Search

Background: The aim of this study was to assess the phenotype of multifocal motor neuropathy (MMN) and amyotrophic lateral sclerosis (ALS) in quantitative MR neurography. Methods: In this prospective study, 22 patients with ALS, 8 patients with MMN, and 10 healthy volunteers were examined with 3T MR neurography, using a high-resolution fat-saturated T2-weighted sequence, diffusion-tensor imaging (DTI), and a multi-echo T2-relaxometry sequence. The quantitative biomarkers fractional anisotropy (FA), radial and axial diffusivity (RD, AD), mean diffusivity (MD), cross-sectional area (CSA), T2-relaxation time, and proton spin density (PSD) were measured in the tibial nerve at the thigh and calf, and in the median, radial, and ulnar nerves at the mid-upper arm. Results: MMN showed a characteristic imaging pattern of decreased FA (p = 0.018), increased RD (p = 0.014), increased CSA (p < 0.001), increased T2-relaxation time (p < 0.001), and increased PSD (p = 0.025) in the upper arm nerves compared to ALS and controls. ALS patients did not differ from controls in any imaging marker, nor were there any group differences in the tibial nerve (p > 0.05). Conclusions: MMN shows a characteristic pattern of quantitative DTI and T2-relaxometry parameters in the upper-arm nerves, primarily indicating demyelination. Peripheral nerve changes in ALS seem to be below the detection level of current state-of-the-art quantitative MR neurography.

In order to minimize the risk of damaging the radial nerve while using a long PHILOS plate for proximal humerus fractures, recent studies have proposed twisting the plate in a helical form. This implies a modified surgical approach being yet unclear whether it leads to different middle to long-term shoulder function. This study compares the one-year shoulder functional outcomes of both techniques (helical vs. control). In this retrospective comparative study, we analyzed 30 patients that fit the inclusion criteria, being 14 treated with a helical plate and 16 with a conventional straight long PHILOS plate. The primary endpoint was the normalized constant score after a minimum follow up of one year. Both groups had a good one-year shoulder function, and no significant difference between the normalized constant scores was seen. There was no significant difference in the surgical complications as well. Opting for a helical long PHILOS plate in order to avoid radial nerve damage provided a safe treatment with similarly good one-year shoulder function compared to straight PHILOS plates. Level 3, Retrospective Cohort Study.

Congenital myopathies are a group of early onset muscle diseases of variable severity often with characteristic muscle biopsy findings and involvement of specific muscle types. The clinical diagnosis of patients typically relies on histopathological findings and is confirmed by genetic analysis. The most commonly mutated genes encode proteins involved in skeletal muscle excitation-contraction coupling, calcium regulation, sarcomeric proteins and thin-thick filament interaction. However, mutations in genes encoding proteins involved in other physiological functions (for example mutations in

