to the current state of knowledge, several internal organs are usually involved in cases of SARS-CoV­2 infections with a fatal course. Pathological changes are primarily found in lung tissues but there are also reports concerning direct or indirect (histo)pathological changes due to SARS-CoV­2 infections in samples from the kidneys, liver and myocardium. Comparing three fatal cases associated with SARS-CoV­2 infections in men using conventional histological staining, there were partly identical findings that enabled interpretations with respect to the chronology and pathophysiology of the disease. Of the men two were invasively ventilated in the intensive care unit and one man died after 8 days in domestic quarantine without treatment. A wide spectrum of findings potentially associated with SARS-CoV­2 must be taken into account.

An in vitro analysis of the size and shape of cryolesions for facet joint denervation.

OBJECTIVES: Lumbar facet joint syndrome (LFJS) is the cause of lower back pain in 15-54% of the patients. Clinical studies of cryotherapy for LFJS have reported promising outcomes. However, few studies have focused on the technical aspects of cryoneurolysis for LFJS. The aim of the study was to determine the size and shape of cryolesions in vitro and to determine how they are affected by the duration of freezing, size of the cryoprobe and distance and angulation to an osseous boundary layer. MATERIALS AND METHODS: Two different cryolesion generators were used. Cryolesions were generated in tempered physiologic NaCl solution in the vicinity of an osseous surface. The size of the cryoprobes, duration of freezing, distance to the bone surface and angulation of the probe were studied. Cryolesions were recorded with a video camera during their emergence. Images at distinct time points were analysed using digital image processing software. RESULTS: The probe size, the system in use and the duration of the freezing cycle were the main determinants for the size of the cryolesion. The vicinity of the osseous boundary resulted in a modest increase in the size of the cryolesion. Angulation of the cryoprobe towards the osseous boundary is of minor importance for the size of the contact area to the nerve. CONCLUSION: For cryoneurolysis of LFJS, duration of freezing, temperature and probe size are the main determinants of lesion size and thus the probability of success of the procedure. A tangential approach of the probe is not essential.

[Complex regional pain syndrome in nerve root compression and after spinal surgery]. / Komplexes regionales Schmerzsyndrom bei Nervenwurzelkompression und nach Wirbelsäulenoperation.

Complex regional pain syndrome (CRPS) is an extremely painful and partially disabling disease. It often occurs secondary to trauma, but also spontaneously. The emergence of CRPS has been reported following nerve root compression and/or spinal surgery, but its incidence is unknown. In this article, the present knowledge about the incidence of CRPS in the context of nerve root compression and spine surgery is reviewed and therapeutic and diagnostic consequences are discussed.

The lipo-facelift: merging the face-lift and liposculpture: eight years experience and a preliminary observational study.

BACKGROUND: Since the introduction of the classic submucosal aponeurotic system (SMAS) face-lift, the surgical approach to improve the changes of an aging face has evolved, and significant technical improvements have been made. However, several problems still have not been solved satisfactorily. These problems include facial lipodystrophy and changes in skin and skin texture. METHODS: The Lipo-Facelift procedure consists of facial liposculpturing performed simultaneously with a biplanar, bivectorial SMAS face-lift procedure. The authors analyzed pre- and postsurgical photographs of 12 patients with a Lipo-Facelift after 3 and 12 months and analyzed their charts for complications. Furthermore, O2C measurement was performed to assess improved microcirculation. The longest follow-up period was 8 years. RESULTS: The Lipo-Facelift demonstrated very satisfying results. Initial swelling and bruising were seen as well as two cases of wound-healing disorders, but no surgical intervention or revision was needed. The findings show lasting improvement of skin quality and a youthful appearance. CONCLUSION: The Lipo-Facelift corrects age-related skin and SMAS changes as well as age-related lipodystrophy, improves skin circulation and skin revitalization, and provides a lasting and natural result. The skin quality resulting from simultaneous lipofilling can be explained by improved angiogenesis due to transferred growth factors in the lipoaspirate. Also, differentiation of progenitor cells to fibroblasts and increased production of collagen contribute to firmer skin. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Complex regional pain syndrome following spine surgery: clinical and prognostic implications.

