AI-support for the detection of intracranial large vessel occlusions: One-year prospective evaluation

Purpose

Few studies have evaluated real-world performance of radiological AI-tools in clinical practice. Over one-year, we prospectively evaluated the use of AI software to support the detection of intracranial large vessel occlusions (LVO) on CT angiography (CTA).

Method

Quantitative measures (user log-in attempts, AI standalone performance) and qualitative data (user surveys) were reviewed by a key-user group at three timepoints. A total of 491 CTA studies of 460 patients were included for analysis.

Results

The overall accuracy of the AI-tool for LVO detection and localization was 87.6%, sensitivity 69.1% and specificity 91.2%. Out of 81 LVOs, 31 of 34 (91%) M1 occlusions were detected correctly, 19 of 38 (50%) M2 occlusions, and 6 of 9 (67%) ICA occlusions. The product was considered user-friendly. The diagnostic confidence of the users for LVO detection remained the same over the year. The last measured net promotor score was -56%. The use of the AI-tool fluctuated over the year with a declining trend.

Conclusions

Our pragmatic approach of evaluating the AI-tool used in clinical practice, helped us to monitor the usage, to estimate the perceived added value by the users of the AI-tool, and to make an informed decision about the continuation of the use of the AI-tool.

Induction of NETosis in ovine colostral PMN upon exposure to Neospora caninum tachyzoites

Colostrum is one of the most important factors influencing the health and development of mammalian neonates. It is well-established that leukocytes, including polymorphonuclear neutrophils (PMN), migrate from the mother to the infant via colostrum uptake. In this study, for the first time, we studied the ability of ovine colostral-derived PMN to extrude neutrophil extracellular traps (NETs) against the abortive apicomplexan parasite Neospora caninum. Although this cell population plays a significant role in the transmission of maternal innate immunity to neonates, little is known about colostral PMN activities in sheep. However, this cell population is a significant source of the transfer of maternal immunity to the neonate. Colostral PMN continues to exert immunological effects even after transitioning into the colostrum. The present study aimed to investigate the extrusion of NETs by ovine colostral PMN exposed to the apicomplexan parasite, N. caninum, which is known to cause devastating reproductive disorders in cattle, small ruminants, wildlife animals, and dogs. The present study is the first to demonstrate that ovine colostral PMN can produce NETs after stimulation with vital N. caninum tachyzoites. Ovine colostrum-derived NETs were detected by chromatin staining and antibody-based immunofluorescence staining of NET-specific structures, including neutrophil elastase (NE) and global histones (H1, H2A/H2B, H3, H4), as well as scanning electron microscopy (SEM) analysis.

Neospora caninum-induced NETosis in canine colostral polymorphonuclear neutrophils

Neospora caninum represents an obligate intracellular apicomplexan parasite of the family Sarcocystidae causing severe reproductive disorders in cattle, small ruminants, wild animals and canids worldwide. Neutrophil extracellular traps (NETs) were recently described as effective host defense mechanism of polymorphonuclear neutrophils (PMN) derived from cattle, dogs, goats and dolphins against N. caninum tachyzoites. Nonetheless, nothing is known so far on canine colostral PMN immune reactions against N. caninum although breeding bitches represent a susceptible dog cohort and infected bitches may spread tachyzoites through transplacental transmission to their offspring. Thus, isolated colostrum PMN from bitches were assessed for PMN phagocytic activities as well as NETs release against viable N. caninum tachyzoites. In vitro interactions of canine colostrum-derived PMN with tachyzoites were analyzed at different ratios and time spans. Extracellular chromatin staining was applied in order to unveil classical molecules of NETs, such as neutrophil elastase (NE), global histones (H1, H2A/H2B, H3, H4) and myeloperoxidase (MPO), via antibody-based immunofluorescence microscopy analysis. N. caninum tachyzoites induced canine NETs in colostral PMN and scanning electron microscopy (SEM) analysis revealed NETs formation by colostral PMN thereby ensnaring tachyzoites after exposure. In summary, NETs released from canine colostral PMN might represent an early and effective maternal defense mechanism of the definitive host helping neonates to reduce initial intracellular replication of not only parasites but of other invasive pathogens after colostrum consumption.

Canine Angiostrongylus vasorum-Induced Early Innate Immune Reactions Based on NETs Formation and Canine Vascular Endothelial Cell Activation In Vitro

Simple Summary

Angiostrongylus vasorum is a cardiopulmonary nematode that affects canids, residing in the pulmonary artery and right atrium/ventricle. Due to its location, the parasite will have a close interaction with the different components of the innate immune system, including endothelial cells and polymorphonuclear neutrophils (PMN). Here we evaluated the expression of adhesion molecules of canine aortic endothelial cells (CAEC), and NETs formation by co-culture of freshly isolated canine PMN with A. vasorum L3. Overall, we found distinct inter-donor variations in adhesion molecule expression among CAEC isolates. Additionally, PMN and A. vasorum co-culture induced NETs release without affecting larval viability.

Abstract

Due to its localization in the canine blood stream, Angiostrongylus vasorum is exposed to circulating polymorphonuclear neutrophils (PMN) and the endothelial cells of vessels. NETs release of canine PMN exposed to A. vasorum infective stages (third stage larvae, L3) and early pro-inflammatory immune reactions of primary canine aortic endothelial cells (CAEC) stimulated with A. vasorum L3-derived soluble antigens (AvAg) were analyzed. Expression profiles of the pro-inflammatory adhesion molecules ICAM-1, VCAM-1, P-selectin and E-selectin were analyzed in AvAg-stimulated CAEC. Immunofluorescence analyses demonstrated that motile A. vasorum L3 triggered different NETs phenotypes, with spread NETs (sprNETs) as the most abundant. Scanning electron microscopy confirmed that the co-culture of canine PMN with A. vasorum L3 resulted in significant larval entanglement. Distinct inter-donor variations of P-selectin, E-selectin, ICAM-1 and VCAM-1 gene transcription and protein expression were observed in CAEC isolates which might contribute to the high individual variability of pathological findings in severe canine angiostrongylosis. Even though canine NETs did not result in larval killing, the entanglement of L3 might facilitate further leukocyte attraction to their surface. Since NETs have already been documented as involved in both thrombosis and endothelium damage events, we speculate that A. vasorum-triggered NETs might play a critical role in disease outcome in vivo.