Generell stellen Wirbelsaulenverletzungen bei Kindern im Alter unter 16 Jahren eine seltene Verletzungsentitat dar. Fur Deutschland liegen keine belastbaren Daten bezuglich der Epidemiologie von Verletzungen der Wirbelsaule im Kindesalter vor. Gerade bei padiatrischen Patienten, bei denen sowohl die Anamnese, die klinische Untersuchung, aber auch die Durchfuhrung der bildgebenden Diagnostik haufig erschwert sind, mussen samtliche Hinweise auf eine Verletzung der Wirbelsaule mitberucksichtigt werden. Das Ziel der vorliegenden Studie war die Bereitstellung epidemiologischer Daten von padiatrischen Patienten mit Wirbelsaulenverletzungen in Deutschland, um diese zukunftig in die Entscheidungsfindung bei der Diagnostik und Therapie dieser Patienten einfliesen lassen zu konnen. Im Rahmen einer nationalen Multizenterstudie wurden retrospektiv Patientendaten innerhalb eines Zeitraums von 7 Jahren aus 6 Wirbelsaulenzentren erhoben. Neben den demografischen Daten wurden der Unfallmechanismus, die betroffene Wirbelsaulenregion und auch die Begleitverletzungen erhoben. Zudem erfolgte die Erfassung der bildgebenden Diagnostik sowie der jeweiligen Therapie. Es konnten 367 Kinder (weiblich: mannlich = 1:1,2) mit insgesamt 610 Verletzungen an der Wirbelsaule in die Studie eingeschlossen werden. Das mittlere Alter betrug 12 (±3,5) Jahre. Die haufigsten Unfallmechanismen in allen Altersgruppen waren ein Sturz aus unter 3 m Hohe sowie Verkehrsunfalle. Die bildgebende Diagnostik musste nur in Ausnahmefallen in Narkose durchgefuhrt werden. Wahrend jungere Kinder (0 bis 9 Jahre) eher Verletzungen im Bereich der Halswirbelsaule erlitten, zeigten sich Verletzungen der thorakolumbalen Wirbelsaule eher bei Kindern >10 Jahren. Die Kinder wiesen haufige Begleitverletzungen an Kopf und Extremitaten auf. Im Bereich der Wirbelsaule befanden sich weitere Verletzungen meist benachbart und nur selten in anderen Regionen. Rund 75 % der Kinder wurden konservativ behandelt. Die Ergebnisse unterscheiden sich von den Erkenntnissen aus der Erwachsenenmedizin und beschreiben spezielle Gegebenheiten fur padiatrische Patienten mit Wirbelsaulenverletzungen. Trotz gewisser Limitationen konnen sie so bei der Entscheidungsfindung uber die durchzufuhrende Diagnostik und Therapie dieser Patienten helfen.

Study Design: Abstract consensus paper with systematic literature review. Objective: The aim of this study was to establish recommendations for treatment of thoracolumbar spine fractures based on systematic review of current literature and consensus of several spine surgery experts. Methods: The project was initiated in September 2008 and published in Germany in 2011. It was redone in 2017 based on systematic literature review, including new AOSpine classification. Members of the expert group were recruited from all over Germany working in hospitals of all levels of care. In total, the consensus process included 9 meetings and 20 hours of video conferences. Results: As regards existing studies with highest level of evidence, a clear recommendation regarding treatment (operative vs conservative) or regarding type of surgery (posterior vs anterior vs combined anterior-posterior) cannot be given. Treatment has to be indicated individually based on clinical presentation, general condition of the patient, and radiological parameters. The following specific parameters have to be regarded and are proposed as morphological modifiers in addition to AOSpine classification: sagittal and coronal alignment of spine, degree of vertebral body destruction, stenosis of spinal canal, and intervertebral disc lesion. Meanwhile, the recommendations are used as standard algorithm in many German spine clinics and trauma centers. Conclusion: Clinical presentation and general condition of the patient are basic requirements for decision making. Additionally, treatment recommendations offer the physician a standardized, reproducible, and in Germany commonly accepted algorithm based on AOSpine classification and 4 morphological modifiers.

Die Riesenzellarteriitis (RZA) kann durch Manifestation an hirnversorgenden Arterien zerebrale Ischamien verursachen und ist eine wichtige Differenzialdiagnose der zerebralen Makroangiopathie. Bevorzugt betroffen sind die extrakraniellen Abschnitte der Vertebralarterien. Wir berichten uber 3 Patienten, bei denen sich eine RZA mit hochgradigen intrakraniellen Vertebralisstenosen und Kleinhirninfarkten manifestierte. Nur bei einer Patientin war eine Polymyalgia rheumatica assoziiert, ansonsten lagen keine Symptome vor, die die klinische Diagnose einer Arteriitis cranialis erlaubt hatten, insbesondere initial keine Kopfschmerzen. Die Diagnose konnte bei allen Patienten durch sonografischen Nachweis des Halo-Zeichens an den Vertebral- und Temporalarterien gestellt werden. Die Stenosebefunde bildeten sich unter Behandlung mit Prednisolon bei 2 Patienten kontinuierlich zuruck, bei einem bestanden sie fort. Eine Manifestation der RZA im intrakraniellen Abschnitt der A. vertebralis gilt als seltener Befund. Da die Arterie langstreckig durch die Vaskulitis betroffen ist, konnte die Diagnose in den von uns beobachteten Fallen durch extrakranielle Farbduplexsonografie gestellt werden. Die Untersuchung ist technisch einfach, erfordert aber Erfahrung des Untersuchers. In unklaren Fallen konnen erganzend PET bzw. PET-CT oder spezielle Sequenzen einer kontrastgestutzten MRT, moglichst mit 3 Tesla-System, zur Diagnosesicherung eingesetzt werden. Wichtig ist die Sonografie – zusammen mit klinischen und laborchemischen Verlaufsparametern – fur das Monitoring von Gefasbefunden zur Optimierung der immunsuppressiven und thrombozytenaggregationshemmenden Therapie.

