[Large Hibernoma of the Proximal Upper Arm and the Axilla - Literature Review and Case Description of a Very Rare Benign Soft Tissue Tumor]

Hibernomas are very rare benign soft tissue tumors arising from brown fat. Malignant transformation or metastases are unknown. Males seems to be affected more often. Most patients are aged 20 to 40, but patients with intraosseous hibernomas are older. In children, hibernomas are extremely rare. The tumors grow slowly and have usually been present for a few years on presentation. Hibernomas are typically located on the thigh, neck, axilla or in the peri- und interscapular region. Diagnostic work-up in symptomatic hibernomas usually includes conventional X-ray and magnetic resonance tomography (MRI) with contrast medium. Asymptomatic hibernomas are often found accidentally in the diagnostic work-up of other diseases. Important differential diagnoses are lipomas, well differentiated liposarcomas, rhabdomyomas, granular cell tumors and sebeceous adenomas. Incisional biopsy should be performed to allow definitive histological diagnosis before definitive therapy. According to the literature, histologically preserved hibernomas can be removed with curative intention and marginal resection. After complete tumor removal, local recurrence has not been described. The following article describes the case of a large hibernoma of the proximal arm, involving the axilla, and describes the epidemiology, clinical behavior, diagnostic work-up, therapy and prognosis of this very rare benign fatty soft tissue tumor, on the basis of a review of current literature.

[Rupture of the Achilles tendon]

The rupture of the Achilles tendon is the most frequent tendon rupture in humans and it is associated with increasing incidence. The main risk factor is intrinsic degeneration of the tendon. During the rupture the person feels a whiplash or dagger thrust-like pain, followed by restricted walking ability and decreased plantar flexion of the ankle. The positive Simmond/Thompson test and a palpable dent above the tendon rupture are pathognomical. Diagnostically, ultrasound of the tendon and lateral x-ray of the calcaneus (bony pull-out of the tendon insertion) are necessary. Regarding correct indication and treatment modalities, most established conservative and surgical therapies realize optimal functional results. Surgical treatment promises better primary stability and slightly earlier better functional results, but there is the potential for surgical complications. Conservative therapy is associated with higher rates of re-rupture and healing of the tendon under elongation. Therefore, therapy planning in Achilles tendon rupture should be determined based on each patient. We recommend surgical treatment in patients with higher sporting demands and in younger patients (< 50 years).

[Clinical results of surgically treated paediatric fractures of the medial humeral epicondyle]

OBJECTIVES

Fractures of the medial humeral epicondyle represent approximately 10 % of all paediatric elbow fractures. material and methods: Surgically treated paediatric fractures of the medial humeral epicondyle were analysed retrospectively for their epidemiological, clinical and surgical parameters. Re-evaluation included clinical function, satisfaction, pain level and MAYO elbow performance score (MEPS).

RESULTS

22 children could be included. A re-evaluation of 91 % of our patients after a follow-up of ∅ 4 years (range: 1-9 years; median: 4 years) after initial surgery was possible. Subjective outcome and objective function were good with moderate limitations. 85 % of our patients showed good to excellent results in the MEPS.

CONCLUSION

Regarding our own good clinical results and potentially lower rates of pseudarthrosis - in comparison to conservatively treated patients - by trend we recommend internal fixation in paediatric fractures of the medial humeral epicondyle. However, operative or conservative treatment must be indicated individually together with the patient and his/her parents.

[Results of surgically treated paediatric supracondylar humeral fractures]

BACKGROUND

About 80 % of all paediatric distal humerus fractures are supracondylar fractures.

PATIENTS AND METHODS

Surgically treated children with supracondylar humeral fractures between 2000-2008 were analysed retrospectively and re-evaluated for function, satisfaction, pain level and with the MAYO elbow performance score (MEPS).

RESULTS

46 patients were included. Open fractures (2 %) and vessel (0 %) or nerve (4 %) lacerations were rare, additional forearm fractures frequent (15 %). Surgery was done by closed/open reduction and crossed K-wire pinning. Main complications were movement restriction and K-wire migration. All fractures healed. 72 % of patients could be re-evaluated Ø 51 months after surgery. The mean differences between non-affected and affected elbows showed 8° for flexion, 1° for extension, 1° for pronation and 0° for supination. In 88 % excellent or good results could be measured with the MEPS.