Trypanosoma brucei brucei Induces Polymorphonuclear Neutrophil Activation and Neutrophil Extracellular Traps Release

Trypanosoma brucei brucei trypomastigotes are classical blood parasites of cattle, these stages might become potential targets for circulating polymorphonuclear neutrophils (PMN). We here investigated NETs extrusion and related oxygen consumption in bovine PMN exposed to motile T. b. brucei trypomastigotes in vitro. Parasite exposure induced PMN activation as detected by enhanced oxygen consumption rates (OCR), extracellular acidification rates (ECAR), and production of total and extracellular reactive oxygen species (ROS). Scanning electron microscopy (SEM) showed that co-cultivation of bovine PMN with motile trypomastigotes resulted in NETs formation within 120 min of exposure. T. b. brucei-induced NETs were confirmed by confocal microscopy demonstrating co-localization of extruded DNA with neutrophil elastase (NE) and nuclear histones. Immunofluorescence analyses demonstrated that trypomastigotes induced different phenotypes of NETs in bovine PMN, such as aggregated NETs (aggNETs), spread NETs (sprNETs), and diffuse NETs (diffNETs) with aggNETs being the most abundant ones. Furthermore, live cell 3D-holotomographic microscopy unveiled detailed morphological changes during the NETotic process. Quantification of T. b. brucei-induced NETs formation was estimated by DNA and nuclear area analysis (DANA) and confirmed enhanced NETs formation in response to trypomastigote stages. Formation of NETs does not result in a decrease of T. b. brucei viability, but a decrease of 26% in the number of motile parasites. Referring the involved signaling pathways, trypomastigote-induced NETs formation seems to be purinergic-dependent, since inhibition via NF449 treatment resulted in a significant reduction of T. b. brucei-triggered DNA extrusion. Overall, future studies will have to analyze whether the formation of aggNETs indeed plays a role in the outcome of clinical disease and bovine African trypanosomiasis-related immunopathological disorders, such as increased intravascular coagulopathy and vascular permeability, often reported to occur in this disease.

Treatment of cows with parturient paresis using intravenous calcium and oral sodium phosphate

INTRODUCTION

The goal of this study was to investigate whether intravenous infusion of 1000 ml 40% calcium borogluconate combined with the oral adminstration of 500 g sodium phosphate leads to a better cure rate and longer-lasting normocalcaemia and normophosphataemia than standard intravenous treatment with 500 ml calcium borogluconate in cows with parturient paresis. Forty recumbent cows with hypocalcaemia and hypophosphataemia were alternately allocated to group A or B. Cows of both groups were treated intravenously with 500 ml 40% calcium borogluconate, and cows of group B additionally received another 500 ml calcium borogluconate via slow intravenous infusion and 500 g sodium phosphate administered via an orogastric tube. Thirty-two cows stood within 8 hours after the start of treatment and 8 did not; of the 32 cows that stood, 18 belonged to group A and 14 to group B (90% of group A vs. 70% of group B; P = 0.23). Seven cows relapsed; of these and the 8 that did not respond to initial treatment, 10 stood after two standard intravenous treatments. Downer cow syndrome occurred in 5 cows, 3 of which recovered after aggressive therapy. The overall cure rate did not differ significantly between groups A and B. Twelve (60%) cows of group A and 14 (70%) cows of group B were cured after a single treatment and of the remaining 14, 11 were cured after two or more treatments. Two downer cows were euthanized and one other died of heart failure during treatment. Serum calcium concentrations during the first eight hours after the start of treatment were significantly higher in group B than in group A, and oral sodium phosphate caused a significant and lasting increase in inorganic phosphate. More cows of group B than group A were cured after a single treatment (P > 0.05). These findings, although not statistically significant, are promising and should be verified using a larger number of cows.

Rumen perforation caused by horn injury in two cows

Post-operative complications of trocarisation and rumenotomy are the most common causes of peritonitis associated with a rumen disorder. Since horn injury leading to rumen perforation has not previously been reported in the literature, two cows with this condition are reported. Small superficial skin lesions were observed in one of the cows and the other had a perforating skin lesion in the left abdomen. Both cows had signs of hypovolaemic shock. Ultrasonography revealed hypoechoic fluid, echoic lesions and occasional fibrinous septa caudoventral to the reticulum. Caudally the fluid extended to the left flank fold and occupied about one third of the peritoneal cavity. The area of the skin perforation in the left abdomen was swollen and the muscle layers could not be differentiated using ultrasonography. Diffuse fibrino-purulent peritonitis was diagnosed in both cows, and because of a poor prognosis, they were euthanased and necropsied. Perforation of the abdominal wall and rumen with diffuse fibrino-purulent peritonitis was present. Ultrasonography is a suitable tool to characterise the inflammatory lesions between the rumen and left abdominal wall and objectify the interpretation of clinical findings. Horn injury should be included in the rule outs for cattle with left abdominal skin wounds and diffuse peritonitis.

Calcifediol versus vitamin D3 effects on gait speed and trunk sway in young postmenopausal women: a double-blind randomized controlled trial

In this double-blind RCT, 4-month treatment with calcifediol compared with vitamin D3 improved gait speed by 18% among young postmenopausal women. Consistently, change in 25(OH)D blood levels over time were significantly correlated with improvement in gait speed in these women. No effect could be demonstrated for trunk sway.

INTRODUCTION

The aim of this study is to test the effect of calcifediol compared with vitamin D3 on gait speed and trunk sway.

METHODS

Twenty healthy postmenopausal women with an average 25(OH)D level of 13.2 ng/ml (SD = ±3.9) and a mean age of 61.5 years (SD = ±7.2) were randomized to either 20 μg of calcifediol or 20 μg (800 IU) of vitamin D3 per day in a double-blind manner. At baseline and at 4 months of follow-up, the same physiotherapist blinded to treatment allocation tested 8-m gait speed and a body sway test battery (Sway star pitch and roll angle plus velocity while walking 8 m, and standing on both legs on a hard and soft surface). All analyses adjusted for baseline measurement, age, and body mass index.

RESULTS

Mean 25(OH)D levels increased to 69.3 ng/ml (SD = ±9.5) in the calcifediol group and to 30.5 ng/ml (SD = ±5.0) in the vitamin D3 group (p < 0.0001). Women receiving calcifediol compared with vitamin D3 had an 18% greater improvement in gait speed at 4-month follow-up (p = 0.046) adjusting for baseline gait speed, age, and body mass index. Also, change in gait speed was significantly correlated with change in serum 25(OH)D concentrations (r = 0.5; p = 0.04). Across three tests of trunk sway, there were no consistent differences between groups and no significant correlation between change in 25(OH)D serum concentrations and change in trunk sway.

CONCLUSIONS

Calcifediol improved gait speed in early postmenopausal women compared with vitamin D3 and change in 25(OH)D level was moderately correlated with improvement in gait speed. A benefit on trunk sway could not be demonstrated.

[Perioperative risk assessment of geriatric patients undergoing noncardiac surgery]

BACKGROUND

Older patients more often suffer perioperative complications than younger people. Especially geriatric patients who require emergency treatment represent a high-risk group. Therefore, perioperative risk assessment supports the treatment team in identifying patients at risk and in defining the treatment plan accordingly.

MATERIALS AND METHODS

A thorough medical history and clinical examination are pivotal elements of any risk stratification. The organ-specific risk assessment is primarily used to plan the surgical and anesthesiological procedures.

RESULTS

For a comprehensive risk assessment in geriatric patients, the organ-specific risk stratification is insufficient. Assessment instruments that reflect the idiosyncrasies of multidimensional disease in geriatric patients can complement risk stratification. These should include the assessment of multimorbidity, frailty, nutrition, activities of daily living, and cognition. In addition to risk prediction, geriatric assessment has the major advantage of providing both a diagnostic and a planning perspective. This allows the implementation of supporting measures for optimal perioperative care, which is the goal of any risk stratification. Risk scores provide a global assessment, but they have their limitations in predicting individual patient risk.