We describe two patients who developed subacute axonal peripheral neuropathy under duodopa treatment. Comprehensive diagnostic workup including muscle and sural nerve biopsy revealed that the most probable cause of subacute axonal peripheral neuropathy was cobalamin and vitamin B6 deficiency in both the patients.

The authors report on a prospectively followed series of 35 patients with injuries of the thoracolumbar spine from T7 to L3. The radiological course after combined posterior-anterior surgery with anterior column reconstruction with a distractible vertebral body replacing implant demonstrated a stable reconstruction technique with almost no re-kyphosing. In 18/18 patients with CT follow-up intervertebral fusion was observed as bony bridging lateral to the VBR implant. The functional/clinical outcome of the patients was analysed with a set of eight validated outcome scales. After an average follow-up period of 2(1/2) years encouraging results were noticed. The neurological improvement rate (or =1 Frankel/ASIA grade) was 8/12 patients (67%) with a complete recovery in 6 cases. 17/29 patients returned to former occupation; 20/29 patients returned to former leisure activities; 24/28 patients rated their general outcome as "unlimited and pain free" or "occasionally and/or mild complaints" with a VAS score of80 (scale 0-100). The psychometric questionnaires revealed good results with strong correlation comparing the different scoring systems statistically: mean McGill Pain Questionnaire 12.5 (0-40); mean Oswestry Disability Index 20% (0-51). 13/29 patients scored4 in the Roland and Morris Disability Questionnaire. The German back pain questionnaire (Funktionsfragebogen Hannover Rücken) showed a mean "functional capacity" of 75%, corresponding with moderate restriction. We concluded the presented method as highly effective to completely reduce and maintain an anatomic spinal alignment. The outcome tended to be better in comparison with non-operatively treated patients as well as with norm populations with low back pain.