CONCLUSION

Regarding bony healing in all patients, well manageable complications, mostly excellent or good results in the MEPS and good function, crossed K-wire pinning after closed/open reduction is a safe standard surgical procedure for this type of fracture.

[Pharyngo-vertebral fistula with transspinous course to the neck skin due to a cervical spondylodesis - case report and review of the literature]

BACKGROUND

Pharyngo-vertebral fistulas - especially with delayed diagnosis - are a rare but grave reported complication in cervical spine surgery.

PATIENTS AND METHODS

We present a patient, sent postoperatively from Italy after cervical spine surgery to our department. The patient has developed a pharyngo-vertebral fistula with transspinous course to the dorsal neck skin due to infected spondylodesis.

CASE REPORT

In the presented patient, the successful closure of the pharyngo-vertebral fistula with transspinous course was made after diverse revisions at the anterior side with a platysma flap, at the posterior one with a drain.

REVIEW OF THE LITERATURE

Aetiology, diagnostic work-up and treatment opinions are discussed in a detailed literature review.

CONCLUSION

To the best of the authors' knowledge the presented pharyngo-vertebral fistula with transspinous course to the dorsal neck skin as a complication after anterior cervical spine surgery has not been reported in the literature before.

[Embolisation of aneurysmal bone cysts as a minimally invasive treatment option - presentation of two cases]

AIM

The aim of this study was to evaluate embolisation as a therapy option for aneurysmal bone cysts of the trunk.

METHOD

Case reports about two males with intermittent pseudo-radicular lumboischialgia and coxalgia are discussed.

RESULTS

The diagnostic work-up and biopsies verified an aneurysmal bone cyst in both males. In one patient the tumour-like lesion was localised in the fifth lumbar vertebral body, in the other in the left ischium and pubis. Arterial embolisation was performed in both cases. Follow-up at 6 and 24 months after embolisation showed a significant increase of sclerosis and a reduced volume of the cysts.

CONCLUSION

In accord with literature data, arterial embolisation seems to be a sufficient and minimally invasive therapy option in aneurysmal bone cysts of the spine and the pubis.

[The prognostic influence of primary tumour and region of the affected spinal segment in 217 surgical patients with spinal metastases of different entities]

AIM

A retrospective study to evaluate the prognostic influence of the primary tumour and the anatomic level of spinal metastases was carried out.

MATERIAL AND METHODS

Between January 1984 and May 2005, 217 patients were surgically treated because of spinal metastases. The prognostic influence for the survival was analysed for the entity of the primary tumour and the localisation of the spinal metastases.

RESULTS

The median survival of the study group was 8.0 months (range: 0-191.5 months). Mamma carcinoma was the most frequent primary tumour with 62 cases (28.6 %). The spinal level of the metastases did not influence the postoperative survival (p = 0.9058). The entity of the primary tumour showed a significant influence for the postoperative survival (p < 0.0001).

CONCLUSION

In spinal metastases, the entity of the primary tumour was of prognostic value; the localisation of the spinal metastases at different spinal levels did not influence the postoperative survival. Therefore, the evaluation of the primary tumour is mandatory for an estimation of the expected survival.

Evaluation of the Tokuhashi prognosis score and its modifications in 217 patients with vertebral metastases

AIM

The Tokuhashi prognosis score consists of six parameters. The sum of points rated for each parameter can be correlated with the prognosis. This study evaluates the score variations that have been done by different authors and Tokuhashi et al. themselves.

METHODS

Two hundred and seventeen consecutive patients, surgically treated for vertebral metastases, were studied retrospectively. We calculated the original and modified score of Tokuhashi and evaluated the predictive value for the individual life expectancy.

RESULTS

The original and modified Tokuhashi score assured a significant predictive value. Modified criteria by the authors showed the highest reliability between the predicted and real survival, and the patients could be allocated correctly to the desirable instrumentation.

CONCLUSION

The original and modified Tokuhashi score showed a significant predictive value. The modified criteria by the authors showed the highest reliability between predicted and real survival.