Gender-specific hip fracture risk in community-dwelling and institutionalized seniors age 65 years and older

In this study of acute hip fracture patients, we show that hip fracture rates differ by gender between community-dwelling seniors and seniors residing in nursing homes. While women have a significantly higher rate of hip fracture among the community-dwelling seniors, men have a significantly higher rate among nursing home residents.

INTRODUCTION

Differences in gender-specific hip fracture risk between community-dwelling and institutionalized seniors have not been well established, and seasonality of hip fracture risk has been controversial.

METHODS

We analyzed detailed data from 1,084 hip fracture patients age 65 years and older admitted to one large hospital center in Zurich, Switzerland. In a sensitivity analysis, we extend to de-personalized data from 1,265 hip fracture patients from the other two large hospital centers in Zurich within the same time frame (total n = 2,349). The denominators were person-times accumulated by the Zurich population in the corresponding age/gender/type of dwelling stratum in each calendar season for the period of the study.

RESULTS

In the primary analysis of 1,084 hip fracture patients (mean age 85.1 years; 78% women): Among community-dwelling seniors, the risk of hip fracture was twofold higher among women compared with men (RR = 2.16; 95% CI, 1.74-2.69) independent of age, season, number of comorbidities, and cognitive function; among institutionalized seniors, the risk of hip fracture was 26% lower among women compared with men (RR = 0.77; 95% CI: 0.63-0.95) adjusting for the same confounders. In the sensitivity analysis of 2,349 hip fracture patients (mean age 85.0 years, 76% women), this pattern remained largely unchanged. There is no seasonal swing in hip fracture incidence.

CONCLUSION

We confirm for seniors living in the community that women have a higher risk of hip fracture than men. However, among institutionalized seniors, men are at higher risk for hip fracture.

Before and after hip fracture, vitamin D deficiency may not be treated sufficiently

Our findings show that only about 20% of seniors receive vitamin D supplementation prior to their index hip fracture or after the event. We further confirm the high prevalence of severe vitamin D deficiency in this population and show that those who receive supplementation have significantly higher 25-hydroxyvitamin D (25(OH)D) status.

INTRODUCTION

The aim of this study is to assess current practice in pre- and post-hip fracture care practice with respect to vitamin D supplementation.

METHODS

We surveyed 1,090 acute hip fracture patients age 65 and older admitted to acute care for hip fracture repair; 844 had serum 25-hydroxyvitamin D levels measured upon admission to acute care, and 362 agreed to be followed at 12 month after their hip fracture. Prevalence of vitamin D supplementation was assessed upon admission to acute care (at the time of hip fracture), upon discharge from acute care, and at 6 and 12 months follow-up.

RESULTS

Of 1,090 acute hip fracture patients (mean age 85 years, 78% women, 59 % community-dwelling), 19% had received any dose of vitamin D prior to the index hip fracture, 27% (of 854 assessed) at discharge from acute care, 22 % (of 321 assessed) at 6 month, and 21% (of 285 assessed) at 12 month after their hip fracture. At the time of fracture, 45% had 25(OH)D levels below 10 ng/ml, 81% had levels below 20 ng/ml, and 96% had levels below 30 ng/ml. Notably, 25(OH)D levels did not differ by season or gender but were significantly higher among 164 hip fracture patients, with any vitamin D supplementation compared with 680 without supplementation (19.9 versus 10.8 ng/ml; p < 0.0001).

CONCLUSION

Only about 20% of seniors receive vitamin D at the time of their fracture and after the event. This is despite the documented 81% prevalence of vitamin D deficiency. Interdisciplinary efforts may be warranted to improve vitamin D supplementation in seniors both before a hip fracture occurs and after.

[Multidimensional geriatric assessment as clinical approach to the multimorbid patient in acute care]

The multidimensional geriatric assessment is an interdisciplinary diagnostic process, taking into account several health dimensions. The resulting know-ledge is used to establish a treatment plan. The multidimensional geriatric assessment has shown its efficacy in the acute care treatment of multidimensionally ill and polymorbid patients in acute geriatric structures. The multidimensional geriatric assessment plays a central role in questions regarding the allocation of resources and is becoming more important because of the demographic development and the rapidly changing framework in our health system. It ensures that older patients don't slip through the net in a more fragmented clinical medicine. Growing evidence allows using this assessment approach in polymorbid patients being treated in specialised fields as traumatology, cardiology, oncology and nephrology.

[Two-years' follow-up after lumbar disc surgery.]

INTRODUCTION

Outcome studies of lumbar disc surgery document a success rate ranging between 49% and 90%, according to the evaluation criteria used. The aim of the present study was to investigate the prognostic value of pain history and of sociodemographic, psychodiagnostic and medical factors for the long-term outcome after lumbar disc surgery.

METHODS

Between selection for and performance of operations for herniated lumbar disc, 100 patients took part in standardized interviews about their clinical and social history. During the same session they answered one questionnaire on depression and one on coping strategies in response to pain. Two years after the operation, 83 patients answered the standardized follow-up questionnaires.

RESULTS

During the follow-up period, 7 (8.4%) patients had further back surgery, and 20% of the patients reported severe back pain on the follow up. With multivariate discriminant analysis, correct prediction of at most moderate back pain or severe back pain 2 years after the operation had been possible in 94.3% of the patients. The important predictors were found to be: duration of subjectively reduced working capability, pain at other locations, consideration or application for disability pension, depression, and severe acute pain. Risk factors for further back surgery were pain at other locations, guest for social support in response to pain, absence of muscle palsy and of Laségue's sign.

CONCLUSION

Anamnestic information on the pain history and psychological factors have prognostic value for the outcome after lumbar disc surgery. If there is no absolute medical indication for disc surgery, we suggest reconsidering the treatment planned for patients with the risk factors specified.

Mild to moderate cognitive impairment is a major risk factor for mortality and nursing home admission in the first year after hip fracture

BACKGROUND

It is not well established if and to what extent mild to moderate cognitive impairment predicts mortality and risk of nursing home admission after hip fracture.

OBJECTIVE

To investigate prospectively whether and to what extent mild to moderate cognitive impairment, contributes to mortality and admission to nursing home in the first year after acute hip fracture.

METHODS

We enrolled 173 patients with acute hip fracture age 65 and older who reached a Mini-Mental State Examination (MMSE) score of at least 15 during acute care after hip fracture repair. An MMSE score of 15 to 24 (median) was classified as mild to moderate cognitive impairment. Primary outcomes were mortality in all and admission to nursing home among seniors who lived at home prior to their hip fracture. Follow-up was 12 months with clinical visits at baseline, 6, and 12 months, plus monthly phone calls. We used Cox proportional hazards models controlling for age, sex, body mass index, baseline number of comorbidities and 25-hydroxyvitamin D status, and severe incident infections to assess the risk of mortality and nursing home admission. Because the study population was enrolled in a factorial design clinical trial testing high dose vitamin D and/or an exercise home program, all analyses also controlled for these treatment strategies.