Die Arbeitsgemeinschaft „Wirbelsaule“ (AG WS) der Deutschen Gesellschaft fur Unfallchirurgie (DGU) stellt im dritten und letzten Teil der zweiten prospektiven multizentrischen Sammelstudie (MCS II) zur Behandlung von Verletzungen der gesamten Brust- und Lendenwirbelsaule Ergebnisse der Nachuntersuchungen (NU) eines 865 Patienten umfassenden Patientenkollektives aus 8 Zentren vor. Teil I der Arbeit befasste sich mit den epidemiologischen Daten des Studienkollektivs und Teil II mit Details zu den Operationen und rontgenologischen Befunden. Der gesamte Studienzeitraum umfasst die Jahre 2002 bis 2006 mit einem 30-monatigen Nachuntersuchungszeitraum vom 01.01.2004 bis 31.05.2006. NU-Ergebnisse wurden in Anlehnung an Teil I und II unter Berucksichtigung von drei charakteristischen Behandlungsgruppen (OP, KONS, PLASTIE), unterschiedlichen Operationstechniken (dorsal, ventral, kombiniert) und der Verletzungslokalisationen (BWS, TLU, LWS) ausgewertet. Die Nachuntersuchungsergebnisse von 638 (74%) Patienten wurden mit Hilfe einer internetbasierten Datenbank zusammengetragen. Nach der Entlassung aus der stationaren Behandlung folgten Aufenthalte von durchschnittlich 4 Wochen in einer Rehabilitationsklinik, die signifikant langer dauerten bei Patienten mit persistierenden neurologischen Ausfallen (O 10,9 Wochen) oder Wirbelsaulenverletzungen, die im Rahmen eines Polytraumas auftraten (O 8,6 Wochen). Ambulant wurde im Mittel fur weitere 4 Monate physiotherapeutisch nachbehandelt, mit signifikant langerer ambulanter Nachbehandlung der Patienten mit neurologischen Ausfallen zum Zeitpunkt der NU (O 8,7 Monate) und Typ-C-Frakturen (O 8,6 Monate). Die Verletzungslokalisation hatte keinen signifikanten Einfluss auf die Dauer der stationaren Rehabilitation und ambulanten Physiotherapie. 382 (72,2%) primar dorsal oder kombiniert operierte Patienten unterzogen sich nach durchschnittlich 12 Monaten einer Operation zur Metallentfernung. Im Verlauf der NU wurden nach Operationen bei 56 (8,8%) Patienten Komplikationen beobachtet, die in 18 (2,8%) Fallen operativ revidiert wurden. Die haufigsten Ursachen der Komplikationen waren Infektionen, Korrekturverluste/Fehlstellungen oder implantatassoziierte Probleme. Klinische Ergebnisse zeigten, dass Raucher im Vergleich zu Nichtrauchern ein 2,9-mal hoheres relatives Risiko fur Wundheilungsstorung hatten. Im Gesamtkollektiv besserte sich der neurologische Zustand bis zur NU bei 81 (60,4%) von 134 Patienten, die zum Zeitpunkt der stationaren Aufnahme neurologische Ausfalle hatten. Verschlechterungen wurden in 8 (1,3%) Fallen dokumentiert. Die Besserungsrate fur komplette QS-Lasionen nach Verletzungen der BWS betrug 9% und 59% am TLU. Die Art der operativen Versorgung (dorsal vs. kombiniert) hatte keinen signifikanten Einfluss auf das neurologische NU-Ergebnis. Das Patientenalter, das Geschlecht und das Vorliegen eines neurologischen Defizites hatte einen statistisch signifikanten Einfluss (p 2 Jahre nach dem Unfall beschwerdefrei. Die relative Haufigkeit der Patienten mit uneingeschrankter Ruckenfunktion war groser nach isoliert dorsaler Operation (24,2%) oder ventraler Behandlung (13,8%) als nach kombinierter Operation 17,3% (p=0,005; χ²-Test). Fur unterschiedliche Verletzungslokalisationen wurden keine signifikanten Unterschiede (p>0,05) errechnet (BWS (17,4%), TLU (22,5%) und LWS (13,6%). Der Anteil der Patienten mit Verletzungen des TLU, die zur NU bezuglich des ventralen Zugangs „vollstandig beschwerdefrei“ waren, unterschied sich nicht signifikant nach offenem (55,6%) oder endoskopischem (63,8%) Vorgehen. 56,3% der Patienten waren bei der NU nach Knochenentnahme am Beckenkamm beschwerdefrei. Im VAS-Wirbelsaulenscore zur NU erreichten Patienten der Behandlungsgruppen OP 58,4 Punkte, KONS 59,8 Punkte und PLASTIE 59,7 Punkte. Statistisch signifikante Unterschiede operativer Subgruppen wurden lediglich an der BWS nachgewiesen, wo Patienten nach isoliert dorsaler Operation mehr Punkte (64,9 Punkte) erreichten als nach kombinierter operativer Behandlung (47,8 Punkt; p=0,004). Mindestens 80% oder mehr des ursprunglichen VAS-Wirbelsaulenscorewertes vor dem Unfall erreichten 56,2% der Patienten der Gruppe OP (dorsal 60,4%, ventral 61,1%, kombinert 51,4%), 52,9% KONS und 67,6% der Gruppe PLASTIE. Nach der Operation waren die Patienten durchschnittlich 4 Monate arbeitsunfahig. Die volle Reintegration von Patienten mit sitzender Tatigkeit vor dem Unfall gelang in 71,1% der Falle. Gingen Patienten einer korperlichen Arbeit nach, war die volle berufliche Reintegration nur in 38,9% der Falle moglich. Zur NU gaben 87 (31,2%) Patienten nach dorsalem und 50 (20,1%) nach kombiniertem Eingriff an, keine Einschrankungen ihrer Freizeitaktivitaten zu haben (p=0,001). Die radiologischen NU-Ergebnisse der Behandlungsgruppen PLASTIE und KONS zeigten ein vergleichbares Ergebnis im sagittalen Wirbelsaulenprofil (GDW von −9° bzw. −8,5°). Durch die operativen Masnahmen konnte die unfallbedingte kyphotische Fehlstellung zunachst korrigiert bzw. reduziert werden. Im weiteren Verlauf der NU muss dann jedoch mit unterschiedlichen Korrekturverlusten in Abhangigkeit von der Operationstechnik und Frakturlokalisation gerechnet werden: Nach kombinierter dorsoventraler Behandlung resultierten statistisch signifikant weniger kyphotische Fehlstellungen zur NU (−3,8°) im Vergleich zur isolierten dorsalen Behandlung (−6,1°; p=0,005; ANOVA). Dies bedeutet, dass der Korrekturgewinn nach kombinierter Behandlung groser als nach isoliert dorsaler oder ventraler Versorgung war. Die Verwendung von Wirbelkorperersatzimplantaten (Cage) zur ventralen Rekonstruktion und Abstutzung zeigte signifikant bessere Ergebnisse mit weniger Korrekturverlust des bisegmentalen GDW zur NU (0,3°) als nach Verwendung von Knochenspanen (NU −3,7°; p