BACKGROUND: Complex regional pain syndrome (CRPS) has been reported following spinal surgery, but its frequency after spinal surgery is unknown. The aim of this study was to determine the frequency of spinal surgery preceding CRPS and to examine these patients regarding the course of the disease and prognostic factors. METHODS: We examined 35 CRPS patients regarding the symptoms and signs of CRPS, the type of CRPS (I or II), the origin and grade of the disease, the type of surgeries prior to CRPS onset, the course of the disease, and the therapies following diagnosis of CRPS. RESULTS: In 6 patients, CRPS began during the postoperative course (lumbar spine surgery, n = 5; cervical spine surgery, n = 1). Four of these patients suffered from CRPS II. The course of the disease in the 6 patients was not different from that of patients with CRPS of other origins. First symptoms of CRPS could be observed 1-14 days after surgery. CONCLUSIONS: CRPS is a rare complication after spinal surgery, but spinal surgery precedes the onset of CRPS of the lower limb in almost one-third of the cases. The first typical symptoms of CRPS emerge within 2 weeks after spinal surgery.

Effects of sub-perception threshold spinal cord stimulation in neuropathic pain: a randomized controlled double-blind crossover study.

BACKGROUND: Recent studies suggest that perception of the paraesthesia elicited by spinal cord stimulation (SCS) is not necessarily required for the pain relieving effect. OBJECTIVE: The purpose of the study was to determine the effect of sub-perception threshold SCS in patients with neuropathic pain. METHODS: Ten patients with implanted SCS systems underwent continuous sub-threshold stimulation and no stimulation in a blinded randomized crossover design. Pain scores under these treatment modalities were compared with usual supra-threshold stimulation. RESULTS: Sub-threshold stimulation elicited significantly lower pain relief than supra-perception threshold SCS. Mean pain scores were 3.6 [max 6.3, min 1.9, standard deviation (SD) 1.3] under supra-threshold stimulation, 5.6 (max 9.0, min 2.4, SD 1.9) under sub-threshold stimulation and 6.4 (max 10.0, min 4.0, SD 2.0) without stimulation. CONCLUSION: Sub-threshold stimulation under otherwise conventional stimulation parameters has a measurable but not clinically sufficient effect. Thus, the pain relieving effect elicited by SCS is not necessarily linked to the perceptibility of stimulation but may instead be attributed to the intensity of the electric field.

[Liposuction]. / Liposuktion.

Liposuction is one of the most commonly performed procedures in aesthetic surgery. The primary aim is body contouring and not weight reduction. The vast amount of available methods for suctioning subcutaneous fat allows an optimal individual treatment plan, keeping in mind the correct indications. Although liposuction is often offered as a minor and harmless surgery, it is a complex procedure. A thorough training of the surgeon and in-depth knowledge about possible complications is essential. In addition to aesthetic indications liposuction is also a valuable tool in reconstructive surgery. For optimal patient selection the skin elasticity has to be considered during the preoperative assessment. Besides pure volume reduction through liposuction, the regenerative possibilities of adipose tissue are of great interest for basic research and clinical applications. Lipofilling or autologous fat transfer is used for a wide variety of aesthetic and reconstructive procedures. Of special interest is the regenerative and reconstructive potential of adipose-derived stem cells (ADSC).

CRPS I following artificial disc surgery: case report and review of the literature.