Chirurgische Therapie und Evaluation von Prognosefaktoren bei Wirbelsäulenmetastasen durch Nieren-Zell-Karzinome

AIM

The aim of this study was the evaluation of surgical results and prognostic factors in spinal metastases of renal cancer.

METHODS

37 surgical patients with spinal metastases of renal cell carcinoma were retrospectively analysed. In 2 patients the cervical, in 16 patients the thoracic, in 4 patients the thoraco-lumbar and in 16 patients the lumbar spine was involved.

RESULTS

In 11 cases (29.7 %) a combined posterior-anterior spondylodesis with vertebral body replacement, in 26 cases (70.3 %) a single posterior instrumentation was done. Perioperatively, 24 complications appeared, 4 of them were lethal. Postoperatively, the neurological situation was unchanged in 26 patients, dischanged in 4 patients and improved in 7 patients. The level of pain was unchanged in 10 patients, dischanged in 3 patients and improved in 24 patients. The mean postoperative survival was 13.6 months. For the postoperative survival the Karnofsky-Index and the Frankel-Score were univariate highly significant, the factors nutritional condition and latency between the primary tumor and the development of spinal metastases showed a lower significancy. No prognostical influence for the postoperative survival could be detected for the factors gender, age, localisation of the metastases, type of operation and the factor solitary/multiple metastases. The multivariate analyses did not attempt any of the univariate significant prognostic factors for the postoperative survival. The postoperative survival was significantly (p: 0.0030) influenced by postoperative adjuvant therapy (radio- and/or chemotherapy). The analysis of each adjuvant therapy form (i. e. chemo-, radio- and combined therapy) attempts this prognostic effect (p: 0.0229).

CONCLUSION

In most patients with spinal metastases of renal cell carcinoma, the singular posterior intrumentation combined with a decompression is a sufficient therapy. To avoid posterior implant failure, in patients with a prognosticated survival of more than one year, a combined posterior-anterior spondylodesis with vertebral body replacement should be done. The prognostic influence of an adjuvant postoperative treatment in the present study must be interpreted in the context of this small, highly selected patient collective. Further standardized studies should be performed to evaluate the prognostic influence of an adjuvant therapy.

Prognose, operative Therapie und Verlauf bei zervikalen und hochthorakalen Tumorosteolysen

INTRODUCTION

This study analyzes the early and mid-term results of our modular rod-screw implant system for the posterior instrumentation of the occipito-cervical, cervical and cervico-thoracic spine (neon occipito-cervical system, Ulrich, Germany) in patients with tumor osteolysis. The prognosis of the patients was evaluated using the Tokuhashi score.

METHODS

The cervical and upper thoracic spines of 14 patients (7 males, 7 females, mean age 61 years, range 40-77 years) with osteolysis due to plasmocytoma (n = 2), bronchial (n = 3), mamma (n = 4), thyroid (n = 2), esophageal (n = 1) and pancreatic (n = 1) carcinomas as well as melanoma (n = 1) were instrumentated between June 2001 and April 2004.

RESULTS

A stable fixation without loosening or failure of the fixator system was achieved in all cases. No impairment of the neurological status was observed. In our cohort different prognosis scores failed to make a reliable estimate of the expected survival at the time of surgery.

CONCLUSION

Posterior instrumentation of the cervical spine including the occipito-cervical and the cervico-thoracic regions with a modular angle-stable rod-screw implant system (neon) offers good stabilization and allows simultaneous decompression. Since tumor masses are predominantly located in the anterior portion of the spine, blood loss can be controlled well. In this patient collective appears difficult to estimate the time of survival by a scoring system.

Chirurgische Behandlung und Prognosefaktoren von Wirbelsäulenmetastasen bei Mamma-Karzinom

AIM

The aim of this study was the evaluation of surgical therapy results and prognosis factors in patients with spinal metastases of breast cancer.

METHODS

55 patients with spinal metastases of breast cancer who were treated surgically were retrospectively evaluated. In 11 patients the cervical, in 27 patients the thoracic and in 17 patients the lumbar spine was affected.