STUDY DESIGN We report the long-term outcome after mono-segmental and bisegmental fusions at the lumbar L4-S1 region of the spine. OBJECTIVE Long-term clinical and radiologic outcome measures were used to determine a lumbar fusion's contribution to degenerative changes in adjacent motion segments (ASD). SUMMARY OF BACKGROUND DATA The role of low lumbar spinal fusions and their long-term contribution to accelerated degenerative changes in the adjacent motion segments continues to be a subject of controversy. PATIENTS AND METHODS We followed-up 102 patients with an average age of 54 (22 to 78) years and a follow-up time of 14 (3 to 22) years. RESULTS Overall results in patients were good, the Oswestry-Disability Index (ODI) showed an average of 26% (0% to 70%) at follow-up, the Visual Analog Scale rose from 2.7 (postoperative) and 2.9 (12 wk follow-up) to 3.6 (latest follow-up) points, respectively. Patient satisfaction with their health-related situation at follow-up was 69% (15% to 100%). Patients who underwent fusions of the segment L5/S1 showed a significant (P

Traumatic facet dislocations and facet-fracture dislocations in the lower cervical spine (C2/C3 to C7/T1) are frequently associated with devastating neurological symptoms. A good outcome can only be achieved if the operator has wide and sound knowledge of reduction techniques and the best possible strategy is devised for the subsequent treatment of these severe lesions.Between 1973 and 1997 a total of 117 of our patients met at least one of the following inclusion criteria: unilateral locked facet dislocation (48%), bilateral locked facet dislocations (23%), unilateral "perched" facet subluxation (14%), bilateral perched facet subluxation (12%), uni- or bilateral dislocation/perched subluxation with facet fractures (3%).Most of the lesions were located at the levels of C5/C6 and C6/7 (n=46 for each). Associated neurological deficits were present initially in 65% of patients: 35% had complete or incomplete spinal cord injuries (tetraplegia), 2% were paraplegic, and 28% had cervical radiculopathies.Closed reduction (e.g. with the aid of a halo ring) should be carried out as soon as possible after lower cervical spine dislocation or facet-fracture dislocation, as both the success rate of reduction and the potential for recovery from neurological deficits are clearly higher when reduction is achieved within the first 4 h after the initial injury.