We report a case of type 1 complex regional pain syndrome (CRPS I) of the left leg following the implantation of an artificial disc type in the L4/5 segment of the lumbar spine using a midline left-sided retroperitoneal approach. This approach included the mobilisation of the sympathetic trunk with incision and resection of the intervertebral disc. The perioperative and immediate postoperative periods were uneventful, but on the second postoperative day the patient complained of a progressive allodynia of the whole left leg in combination with weakness of the limb. Neurological examination did not reveal any radicular deficit or paresis. A sympathetic reaction following the mobilisation of the sympathetic trunk during the ventral preparation of the spine was suspected and investigated further. A diagnosis of CRPS I was proposed, and the patient was treated with analgesia, co-analgesics for pain alienation, and systemic corticosteroid therapy. A computed tomography-guided sympathetic block and lymphatic drainage were performed. Following conservative orthopaedic rehabilitation therapy, the degree of pain, allodynia, weakness, and swelling were reduced and the condition of the patient was ameliorated. The cost-benefit ratio of spinal arthroplasty is still controversial. The utility of this paper is to debate a possible cause of a painful complication, which can invalidate the results of a successful operation.

A four-muscle-flap for thoracomyoplasty in patients with sacrificed thoracodorsal vessels.

UNLABELLED: Defects after prior posterolateral thoracotomy and with concomitant bronchiopleural fistula remain a challenge for the plastic surgeon. In most of the cases, the thoracodorsal artery division after posterolateral thoracotomy impairs the vascularisation supply of the latissimus dorsi, resulting in the loss of this option for closure of the pleural cavity. Therefore, the adequate filling of residual empyema space and/or surgical closure of the bronchial stump insufficiency needs additional tissue to overcome this situation. We present an alternative approach using a four-muscle-flap technique including the infraspinatus, the subscapularis and the teres major and minor muscle group, all pedicled from the subscapular artery as a part of a modified thoracomyoplasty technique for closing the residual empyema space and bronchial stump insufficiency. METHODS: Between 2002 and 2008, we performed the four-muscle-flap on seven patients (mean age 68±7.9 years) with residual empyema space. Three cases were combined with a bronchopleural fistula. All patients received a two-stage procedure. First, the thoracic surgeons performed an open-window thoracostomy. This procedure was followed by the definitive surgical treatment after 3-6 months. In cases with an additional bronchial insufficiency, the stump was covered in with a subscapularis muscle. The infraspinatus and the teres muscle group were used to fill the pleural cavity, in combination with the thoracoplasty. RESULTS: In this series, no mortality connected to the procedure was noted. The mean postoperative stay in the intensive care unit (ICU) was 3±2.9 days and the patients were discharged from the hospital after 15±7.6 days. Minor postoperative complications occurred in two cases. Shoulder abduction in all patients was possible up to 90° and has decreased around 15±10° postoperatively. CONCLUSIONS: The division of the thoracodorsal pedicle and the consecutive loss of the latissimus as a reconstructive option remain challenging. The lower shoulder girdle muscles (infraspinatus, subscapularis, teres minor and major) are an adequate alternative for filling residual empyema spaces. The constraint in shoulder movement is minor and acceptable in such situations.

Chronic low back pain: course of disease from the patient's perspective.

Chronic back pain often leads to permanent disability and-apart from significant human suffering-also creates immense economic costs. There have been numerous epidemiological studies focussing on the incidence and the course of chronic low back pain. Less attention has been paid to the impact of subjective perception of the disease and the degree of healthcare use of these patients. The aim of this study was to gather data about patients with chronic low back pain and compare these data with patients suffering from chronic pain in other body regions. The first 300 pain questionnaires collected by the interdisciplinary pain centre at the University Hospital in Freiburg between January 2000 and September 2001 were analysed. This pain questionnaire is a modified version of the pain questionnaire of the DGSS (Deutsche Gesellschaft zum Studium des Schmerzes-German Chapter of the IASP). It collects demographic and socioeconomic information, as well as information regarding the course of the disease, and the subjective description of pain and the pain-related impairment. The subjective view of the course of disease, shows differences between patients with low back pain and patients with chronic pain of other origin, particularly regarding physical strain as the assumed cause of pain, but also regarding the frequency of prior treatments and cures. The subjective perception of the course of the pain disorder in patients with low back pain compared to patients with chronic pain in other parts of the body shows differences mainly related to the capacity for physical exertion. The frequency of ineffective prior treatments and cures underlines the necessity for early initiation of effective pain treatment aimed at prevention of the pain disorder becoming chronic.