RESULTS

Of 173 acute hip fracture patients enrolled, 79% were women, 77% were admitted from home, and 80% were vitamin D deficient (<20ng/ml). Mean age was 84 years. 54% had mild to moderate cognitive impairment. Over the 12-month follow-up, 20 patients died (27% of 173) and 47 (35% of 134) were newly admitted to a nursing home. Mild to moderate cognitive impairment was associated with a more than 5-fold increased risk of mortality (HR=5.77; 95% CI: 1.55-21.55) and a more than 7-fold increased risk of nursing home admission (HR=7.37; 95% CI: 1.75-30.95). Additional independent risk factors of mortality were male gender (HR=3.55; 95% CI: 1.26-9.97), low BMI (HR=7.25; 95% CI: 1.61-33.74), and baseline 25-hydroxyvitamin D level (per 1ng/ml: HR=0.93; 95% CI: 0.87-0.998; p=0.04).

CONCLUSIONS

Mild to moderate cognitive impairment in patients with acute hip fracture is associated with a high risk of mortality and nursing home admission during the first year after hip fracture. Female gender, a greater BMI and a higher 25-hydroxyvitamin D status may protect against mortality after hip fracture independent of cognitive function.

The bothersomeness of patient self-rated "complications" reported 1 year after spine surgery

PURPOSE

The last few decades have witnessed a paradigm shift in the assessment of outcome in spine surgery, with patient-centred questionnaires superseding traditional surgeon-based assessments. The assessment of complications after surgery and their impact on the patient has not enjoyed this same enlightened approach. This study sought to quantify the incidence and bothersomeness of patient-rated complications 1 year after surgery.

METHODS

Patients with lumbar degenerative disorders, operated with the goal of pain relief between October 2006 and September 2010, completed a questionnaire 1 year postoperatively enquiring about complications arising as a consequence of their operation. They rated the bothersomeness of any such complications on a 5-point scale. Global outcome of surgery and satisfaction at the 12-month follow-up were also rated on 5-point Likert scales. The multidimensional Core Outcome Measures Index (COMI) was completed preoperatively and at the 12-month follow-up.

RESULTS

Of 2,282 patients completing the questionnaire (92% completion rate), 687 (30.1%) reported complications, most commonly sensory disturbances (36% of those with complications) or ongoing/new pain (26%), followed by motor problems (8%), pain plus neurological disturbances (11%), and problems with wound healing (6%). The corresponding "bothersomeness" ratings for these were: 1% not at all, 23% slightly, 27% moderately, 31% very, and 18% extremely bothersome. The greater the bothersomeness, the worse the global outcome (Rho = 0.51, p < 0.0001), patient satisfaction (Rho = 0.44, p < 0.0001) and change in COMI score (Rho = 0.52, p < 0.0001).

CONCLUSION

Most complications reported by the patient are perceived to be at least moderately bothersome and hence are not inconsequential. Complications and their severity should be assessed from both the patient's and the surgeon's perspectives--not least to better understand the reasons for poor outcome and dissatisfaction with treatment.

To fuse or not to fuse in lumbar degenerative spondylolisthesis: do baseline symptoms help provide the answer?

INTRODUCTION

Clinical symptoms in lumbar degenerative spondylolisthesis (LDS) vary from predominantly radiating pain to severe mechanical low back pain. We examined whether the outcome of surgery for LDS varied depending on the predominant baseline symptom and the treatment administered [decompression with fusion (D&F) or decompression alone (D)].

METHODS

213 consecutive patients (69 ± 9 years; 155f, 58 m) participated. Inclusion criteria were LDS, maximum three affected levels, no previous surgery at the affected level, and D (N = 56) or D&F (N = 157) as the operative procedure. Pre-op and at 12 months' follow-up (FU), patients completed the multidimensional Core Outcome Measures Index (COMI) including 0-10 leg-pain (LP) and LBP scales. At 12 months' FU, patients rated global outcome which was then dichotomised into "good" and "poor".

RESULTS

Pre-operatively, LBP and COMI scores were significantly worse (p < 0.05) in the D&F group than in the D group. The improvement in COMI at 12 months' FU was significantly greater for D&F than for D (p < 0.001) and was not influenced by the patient's declared "main problem" at baseline (back pain, leg pain, or neurological disturbances) (p > 0.05). There was a higher proportion (p = 0.01) of "good" outcomes at 12 months' FU in D&F (86%) than in D (70%). Multiple regression analysis, controlling for possible confounders, revealed treatment group to be the only significant predictor of outcome (adding fusion = better outcome).

DISCUSSION

Our study indicated that LDS patients showed better patient-based outcome with instrumented fusion and decompression than with decompression alone, regardless of baseline symptoms. This may be due to the fact that the underlying slippage as the cause of the stenosis is better addressed with fusion.

Five-year outcome of surgical decompression of the lumbar spine without fusion

As the average life expectancy of the population increases, surgical decompression of the lumbar spine is being performed with increasing frequency. It now constitutes the most common type of lumbar spinal surgery in older patients. The present prospective study examined the 5-year outcome of lumbar decompression surgery without fusion. The group comprised 159 patients undergoing decompression for degenerative spinal disorders who had been participants in a randomised controlled trial of post-operative rehabilitation that had shown no between-group differences at 2 years. Leg pain and back pain intensity (0-10 graphic rating scale), self-rated disability (Roland Morris), global outcome of surgery (5-point Likert scale) and re-operation rates were assessed 5 years post-operatively. Ten patients had died before the 5-year follow-up. Of the remaining 149 patients, 143 returned a 5-year follow-up (FU) questionnaire (effective return rate excluding deaths, 96%). Their mean age was 64 (SD 11) years and 92/143 (64%) were men. In the 5-year follow-up period, 34/143 patients (24%) underwent re-operation (17 further decompressions, 17 fusions and 1 intradural drainage/debridement). In patients who were not re-operated, leg pain decreased significantly (p < 0.05) from before surgery to 2 months FU, after which there was no significant change up to 5 years. Low back pain also decreased significantly by 2 months FU, but then showed a slight, but significant (p < 0.05), gradual increase of <1 point by 5-year FU. Disability decreased significantly from pre-operative to 2 months FU and showed a further significant decrease at 5 months FU. Thereafter, it remained stable up to the 5-year FU. Pain and disability scores recorded after 5 years showed a significant correlation with those at earlier follow-ups (r = 0.53-0.82; p < 0.05). Patients who were re-operated at some stage over the 5-year period showed significantly worse final outcomes for leg pain and disability (p < 0.05). In conclusion, pain and disability showed minimal change in the 5-year period after surgery, but the re-operation rate was relatively high. Re-operation resulted in worse final outcomes in terms of leg pain and disability. At the 5-year follow-up, the "average" patient experienced frequent, but relatively low levels of, pain and moderate disability. This knowledge on the long-term outcome should be incorporated into the pre-operative patient information process.