Das Behandlungskonzept fur die ventrale Rekonstruktion der thorakolumbalen Wirbelsaule ist Gegenstand der Diskussion. Die ersten 50 Patienten (29 mannlich, 21 weiblich, 43 Jahre), die mit dem Titanwirbelkorperersatz Synex operativ behandelt wurden, werden prospektiv erfasst und im stationaren Verlauf sowie bei klinischer und radiologischer Nachuntersuchung nach 12 und 20 Monaten beobachtet. 25/45 Patienten gingen nach 1 Jahr, 29/39 nach 20 Monaten wieder den alten Freizeitaktivitaten nach. Nach 12 Monaten war jeder Zweite, nach 1,5 Jahren zwei Drittel der Patienten wieder im alten Beruf tatig. 25/45 Patienten hatten nach 1 Jahr, spater 6/39 allenfalls geringe Ruckenbeschwerden. Im Follow-up erzielten die Patienten im validierten Wirbelsaulenscore 65/100 gegenuber 87/100 vor dem Unfall. Erreicht wurde eine signifikante Korrektur von 16,9°, der Korrekturverlust im Verlauf betrug 2,3°. Der Korrekturverlust nach Rekonstruktion der ventralen Saule mit Synex war minimal. Ein Grosteil der Patienten erzielte ein gutes klinisches Outcome mit recht hoher beruflicher Wiedereingliederungsrate. Langzeitergebnisse stehen noch aus.

The goal of our study was to evaluate two newly developed implant designs and their behavior in terms of subsidence in lumbar vertebral bodies under cyclic loading. The new implants were evaluated in two different configurations (two small prototypes vs. one large prototype with similar load-bearing area) in comparison to a conventional screw-based implant (MACS TL). A pool of 13 spines with a total of 65 vertebrae was used to establish five testing groups of similar bone mineral density (BMD) distribution with eight lumbar vertebrae each. In additional to BMD assessment via dual-energy X-ray absorptiometry, cancellous BMD and structural parameters were determined using a new generation in vivo 3D-pQCT. The specimens were loaded sinusoidally in force control at 1 Hz for 1000 cycles at three load levels (100, 200, and 400 N). A survival analysis using the number of cycles until failure (Cox regression with covariates) was applied to reveal differences between implant groups. All new prototype configurations except the large cylinder survived significantly longer than the control group. The number of cycles until failure was significantly correlated with the structural parameter Tb.Sp. and similarly with the cancellous BMD for three of five implants. In both large prototypes the cycle number until failure significantly correlated with the preoperative distance to the upper endplates. Although the direct relationship between bone structure or density and mechanical breakage behavior cannot be conclusively proven, all the prototypes adapted for poor bone structure performed better than the comparable conventional implant. © 2006 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res

Die Autoren schildern die Grundlagen aktueller Behandlungskonzepte fur die Verletzungen der Brust- und Lendenwirbelsaule. Unter Bezugnahme auf biomechanische Konzepte und die Klassifikation der Verletzungen werden Erfahrungen und Ergebnisse geschildert, die bis heute erzielt und veroffentlicht wurden. Die Vor- und Nachteile von operativen und nichtoperativen Behandlungskonzepten werden dargestellt. Auserdem schildern die Autoren die verschiedenen Operationsmethoden, die heute zur Anwendung kommen. Erste eigene Ergebnisse mit dem Wirbelkorperersatzimplantat Synex werden vorgestellt.

Transpedicular instrumentation in the thoracic spine is technically difficult because of small pedicle diameters. There are not many studies assessing in vivo accuracy, complications, and the revision rate of transpedicular screws in the thoracic spine. In this retrospective study 278 thoracic pedicle screws of 43 patients were assessed using a scoring system and postoperative computed tomography (CT) scans. 43 consecutive patients with traumatic thoracic spine fractures underwent posterior transpedicular reduction and fixation. The universal spine system was used for placement of 278 pedicle screws under fluoroscopic control. Fractures were classified according to the Magerl classification by plain radiographs and CT scans. Evaluation of pedicle screw placement was assessed by a scoring system from grade I to grade III. Revision rate of pedicle screws as well as pre- and postoperative neurologic status were analyzed. In the thoracic spine, vertebral body T7 was mainly fractured followed by T6 and T5. In 37 (86.0%) of 43 patients type C fractures and in three patients each type A and B fractures were determined, respectively. Of all 278 pedicle screws, 78.1% were inserted in pedicles T4–T9. The rate of optimally placed grade I screws was 84.5%. Grade II screws were scored in 6.8% and grade III screws in 8.6%. The revision rate of all pedicle screws was 5.0%, whereas 64.3% of these were grade III. None of the patients suffered neurologic or vascular structure compromise postoperatively. Although most pedicle screws were placed in pedicles of the middle thoracic spine where the pedicle width is smallest, most screws were optimally placed with grade I. The revision rate of pedicle screws was acceptable and associated with the grade of pedicle screw placement.