[Alloplastic cancellous bone replacement and fibrin glue in hand surgery]. / Alloplastischer Spongiosaersatz mit Fibrinkleber in der Handchirurgie.

INTRODUCTION: Alloplastic replacement of cancellous bone is being increasingly used in the clinical setting. The use in hand surgery, however, is only sparsely documented. MATERIALS AND METHODS: We report about the use of micro- and macroporous biphasic calicium phosphate granulate (Tricos (®)) in combination with fibrin sealant (Tissucol (®)) in six patients undergoing surgery of the hand involving cancellous bone deficits. The indications ranged from carpal stabilisation to DIP athrodesis. Follow-up time was up to 15 months. RESULTS: Because cancellous bone harvesting could be avoided, morbidity and the extent of surgery could be reduced in all patients. Healing was uneventful and the clinical course as documented by X-ray controls, toleration of physiotherapeutic exercises and stability was analogous to that of conventional surgery involving cancellous bone grafting. CONCLUSION: These first results indicate that alloplastic replacement of spongiosa grafts, especially by micro- and macroporous biphasic calcium phosphate granulate can possibly be successfully used in surgery of the hand. The extent of bony remodelling still needs to be determined by further examination.

CT-guided cervical selective nerve root block with a dorsal approach.

BACKGROUND AND PURPOSE: Cervical transforaminal blocks are frequently performed to treat cervical radicular pain. These blocks are performed mostly under fluoroscopy, but a CT-guided technique has also been described. The aim of this study was to review the results of CT-guided CSNRB by using a dorsal approach, to describe the contrast patterns achieved with this injection technique, and to estimate the degree of specificity and sensitivity. MATERIALS AND METHODS: We used a CT-guided technique with a dorsal approach leading to a more extra-than transforaminal but a selective nerve root block as well. Of 53 blocks, we performed 38 for diagnostic and 15 for therapeutic indications. Pain relief was measured hourly on a VAS. The distribution of contrast and the angle of the trajectory of the injection needle were analyzed as well as the degree of pain relief. RESULTS: Contrast was found in the intraforaminal region in 8 (15%) blocks, extraforaminally in 40 (78%) blocks, and intraspinally in 3 (6%) blocks. The mean angle between the needle and the sagittal plane was 26.6° (range, from 1° to 50°). The mean distance between needle tip and nerve root was 4.43 mm (range, 0-20 mm). Twenty-six (68.4%) of the 38 diagnostic blocks led to a decrease in the pain rating of >50%. There were no complications or unintended side effects, apart from occasional local puncture pain. CONCLUSIONS: We conclude that CT-guided CSNRBs using a dorsal approach are feasible and that they are sensitive and specific.

Aesthetic breast augmentation and thoracic deformities.

To ensure the best results from aesthetic breast augmentation, preoperative evaluation and adequate patient information are essential. However, assessment of the underlying thoracic shape often is neglected. Patients with obvious deformities are aware of the problematic reconstruction, whereas patients with mild or moderate deformities often are not aware of their condition and fail to see that standard breast augmentation will lead to unsatisfying results. The authors reviewed their charts for patients with breast augmentation and mild to moderate thoracic deformities, then compiled the therapeutic possibilities and the outcome. Of the 548 patients who underwent breast augmentation, 7.1% (n = 39) exhibited low- or midgrade thoracic wall deformities. Almost none of the patients were aware of their deformity. The patients were augmented with silicone-filled, textured round implants. Placement and volume were adapted to the anatomic situation. A reoperation was not performed in any case, and both patient and physician satisfaction was high. The percentage of patients with thoracic deformity in this group was high compared with an overall incidence of less than 2%. This emphasizes the need for cautious physical examination and preoperative documentation. By individualized surgical planning and diligent implant selection, optimal results and patient satisfaction can be achieved.