THE ANTIPROTEOLYTIC ACTIVITY OF SERUM : I. THE NATURE AND EXPERIMENTAL VARIATION OF THE ANTIPROTEOLYTIC ACTIVITY OF SERUM

1. An equation is derived for the calculation of a constant which, experimental results indicate, may be a more reliable index of the antiproteolytic activity of serum than those equations hitherto used. 2. (a) Intramuscular administration of trypsin resulted in a slow rise in the antiproteolytic activity of the serum, followed by a lesser decline. (b) Intravenous administration resulted in no appreciable variation. (c) Oral administration resulted in a rapid rise, which was sustained during the period of administration. (d) Intramuscular, intravenous, or oral administration of denatured trypsin resulted in no appreciable variation. (e) The extent of the local necrosis following subcutaneous injection of trypsin varied inversely with the antiproteolytic activity of the serum. 3. The experimental results indicate that the products of protein hydrolysis in the intestine and parenterally are an important factor in the antiproteolytic activity of the serum. They also indicate that antibodies to trypsin are not an important factor in the antiproteolytic activity of the serum.

THE ANTIPROTEOLYTIC ACTIVITY OF SERUM : III. PHYSIOLOGICAL SIGNIFICANCE. THE INFLUENCE OF TRYPSIN AND OF ANTIPROTEASE ON BACTERIAL GROWTH AND SULFONAMIDE ACTION

1. Heating diluted serum at 80 degrees C. for 10 minutes made it a better medium for bacterial growth. This is believed to have been at least partly due to destruction of the serum antiprotease. 2. Growth was accelerated, and proceeded further, in the presence of trypsin. 3. Growth was somewhat retarded in the presence of pancreatic trypsin inhibitor. 4. The bacteriostatic action of sulfathiazole in serum was reduced by heating the serum at 80 degrees C., and much more markedly (in any of the media studied) by adding trypsin. It was greater in serum and albumen than in peptone and meat infusion. 5. The significance of the experimental results was considered in relation to the possible influence of leucoprotease and of serum antiprotease on bacterial growth and sulfonamide action.

THE ANTIPROTEOLYTIC ACTIVITY OF SERUM : II. PHYSIOLOGICAL SIGNIFICANCE. THE INFLUENCE OF PURIFIED TRYPSIN INHIBITOR ON THE COAGULATION OF THE BLOOD

1. Serum antitrypsin and pancreatic trypsin inhibitor inhibited the coagulation of plasma in vitro. 2. This could be largely prevented by trypsin. 3. The anticoagulant action of the trypsin inhibitor was apparently due to its antiprothrombic action. It had no appreciable antithrombic action. 4. Examination of the blood of two hemophiliacs indicated that the prolonged coagulation time of their blood is not due to an excess of trypsin inhibitor. 5. Examination of the blood of heparinized dogs indicated that heparin does not appreciably contribute to the antiproteolytic activity of the serum.

[The spinal intervertebral disc]

The spinal intervertebral disc can cause neurocompression or pain as a result of degeneration. Surgical interventions, therefore, include decompression, fusion, disc replacement or a combination thereof. Identifying the painful segment in the case of axial pain requires accurate segment diagnosis and may require invasive diagnostic measures (joint infiltration, discography), since imaging is often not fluid enough. In the case of fusion following disc removal, the placeholder is substitued in the form of a cage or autologous iliac crest graft. Alternatively, when dorsal elements are intact, a disc prosthesis can be inserted. In the case of compression, removal of the compromised structures (disc, osteophytes) becomes necessary. If the indication is correctly made and the appropriate surgical technique used, good results can be expected from cervical spine surgery.

A prospective, cohort study comparing translaminar screw fixation with transforaminal lumbar interbody fusion and pedicle screw fixation for fusion of the degenerative lumbar spine

In a prospective observational study we compared the two-year outcome of lumbar fusion by a simple technique using translaminar screws (n = 57) with a more extensive method using transforaminal lumbar interbody fusion and pedicular screw fixation (n = 63) in consecutive patients with degenerative disease of the lumbar spine. Outcome was assessed using the validated multidimensional Core Outcome Measures Index. Blood loss and operating time were significantly lower in the translaminar screw group (p < 0.01). The complication rates were similar in each group (2% to 4%). In all, 91% of the patients returned their questionnaire at two-years. The groups did not differ in Core Outcome Measures Index score reduction, 3.6 (sd 2.5) (translaminar screws) vs 4.0 (sd 2.8) (transforaminal lumbar interbody fusion) (p = 0.39); ‘good’ global outcomes, 78% (translaminar screws) vs 78% (transforaminal lumbar interbody fusion) (p = 0.99) or satisfaction with treatment, 82% (translaminar screws) vs 86% (transforaminal lumbar interbody fusion) (p = 0.52).

The two fusion techniques differed markedly in their extent and the cost of the implants, but were associated with almost identical patient-orientated outcomes.

Extensive three-point stabilisation is not always required to achieve satisfactory patient-orientated results at two years.

Microdiscectomy compared with standard discectomy: an old problem revisited with new outcome measures within the framework of a spine surgical registry

Studies comparing the relative merits of microdiscectomy and standard discectomy report conflicting results, depending on the outcome measure of interest. Most trials are small, and few have employed validated, multidimensional patient-orientated outcome measures, considered essential in outcomes research. In the present study, data were collected prospectively from six surgeons participating in a surgical registry. Inclusion criteria were: lumbar/lumbosacral degenerative disease; discectomy/sequestrectomy without additional fusion/stabilisation; German or English-speaking. Before and 3 and 12 months after surgery, patients completed the Core Outcome Measures Index comprising questions on leg/buttock pain, back pain, back-related function, symptom-specific well-being, general quality-of-life, and social and work disability. At follow-up, they rated overall satisfaction, global outcome, and perceived complications. Compliance with the registry documentation was excellent: 87% for surgeons (surgery forms), 91% for patients (for 12 months follow-up). 261 patients satisfied the inclusion criteria (225 microdiscectomy, 36 standard discectomy). The standard discectomy group had significantly greater blood-loss than the microdiscectomy (P < 0.05). There were no group differences in the proportion of surgical complications or duration of hospital stay (P > 0.05). The groups did not differ in relation to any of the patient-orientated outcomes or individual outcome domains (P > 0.05). Though not equivalent to an RCT, the study included every single eligible patient in our Spine Center and allowed surgeons to use their regular procedure; it hence had extremely high external validity (relevance/generalisability). There was no clinically relevant difference in outcome after lumbar disc excision dependent on the use of the microscope. The decision to use the microscope should rest with the surgeon.

