[Supinator tunnel syndrome--a differential diagnosis of so-called tennis elbow]. / Das Supinatorlogensyndrom--eine Differentialdiagnose zum sogenannten Tennisellenbogen.

The increasing activity in sport lead especially in untrained persons to overstress of the elbow joint. Often one tends to diagnose a epicondlylits humeri radialis i.E. tennis elbow. In 1873, Runge (16) first described what we now call epicondylitis humeri radialis, i.e. what Morris (10) 1882 called "Tennis elbow." Its etiology is still under discussion, and the diagnosis of tennis elbow necessitates exact and detailed differential diagnostic efforts. In the work presented, we describe one major differential diagnosis, the posterior interosseous nerve syndrome or supinator entrapment syndrome. With sketches and anatomical preparations we describe the course of the radial nerve around the elbow joint and of its ramus profundus within the supinator muscle pouch. Listing representative causes of this syndrome, we also comment on clinical aspects and our surgical method of choice. We have interviewed and reexamined 6 of our patients suffering from a so called therapy-resistant epicondylitis humeri radialis. Due to their clinical picture all six had been operated for posterior interosseous nerve syndrome/supinator muscle entrapment syndrome. We present our results including neurophysiological evaluations. In relapsing, therapy resistant and diagnostically untypical humeral radial epicondylitis, a posterior interosseous nerve syndrome should be considered. After clinical and electromyographic examination a revision of the supinator channel is justified in selected cases.

[Interdisciplinary cooperation in rehabilitation--problem solving following severe craniocerebral injury]. / Interdisziplinäre Zusammenarbeit in der Rehabilitation--Problemlösungen nach schwerem Schädelhirntrauma.

Therapy and rehabilitation of patients with craniocerebral trauma is particularly difficult to programme on account of the neuropsychological defects and personality changes found in this population. The Ulm rehabilitation hospital seeks to face up to this fact by intense interdisciplinary cooperation in the nursing and medical sector, the fields of logopaedics, Occupational Therapy, physiotherapy, immediate post-acute therapy including cerebral training, as well as the entire field of vocational rehabilitation. A dense time schedule has been established for graded introduction of the necessary therapeutic interventions in the sense of a therapy chain, with intense information flows among the therapists involved, thus ensuring a continuous process and joint adjustment of programming to the individual course, to new problems that may arise. The implementation of this concept is set out on the example of a young patient with craniocerebral injury, who had received treatment in various of our departments for a total of 12 months, finally bringing him up to the conclusion of his vocational education.

Comparison of Doppler CO2 test, patterns of infarction in CCT, and clinical symptoms in carotid artery occlusions.

In patients with an internal carotid artery (ICA) occlusion the CO2 reactivity (autoregulatory reserve) is supposed to give information about the function of the collateral supply. To prove this hypothesis we compared the CO2 reactivity measured by transcranial Doppler sonography to the ipsilateral clinical symptoms and the patterns of infarction in cranial computed tomography (CCT). We studied 251 cases of ICA occlusion. Of the 141 cases with normal autoregulatory reserve, 37 (27%) had recently developed an ipsilateral neurological deficit. Of the 44 cases with exhausted CO2 reactivity, 28 (64%) had experienced an event. The difference is highly significant (p less than 0.0001). In 59 of the 75 patients for whom CCT images were available, we found signs of vascular-ischemic lesions. Of the 30 patients with hemodynamic infarctions, 13 showed an exhausted autoregulatory reserve, while of 19 cases with territorial infarctions only 1 and of 10 with lacunar infarctions none had an exhausted CO2 reactivity. The difference is significant (p less than 0.01).

[Reproducibility of ultrasound criteria for characterizing carotid artery stenoses]. / Reproduzierbarkeit sonographischer Kriterien zur Charakterisierung von Karotisstenosen.

Comparisons with intraoperative findings suggest that Duplex scanning may be of value in predicting the morphology of carotid artery stenoses. Such studies, however, are based on the results obtained by experienced investigators. To clarify whether sonographic criteria can be standardized, 6 investigators from different hospitals each documented 30 carotid artery stenoses of greater than or equal to 40% diameter reduction which could be imaged in at least 2 planes. Three sonographic criteria (plaque surface, echo density, echo structure), each with 8 categories, were assessed from the image documentations by the 6 as well as by 2 independent further investigators. Depending on the experience and on the device used 29-81% of all stenoses greater than or equal to 40% examined in the different laboratories could be included in the study. The +/- 1 category concordance between the different investigators averaged 50-60% for all sonographic criteria independent from the degree of stenosis and from the image quality. Because of lack of sufficient reproducibility the subjective assessment of sonographic criteria is found to be not suitable for use in multicentre studies.

Morphological characterization of carotid artery stenoses by ultrasound duplex scanning.

Ulcerations and intraplaque hemorrhages are thought to play an important role in the development of neurological deficits in carotid artery stenoses. To assess the ability of duplex scanning to predict plaque morphology we compared different sonographic criteria (plaque border, plaque density, plaque structure) with the morphological findings in 169 consecutive carotid endarterectomies (144 cases with diameter reduction greater than 50%). Two percent of the sonograms were inadequate, and 20% showed poor image quality. Regular plaque borders revealed a smooth or at most minimally ulcerated surface in 92%. Grossly ulcerated stenoses, however, were only found in 27% of the irregular plaques. Moreover, the plaque border was nonvisible in 35% of all cases. Simple, fibro-atheromatous plaques were found to be echogenic in 72% and echolucency was present in 80% of the stenoses with relevant intraplaque hemorrhage. In conclusion, duplex scanning proved to be capable of detecting smooth, fibro-atheromatous stenoses with high accuracy. Ulcerations, however, cannot be predicted reliably, and intraplaque hemorrhage cannot be differentiated from atheromatous debris.

Transcranial Doppler CO2 test for the detection of hemodynamically critical carotid artery stenoses and occlusions.

Cerebral CO2-reactivity was tested by transcranial Doppler sonography (Doppler CO2 test) in 232 patients. Time averaged flow velocity in the middle cerebral artery at the 40 mm Hg blood pCO2 level was taken as a reference point, and the relative increase of flow in hypercapnia of 46.5 mm Hg pCO2 was defined as "Normalized Autoregulatory Response" (NAR). A total of 82 patients with no evidence of cerebrovascular disease gave "normal" values for NAR (23.2 +/- 5.2 SD). In 150 patients with 233 stenoses and occlusions of the internal carotid artery NAR was significantly decreased in higher-grade stenoses (P = 0.01 for 80% diameter reduction, P less than 10(-6) for 90% or more). In such stenoses, patients with NAR less than 14 had suffered more frequently (P less than 0.01) from ipsilateral transient ischemic attacks and/or stroke during the previous 6 months than patients with "normal" NAR. Preoperative NAR less than 14 always improved to "normal" values following carotid surgery, while preoperative NAR greater than 19 remained unchanged (60 cases). The transcranial Doppler CO2 test is thought to be a reliable noninvasive method to detect hemodynamically critical carotid stenoses and occlusions. This may be of interest in selecting patients for superficial temporal artery-middle cerebral artery bypass and carotid surgery. For practical use 4 categories of NAR are suggested.