Esophageal perforation in ankylosing spondylitis (AS) is a rare complication in anterior cervical spine surgery and has not been reported before. A 50-year-old patient with AS developed incomplete tetraplegia after minimal trauma. C5 pedicle fracture was diagnosed and treated predominantly by physical therapy until neurological symptoms progressed. Cervical spine MRI showed C6/7 fracture and spinal cord compression. The patient underwent dorsal laminectomy, C5-7 anterior cervical fusion using allograft iliac crest and CASPAR-plate fixation. Delayed esophageal perforation appeared 10 months postoperatively when he came first to our hospital. He complained of dysphagia and developed acute dyspnea. Posterior stabilization with two plates was performed followed by removal of the ventral plate and screws. The esophageal laceration was sutured. The patient was treated with antibiotics and percutaneous endoscopic gastrostomy. Position of fracture and implants were accurate at 18 months postoperatively. The patient had persistent minor neurological deficits (Frankel D) at last follow-up. We conclude that esophageal perforation after anterior spinal fusion is a rare complication. Minor traumas in patients with AS are unstable and can result in significant spinal injury. Dorsoventral stabilization should be performed to avoid further complications.

Background. There are several therapeutic strategies for restoring the anterior column of the vertebral body after trauma, tumor and infection. We present a multicenter study with a new distractable titanium implant for vertebral body replacement. Methods. Prospective documentation was collected of the first 126 patients treated with Synex during the 1st year of the clinical course. There was an evaluation of surgical indication, classification, localisation of the lesion, operative details, complications, and clinical course. Results. A total of 70 men and 56 women (average age 46.9 years) underwent surgery for vertebral fracture, correction of posttraumatic kyphosis, infection, vertebral tumor and metastasis, and other diseases such as ankylosing spondylitis. Synex was used in open and minimally invasive surgery. In almost every case, an additional anteriorly or posteriorly stabilizing implant was used. Anterior fusion was performed with cement in tumors and autologous bone in fractures. Mono- and multisegmental lesions in the thoracic and lumbar spine were treated. Conclusions. The Synex implant is very easy to manage and is suitable for many indications such as vertebral fracture, correction of posttraumatic kyphosis, infection, vertebral tumor/metastasis, and other diseases. The vertebral body replacement can be used for defects of different sizes with the option of in situ distraction. No cases of implant failure, dislocation, or other implant-related complication have been observed. As a consequence of this prospective series, an additional implant size has been added, and the distraction device (spreading forceps) has been modified for more powerful spreading.

In order to study differences between sugar transport in oligosaccharide-translocating and sucrose-translocating species, two members of the Scrophulariaceae, Asarina barclaiana Pennell and Alonsoa meridionalis O. Kuntze, were analysed regarding minor-vein anatomy, sugar concentrations in leaves and phloem sap, and expression of sucrose transporters. The minor veins of Asarina barclaiana possess mainly transfer cells and modified intermediary cells and those of Alonsoa meridionalis have intermediary cells and ordinary companion cells. Phloem sap from these plants was collected by the laser-aphid-stylet technique. The main carbon transport forms in Asarina were sucrose and in Alonsoa raffinose and stachyose. The sum of the carbohydrate concentrations in the phloem sap of both species was as high as that in apoplastic phloem loaders. In Asarina the ratio of the sucrose concentration in the phloem to that in the cytosol of source cells was about 35 and the corresponding ratio in Alonsoa was about two. Sucrose transporter cDNAs were isolated from leaves of both species. By means of semi-quantitative reverse transcription-polymerase chain reaction, sucrose transporter mRNA was detected in different organs and also in the phloem sap. This is the first time that sucrose transporters have been found in oligosaccharide-translocating species and that the mRNA of these sucrose transporters has been localized directly in the phloem sap. Taken together, our observations indicate that Asarina is an apoplastic phloem loader, while the results for Alonsoa are ambiguous: some properties are typical of the symplastic phloem-loading mechanism, but probably a sucrose transporter is involved in loading and/or retrieval of sucrose into the phloem.