The quality of spine surgery from the patient's perspective. Part 1: the Core Outcome Measures Index in clinical practice

The Core Outcome Measures Index (COMI) is a short, multidimensional outcome instrument, with excellent psychometric properties, that has been recommended for use in monitoring the outcome of spinal surgery from the patient's perspective. This study examined the feasibility of implementation of COMI and its performance in clinical practice within a large Spine Centre. Beginning in March 2004, all patients undergoing spine surgery in our Spine Centre (1,000-1,200 patients/year) were asked to complete the COMI before and 3, 12 and 24 months after surgery. The COMI has one question each on back (neck) pain intensity, leg/buttock (arm/shoulder) pain intensity, function, symptom-specific well being, general quality of life, work disability and social disability, scored as a 0-10 index. At follow-up, patients also rated the global effectiveness of surgery, and their satisfaction with their treatment in the hospital, on a five-point Likert scale. After some fine-tuning of the method of administration, completion rates for the pre-op COMI improved from 78% in the first year of operation to 92% in subsequent years (non-response was mainly due to emergencies or language or age issues). Effective completion rates at 3, 12 and 24-month follow-up were 94, 92 and 88%, respectively. The 12-month global outcomes (from N = 3,056 patients) were operation helped a lot, 1,417 (46.4%); helped, 860 (28.1%); helped only little, 454 (14.9%); did not help, 272 (8.9%); made things worse, 53 (1.7%). The mean reductions in COMI score for each of these categories were 5.4 (SD2.5); 3.1 (SD2.2); 1.3 (SD1.7); 0.5 (SD2.2) and -0.7 (SD2.2), respectively, yielding respective standardised response mean values ("effect sizes") for each outcome category of 2.2, 1.4, 0.8, 0.2 and 0.3, respectively. The questionnaire was feasible to implement on a prospective basis in routine practice, and was as responsive as many longer spine outcome questionnaires. The shortness of the COMI and its multidimensional nature make it an attractive option to comprehensively assess all patients within a given Spine Centre and hence avoid selection bias in reporting outcomes.

[Lumbar total disc replacement]

Total disc replacement has been introduced to avoid the biomechanical changes often caused in adjacent segments by the traditional fusion of two or more vertebrae in the lumbar spine. It also aims to maintain mobility and eliminate pain. Total disc replacement using a flexible prosthesis is currently a popular solution. The main indication for this procedure is low back pain caused by disc degeneration. Diagnostic procedures are important to correctly identify and localize the affected disc. To this end, discography represents the most reliable test; however, imaging and clinical investigations are also important adjuncts. To date, there are insufficient long-term data available on the relatively new total disc replacement technique to be able to confirm its superiority compared to traditional fusion procedures in terms of low back pain and patient satisfaction, but short- and mid-term results indicate that, when correctly indicated, both procedures have similar outcomes.

Predictors of multidimensional outcome after spinal surgery

The variables identified as predictors of surgical outcome often differ depending on the specific outcome variable chosen to designate "success". A short set of multidimensional core outcome measures was recently developed, in which each of the following domains was addressed with a single question and then combined in an index: pain, function, symptom-specific well-being, general well-being (quality of life), disability (work and social). The present study examined the factors that predicted surgical outcome as measured using the multidimensional core measures. 163 spinal surgery patients (mixed indications) completed questionnaires before and 6 months after surgery enquiring about demographics, medical/clinical history, fear-avoidance beliefs (FABQ), depression (Zung self-rated depression), and the core measures domains. Multiple regression analyses were used to identify predictor variables for each core domain and for the multidimensional combined core-set index. The combination of baseline symptoms, medical variables (pain duration, previous spine operations, number of levels treated, operative procedure) and psychosocial factors (FABQ and Zung depression) explained 34% of the variance in the core measures index (P < 0.001). With regard to the individual domain items, the medical variables were better in predicting the items "pain" and "symptom-specific well-being" (R (2) = 6-7%) than in predicting "function", "general well-being" or "disability" (each R (2) < 4%). The inverse pattern was shown for the psychosocial predictors, which accounted for in each case approximately 20% variance in "function", "general well-being" and "disability" but only 12-14% variance in "pain" and "symptom-specific well-being". Further to previous studies establishing the sensitivity to change of the core-set, we have shown that a large proportion of the variance in its scores after surgery could be predicted by "well-known" medical and psychosocial predictor variables. This substantiates the recommendation for its further use in registry systems, quality management projects, and clinical trials.

The association between cervical spine curvature and neck pain

Degenerative changes of the cervical spine are commonly accompanied by a reduction or loss of the segmental or global lordosis, and are often considered to be a cause of neck pain. Nonetheless, such changes may also remain clinically silent. The aim of this study was to examine the correlation between the presence of neck pain and alterations of the normal cervical lordosis in people aged over 45 years. One hundred and seven volunteers, who were otherwise undergoing treatment for lower extremity problems in our hospital, took part. Sagittal radiographs of the cervical spine were taken and a questionnaire was completed, enquiring about neck pain and disability in the last 12 months. Based on the latter, subjects were divided into a group with neck pain (N = 54) and a group without neck pain (N = 53). The global curvature of the cervical spine (C2-C7) and each segmental angle were measured from the radiographs, using the posterior tangent method, and examined in relation to neck complaints. No significant difference between the two groups could be found in relation to the global curvature, the segmental angles, or the incidence of straight-spine or kyphotic deformity (P > 0.05). Twenty-three per cent of the people with neck pain and 17% of those without neck pain showed a segmental kyphosis deformity of more than 4 degrees in at least one segment--most frequently at C4/5, closely followed by C5/6 and C3/4. The average segmental angle at the kyphotic level was 6.5 degrees in the pain group and 6.3 degrees in the group without pain, with a range of 5-10 degrees in each group. In the group with neck pain, there was no association between any of the clinical characteristics (duration, frequency, intensity of pain; radiating pain; sensory/motor disturbances; disability; healthcare utilisation) and either global cervical curvature or segmental angles. The presence of such structural abnormalities in the patient with neck pain must be considered coincidental, i.e. not necessarily indicative of the cause of pain. This should be given due consideration in the differential diagnosis of patients with neck pain.

Development of a German version of the Oswestry Disability Index. Part 1: cross-cultural adaptation, reliability, and validity

Patient-orientated assessment methods are of paramount importance in the evaluation of treatment outcome. The Oswestry Disability Index (ODI) is one of the condition-specific questionnaires recommended for use with back pain patients. To date, no German version has been published in the peer-reviewed literature. A cross-cultural adaptation of the ODI for the German language was carried out, according to established guidelines. One hundred patients with chronic low-back pain (35 conservative, 65 surgical) completed a questionnaire booklet containing the newly translated ODI, along with a 0-10 pain visual analogue scale (VAS), the Roland Morris Disability Questionnaire, and Likert scales for disability, medication intake and pain frequency [to assess ODI's construct (convergent) validity]. Thirty-nine of these patients completed a second questionnaire within 2 weeks (to assess test-retest reliability). The intraclass correlation coefficient for the test-retest reliability of the questionnaire was 0.96. In test-retest, 74% of the individual questions were answered identically, and 21% just one grade higher or lower. The standard error of measurement (SEM) was 3.4, giving a "minimum detectable change" (MDC(95%)) for the ODI of approximately 9 points, i.e. the minimum change in an individual's score required to be considered "real change" (with 95% confidence) over and above measurement error. The ODI scores correlated with VAS pain intensity (r = 0.78, P < 0.001) and Roland Morris scores (r = 0.80, P < 0.001). The mean baseline ODI scores differed significantly between the surgical and conservative patients (P < 0.001), and between the different categories of the Likert scales for disability, medication use and pain frequency (in each case P < 0.001). Our German version of the Oswestry questionnaire is reliable and valid, and shows psychometric characteristics as good as, if not better than, the original English version. It should represent a valuable tool for use in future patient-orientated outcome studies in German-speaking lands.