The mobilisation of mononuclear cells and endothelial progenitor cells after burn injury in a porcine model.

BACKGROUND: Mononuclear blood cells (MNCs) consist of heterogeneous cell populations, for example, CD34+ cells and endothelial progenitor cells (EPCs). EPCs are involved in vasculogenesis, but little is known about their role during burn trauma. AIM: This study investigates the role of MNCs and their subpopulations during and after burn injury in an experimental porcine setting. METHODS: Eighteen 8-week-old German land pigs were scalded by immersion in 70 degrees C hot water for 3 min, resulting in a 30% total body surface area (TBSA) full-thickness burn. Vascular endothelial growth factor (VEGF) serum concentrations and MNC, EPC and CD34+ cell counts were measured at eight different time points up to 48 h following trauma. RESULTS: The experimental porcine setting made it possible to determine the cell counts of MNCs, EPCs and CD34+ cells directly during burn trauma, which has not been described before. The data revealed a fulminant drop in MNC and EPC during burn trauma, whereas the CD34+ cell fraction rose. Besides significant changes in the VEGF serum concentration, a correlation between VEGF and EPC was also observed. CONCLUSION: The results show that MNCs and their subpopulations are significantly affected by burn trauma and underpin their potential diagnostic and therapeutic importance during and after burn injury.

[The impact of silicone spray on scar formation. A single-center placebo-controlled double-blind trial]. / Einfluss eines Silikonsprays auf die Narbenbildung. Doppelblinde, placebokontrollierte, unizentrische Studie.

For more than two decades silicone has successfully been employed in the treatment and prevention of hypertrophic scars and keloids as a painless noninvasive modality with few side effects. In the present trial, after 3 months of treatment the Patient Scar Assessment Scale demonstrated that patient satisfaction with the silicone application was significantly higher compared to placebo. When treatment was stopped after 3 months, the topical silicone spray did not exhibit any lasting long-term impact on the objective results of scar formation. Due to the significant differences in patient satisfaction once treatment has ended and since the administration is safe and simple, any final decision on treatment indication should be tailored to the patient and include the psychological well-being of the patient as well as the temporary improvement in scar formation during treatment.

Intra-alveolar IL-6 levels following burn and inhalation injury.

Burn combined with inhalation injury is a major challenge and requires further study. Using a small-animal model, excretion of IL-6 was investigated during the first 6h after exposure of rats to wood/polyvinyl chloride smoke, with and without concomitant skin burn. In controls, respirator therapy alone was found to release IL-6 into the serum and the alveolar space. These levels of IL-6 were reduced when associated with either inhalation injury or burn, but were increased when the traumas were combined. Thus, during the first 6h of mechanical respiration the presence of burn or of inhalation injury seems to decrease IL-6 excretion, but a combination of these traumas reverses this effect.

Cervical CT-guided, selective nerve root blocks: improved safety by dorsal approach.

Cervical transforaminal blocks are frequently performed as a treatment of cervical radicular pain. These blocks are performed mostly under fluoroscopy, but a CT-guided technique also has been described. We describe a modification that leads to a more extraforaminal than transforaminal and equally selective nerve root block.

[Perineal approach to repair rectal and cutaneous fistulas involving the urethra and bladder]. / Perinealer Zugang zur Korrektur von rektalen und kutanen Fisteln zu Urethra und Blase.

The perineal approach was used in ten patients for the repair of fistulas involving the bladder or prostatic urethra. In the case of radiotherapy-induced (n=2) or recurrent fistulas (n=4) fecal diversion and interposition of the gracilis muscle was performed. In addition in three patients prostatectomy was performed. All fistulas were repaired successfully with minimal morbidity.