Previous studies concerning ruptures of the lateral ligaments of the ankle dealt with acute first ruptures. There are a few articles about chronic instability of the ankle but no prospective investigations have been reported concerning the treatment of recurrent ruptures. Good results were obtained following after non-operative treatment of acute ruptures of the fibular ligaments of the ankle joint. This prospectively randomized study was commenced to test whether recidivations of the rupture of the lateral ligaments can also be treated non-operatively or if they are in need of operative repair. The second question to be answered was whether these injuries should be treated differently dependening on the treatment of the first rupture. From December 1986 to November 1989, 109 patients with a recidivation of a rupture of the ankle joint lateral ligaments were included in this prospective trial at the Department of Trauma Surgery, Hannover Medical School. They were divided into two groups depending on the therapy used to treat the first injury: The relapse was classified as a second-stage-rupture in cases where treatment of the first ligament rupture did not involve an operation and as a rerupture if the initial rupture was surgically repaired. Half of each group was treated randomly either with surgical ligament repair or without. A total of 100 patients (92 %) at an average age of 24 years (11 to 49 years) was seen for follow-up examination one year after the relapse: The follow-up included the patient's subjective assessment, a clinical examination, and stress radiography. A 70 point score was used for evaluation of the total result. Two wound infections requiring reoperation were observed in the operative treatment groups. The follow-up examination revealed better results in both operative treatment groups (A and C), which was statistically significant (P < 0.05). Patients with a second-stage-rupture showed a significantly higher (P < 0.001) stability by stress radiography after surgical treatment (group A) in contrast to non-operative treatment (group B). In addition, the subjective and clinical results indicated a tendency towards better results which were not statistically significant (P < 0.09 and P < 0.07). In cases of rerupture the patient's subjective assessment revealed significantly more (P < 0,05) complaints after non-operative treatment (group D). Clinical results were comparable, and radiologic assessment showed a tendency towards higher joint stability after surgical treatment (group C), although it was not statistically significant (P < 0.07). Based on the results presented, the authors recommend the surgical repair of ankle joint ligaments in cases of second-stage- or rerupture.

STUDY DESIGN Biomechanical in vitro testing of primary and secondary stability in 12 human thoracolumbar spinal specimens using a spine simulator. OBJECTIVE In a corpectomy model anterior plate systems were investigated for their ability to restore spinal stability particularly focusing on the influence of angular stability, bone mineral density (BMD) and failure mode. SUMMARY OF BACKGROUND DATA The concept of isolated anterior column reconstruction following thoracolumbar fractures using newly developed minimally invasive spine surgical techniques has attracted major clinical interest. In analogy to angular stable plate systems in long bone fixation the application of locking plates to the spine is aimed to limit loss of reduction and to improve stability. METHODS Twelve human spinal specimens (Th11-L3) were tested in a 6-degree-of-freedom spine simulator under pure moments of 7.5 Nm to investigate primary and secondary stiffness of 2 different anterior reconstruction options: (1) Synex II cage and MACS TL polyaxial anterior plating system, (2) Synex II cage and ArcoFix angular stable anterior plating system. An increasing 4-step cyclic loading model was included. RESULTS The angular stable plate system showed superior stability compared to the nonangular system in axial rotation and lateral bending. Flexion/extension loading demonstrated no difference between the systems in range of motion. A positive correlation between BMD and the number of load cycles until failure for the nonangular stable system (R2 = 0.90) was found. Different failure modes were investigated for the plating systems. The MACS system showed loosening at the connection between screw and plate inducing tilting under flexural load and final failure. The ArcoFix system revealed increased stability under cyclic loading and failed by parallel sintering to the endplate. CONCLUSION Anterior angular stable fixation showed higher primary and secondary stability following thoracolumbar corpectomy. In specimens with lower BMD the use of angular stable systems substantially increased stability. Angular stable systems, however, differ in the way of construct failure.