SSE Spine Tango – content, workflow, set-up

The Spine Tango registry is now accessible via the SSE webpage under www.eurospine.org-Spine Tango. Links to the Swiss/International, German and Austrian modules are provided as well as information about the philosophy, methodology and content. Following the links, the users are taken to the respective national modules for registration or log-in and data entry. The Swiss/International module, also accessible under www.spinetango.com, is used by all Swiss and international users, who do not have a separate national module. The physician administered forms for surgery, staged surgery and follow-up can be downloaded as PDFs.The officially recommended Spine Tango patient forms are also available. All forms were implemented in an online version and as scannable optical mark reader forms which can be ordered from the corresponding author.

Development of a German version of the Oswestry Disability Index. Part 2: sensitivity to change after spinal surgery

When functional scales are to be used as treatment outcome measures, it is essential to know how responsive they are to clinical change. This information is essential not only for clinical decision-making, but also for the determination of sample size in clinical trials. The present study examined the responsiveness of a German version of the Oswestry Disability Index version 2.1 (ODI) after surgical treatment for low back pain. Before spine surgery 63 patients completed a questionnaire booklet containing the ODI, along with a 0-10 pain visual analogue scale (VAS), the Roland Morris disability questionnaire, and Likert scales for disability, medication intake and pain frequency. Six months after surgery, 57 (90%) patients completed the same questionnaire booklet and also answered Likert-scale questions on the global result of surgery, and on improvements in pain and disability. Both the effect size for the ODI change score 6 months after surgery (0.87) and the area under the receiver operating characteristics (ROC) curve for the relative improvement in ODI score in relation to global outcome 6 months after surgery (0.90) indicated that the ODI showed good responsiveness. The ROC method revealed that a minimum reduction of the baseline (pre-surgery) ODI score by 18% (equal to a mean 8-point reduction in this patient group) represented the cut-off for indicating a "good" individual outcome 6 months after surgery (sensitivity 91.4% and specificity 82.4%). The German version of the ODI is a sensitive instrument for detecting clinical change after spinal surgery. Individual improvements after surgery of at least an 18% reduction on baseline values are associated with a good outcome. This figure can be used as a reliable guide for the determination of sample size in future clinical trials of spinal surgery.

[Surgical aspects of the cervical spine in rheumatoid arthritis]

Approximately 20% percent of the patients with rheumatoid arthritis show pathology in the cervical spine. The translational instability between axis and atlas might be painful and leads in the long term to myelopathic changes due to chronic traumatization of the myelon. Ongoing osseous resorption of the lateral masses of the atlas cause upward migration of the dens into the foramen magnum. In the subaxial cervical spine, the inflammatory process causes instability and deformity. Neck pain is the most common indication for surgery, but neurological symptoms with myelopathy or radicular deficits might be the primary cause for surgery. Neurophysiological investigation is suitable to obtain objective results. Stabilization of the atlantoaxial segment is the most common procedure for treatment of atlantoaxial instability. It is performed by screw fixation technique from a posterior approach. In case of severe occipitocervical dislocation, the fixation has to be extended to the occiput. Persistent dislocation or compression by the dislocated dens has to be treated by transoral decompression. In the subaxial spine, instabilities may be treated by posterior plate fixation with lateral mass screws or pedicle screws. Concomitant nar-rowing of the spinal canal should be approached by anterior decompression with corpectomy and/or posterior laminectomy. The timing of surgery in rheumatoid patients is crucial to obtain satisfactory clinical results.

[Fall risk factors and fall injuries in hospitalized elderly patients]

Fall Risk Factors have been analysed (RAI-MDS-System) in a population of patients, who were hospitalised between 1995 and 2000 in a geriatric department of a community hospital. In multivariate analysis, viseral-problems, incontinence and depression were fall-protective factors, whereas problems with transfer, the use of assistive walking-aids, female gender and age were fall risk-factors. No independent contribution to the fall-risk was delivered by memory-impairment, problems in decision-making, low body-mass-index, the use of more than three medications and the use of restraints. Fall injuries were analysed in a patient population (n = 218), that was hospitalized in the year 2001 in the geriatric department of a community hospital after a fall. The analysis showed an enormous heterogenicity of the injury-patterns: 58.7% of the fall-patients suffered from a fracture, 10.6% of them had more than one fracture, 34% suffered from other injuries. 77 surgical interventions were performed. The mean length of stay of the fall-patients was 4.5 days higher than the mean of all geriatric patients.

[Epidural injections. What is certain?]

Injection of 17-20 ml of local anesthetic combined with corticosteroids via hiatus canalis sacralis or epidural between spinal processes in the lumbar region leads to distribution up to the level of the thoracolumbar junction. The indication for therapeutic peridual or epidural injections are radicular symptoms as a result of disc herniation, foraminal stenosis as well as neurogenic claudication. Contraindications are anticoagulation or local infection. Complications and side effects occur extremely seldom. There is only one RCT for radiculopathy and epidural steroids.

[Delirium. A 74-year-old retired butcher's shop employee]

Bei einer Patientin mit einer rasch fortschreitenden kognitiven Störung wird ein Sick-Sinus-Syndrom diagnostiziert, die kognitive Störung verschlechtert sich auch nach Implantation eines Herzschrittmachers weiter. Schliesslich wird eine Epstein-Barr-Virus-Enzephalitis diagnostiziert. Im Verlauf ist die ausgeprägte kognitive Störung vollständig regredient.

[Possible cause of a deep venous thrombosis. Patient: 77-year-old man, retired]

Bei einem 77-jährigen Patienten mit multifaktorieller Gangstörung wird eine tiefe Beinvenenthrombose rechts diagnostiziert; unter der Antikoagulationstherapie tritt eine Thrombose links auf. Es wird ein inflammatorisches Bauchaortenaneurysma entdeckt, welches die Vena cava komprimiert und das erfolgreich konservativ mittels Prednison behandelt wird.

A European spine registry

New joint replacement registries are being widely implemented across national and international organizations. The need for a continuous long-term post-market surveillance of implants has been recognized, and has become increasingly important to ensure the quality of prosthetic components. Registry data with large case numbers represent an acceptable alternative to controlled randomized clinical trials, which are often difficult to conduct in orthopedic surgery. The variety of implants and procedures in spinal surgery not only induces the same need for long-term monitoring of post-surgical product performance as in the joint replacement subspecialties, but also renders essential the establishment of a comprehensive spine registry for all major pathologies and interventions. In cooperation with the M.E. Müller Institute for Evaluative Research in Orthopedic Surgery (MEM-CED) at the University of Berne, Switzerland, the Spine Society of Europe (SSE) has launched Spine Tango: the first modular and multilevel European online registry for spinal surgery. Within Spine Tango, the major challenge in registry design and structure is the definition of and agreement upon a core set of questions as a common European dataset. Additional questions for national or individual interest can also be dynamically added to the core dataset. An automated implant tracking system has also been setup, which allows highly precise product documentation without additional work for clinical staff members.

The use of plate fixation in anterior surgery of the degenerative cervical spine: a comparative prospective clinical study

The method of anterior mono- or bisegmental cervical spine fusion is a well-established procedure for degenerative conditions of the cervical spine. While the early reports promote fusion with bone graft alone, recent studies report superior results with the addition of anterior plating. The objective of this study was to evaluate the influence of using plates in anterior cervical spine fusion in a prospective study. Fifty candidates for anterior monoor bisegmental cervical spine fusion were randomly and prospectively selected and assigned to a plated and a non-plated group. After a minimum follow-up of 22 months, patients were clinically and radiologically examined. The reduction in pain, improvement in neurology and functional assessment showed a significant improvement in both groups compared to the preoperative values. The total neurological score improved significantly in both groups, but the changes were greater in the group with plates. There was no significant difference between the groups for fusion rating, but graft quality (graft height) was significantly better in the plated group. We conclude that the overall data do not suggest better results with plating in mono- or bisegmental anterior spine fusions. Indications for additional internal fixation are restricted to special conditions with increased instability, insufficient bone quality or inappropriate graft placing.

[Physiotherapy for the elderly]

One of the main goals of physical therapeutic procedures in the elderly is the restoration or maintenance of functional autonomy in daily living activities. Whilst necessity for care and assistance in an aged population rises dramatically with age, physical therapy can efficiently reduce these needs. For an optimal therapeutic approach the therapists should take into account the particular characteristics of the ageing process as well as the predominant comorbidities, which should be correctly assessed in order to integrate those context factors into the rehabilitation program. This is only possible with a good functioning teamwork: The team should therefore include physicians, nurses, physiotherapists as well as social workers and other professionals. We describe here the theoretical basis of the particular aspects of physiotherapy for the elderly and we illustrate this approach exemplarily for falls prevention through resistance- and balance training.

Transarticular screw fixation for atlanto-occipital dislocation

STUDY DESIGN

A case report of traumatic atlanto-occipital dislocation managed by transarticular screw fixation.

OBJECTIVES

To present a case with initial failed wire fixation but successful reduction and fixation with transarticular screw fixation and occipitocervical plate stabilization.

SUMMARY OF BACKGROUND DATA

Atlanto-occipital dislocation is generally a fatal injury, except when it occurs in children. Management of this injury is difficult because of multidirectional instability and the problems associated with technical stabilization.

METHODS

Intraoperative atlanto-occipital reduction was achieved and maintained by direct C0-C1 transarticular screw fixation. To protect this fixation, a posterior occipitocervical fusion at C0-C2 using a Y-plate was performed.

RESULTS

The internal fixation and reduction were maintained, indicating a good surgical outcome, at examination 2 years after surgery. The initially severe neurologic deficit was reduced to some motor weakness of the right hand and weakness of oculomotor function.

CONCLUSIONS

Anatomic reduction and reliable fixation with transarticular screws may provide satisfactory clinical results with important neurologic recovery in cases of atlanto-occipital dislocation.

Translaminar screws in the atlas

STUDY DESIGN

This was a retrospective review of a new surgical technique.

OBJECTIVES

To describe a new method of fixation augmentation in posterior C1-C2 spondylodesis.

SUMMARY OF BACKGROUND DATA

Posterior atlantoaxial spondylodesis using transarticular screws is often supplemented with sublaminar wires to enhance stability. This technique is not possible if the arch of C1 is deficient. A method of stabilizing the segment and the graft was developed, and the early results were reviewed.

METHODS

Five patients with a deficient posterior arch of the atlas, who also needed atlantoaxial spondylodesis, were reviewed. In each patient, fixation was augmented with translaminar screws that attached the graft to the arch of C1.

RESULTS

In all five patients, solid arthrodesis was achieved, and all had substantial relief of pain. There were no neurologic complications or failures of fixation.

CONCLUSIONS

The method of fixation of graft to the atlas using translaminar screws is a safe and reasonable alternative to external halo immobilization or more extensive surgery, such as occiput to C2 fusion.

Atlantoaxial immobilization in rheumatoid arthritis: a prophylactic procedure?

Timing of surgical intervention in atlantoaxial instability due to rheumatoid arthritis is still controversial. An aim of this study was to investigate whether atlantoaxial fusion can prevent progression of instability and upward migration of the dens. Thirty-two patients with rheumatoid arthritis, who underwent posterior atlantoaxial fixation due to instability, were clinically and radiologically examined after a minimum follow-up of 5 years. The radiological measurements focussed on the extent of cranial vertical migration after atlantoaxial fusion. In none of the 20 patients available for follow-up examination was a vertical cranial migration observed, in spite of the ongoing course of the disease. These findings are in concordance with findings in the literature, and strongly suggest that, with atlantoaxial stabilization, the inflammatory process with destruction of the lateral masses of the atlas is able to prevent further deterioration with vertical cranial migration.

Posterior occipitocervical fusion in rheumatoid arthritis and other instabilities

Occipitocervical fixation remains a surgical challenge. A Y-plate in combination with transarticular screw fixation provides a simple and economically favorable solution to this problem. By integrating the transarticular screws into the Y-plate immediate postoperative reliable stabilization is achieved. Clinical results confirm the reliability and the low rate of pseudarthrosis with this surgical technique.

[Vitamin B12 deficiency in geriatrics]

Cobalamin deficiency increases with advancing age. The cut-off point of serum concentration should be raised, because many elderly people with "normal" serum vitamin B12 concentrations are metabolically deficient in cobalamin. The measurement of the metabolites homocysteine and/or methylmalonic acid is recommended. Cobalamin deficiency may result in a variety of atypical symptoms. Hematological changes typical of megaloblastic anemia are absent in a majority of patients with neuropsychiatric disorders. Generally underlying pernicious anemia is not the main cause of cobalamin deficiency in the elderly. Protein-bound cobalamin malabsorption due to atrophic gastritis with hypo- or achlorhydria is a common cause of cobalamin deficiency in elderly people. An important manifestation of cobalamin deficiency is cognitive impairment. Much controversy exists on the subject of the association of dementia of the Alzheimer type with cobalamin deficiency. In several studies dementia has been related to low serum cobalamin levels. Physicians should be liberal of cobalamin therapy. The window of opportunity for effective intervention may be as short as one year from the onset of medical symptoms. At last a compilation of recommendations is given.

Occipitocervical fusion in patients with rheumatoid arthritis

Instability and deformity of the cervical spine caused by rheumatoid arthritis is a well known entity. Operative intervention is indicated for patients with progressive deformity and when pain is resistant to conservative treatment. In a series of 39 patients who underwent posterior occipitocervical fusion with a Y plate, 22 patients were observed clinically and radiographically at average 41.5 months after surgery. In 35 of the 39 patients the main indication for surgery was pain, and in 30 of the 39 patients additional neurologic deficit (radiculopathy or myelopathy) was present. Thirty-one of the 39 patients had atlantoaxial instability. The atlantoaxial instability was associated with cranial migration of the dens in 19 patients. According to the classification of Conaty and Mongan 77.3% patients had satisfactory results and 22.7% had unsatisfactory results. Of the 30 patients with neurologic deficit, nine patients had a significant improvement. No patient had a worse result after surgery. Solid fusion was seen in all 22 patients at followup. Seven patients experienced complications directly related to the surgical procedure. Posterior fixation combined with anterior decompression in the presence of spinal stenosis represents a useful and safe method to treat instability and deformity caused by rheumatoid arthritis. Early surgical procedures may reduce the complication rate.