RESULTS

Postoperatively, 45 patients (81.8 %) described a reduction in pain and 5 patients (50 %) reported a neurological improvement. Perioperative complications appeared in 27 patients (49.1 %), 2 patients died. For the entire group, the mean postoperative survival was 27.2 +/- 28.6 months and the median survival 16.2 months. In patients with solitary metastasis the univariate analysis did not show a significantly longer postoperative survival than in patients with additional visceral metastases (p = 0.0659), but patients with solitary metastasis showed a significantly longer survival than those with multiple osseous and/or visceral metastases (p = 0.0325). In the univariate analysis, the classification of the primary tumour, the duration of symptoms, the localisation of the metastases, the patient's age and the kind of surgical procedure (posterior stabilising instrumentation versus combined posterior-anterior treatment with intralesional resection of the affected vertebra and vertebral body replacement) did not show a significant influence on the postoperative survival. The multivariate analysis did not show a significant prognostic influence for the potentially prognostic factors, however, solitary and multiple metastasis showed the highest statistical influence for the prognosis (p = 0.1187), followed by the classification of the primary tumour (p = 0.1243).

CONCLUSION

Pain reduction and neurological improvement can be reached by a stabilisation of the diseased spinal region. Patients with spinal metastases due to breast cancer showed a relatively long postoperative median and mean survival. Therefore, the preoperative evaluation of extent of the disease and the therapy concept should be individually adapted. The surgical procedure (posterior stabilising instrumentation versus combined posterior-anterior approach with vertebrectomy and vertebral body replacement) does not significantly influence the survival.

Wirbelkörperersatz durch expandierbare Titan-Cages

OBJECTIVES

The aim of vertebral body replacement is the stabilisation and restoration of the anterior column of the spine with removal of the diseased region. We present our results of stabilisation, pain reduction and neurological improvement using vertebral-body replacement systems

METHODS

Between April 1997 and December 2002, 53 patients with malignant vertebral destruction or instability due to traumatic and osteoporotic fracture were treated. We evaluated the results after vertebrectomy and vertebral body replacement by using expandable titanium cages in a retrospective study.

RESULTS

The average follow-up time was 18.9 +/- 19.9 months. The mean operation time was 173.2 +/- 77.4 minutes. Intraoperatively, we saw no implant-related complications. Perioperatively, complications appeared in 18 patients (34.0 %). 4 of them were severe, with 2 patients dying. In the total follow-up, 16 patients died, 10 of them (62.5 %) due to tumour progression. Pain reduction was reported in 52.7 %, neurological improvement in 48.0 %. One patient had a loosening of his posterior instrumentation in the further follow-up due to tumour growth with dislocation of the cage and a deterioration of his neurological deficit.

CONCLUSION

By using vertebral body replacement systems, sufficient stabilisation of the vertebral column, pain reduction and neurological improvement can be achieved with an acceptable perioperative risk.

[Posterior dynamic stabilization as an alternative for dorso-ventral fusion in spinal stenosis with degenerative instability]

AIM

Our retrospective study analyzed the outcome of patients with degenerative lumbar instability with spinal stenosis, who underwent decompression surgery with dorsoventral fusion (Group I) and decompression surgery with posterior dynamic stabilization (Group II).

METHOD

For 10 patients in each group intra- and postoperative data were obtained and the functional outcome was evaluated with the "Oswestry Low Back Pain Disability Questionnaire" (OQ) and the "Short Form 36 Health Survey Questionnaire" (SF-36). The average follow up was 14.4 months in Group I, 15.2 months in Group II.

RESULTS

In Group I the OQ averaged postoperatively 32 points (preoperatively 46 points), the "Physical Component Summary" (PCS) of SF-36 averaged 34 points (preoperatively 24 points), the "Mental Component Summary" (MCS) averaged 43 points (preoperatively 36). In Group II the values at follow up were as follows: OQ 33 points (preoperatively 54), PCS 34 points (preoperatively 28) and MCS 46 points (preoperatively 36). The average hospitalization was 28.4 days in Group I, 19.3 days in Group II and the average operation time was 218 minutes in Group I, 163 minutes in Group II.

CONCLUSION

When compared the functional outcome, the dynamic stabilization seems to be a promising alternative to fusion in patients with degenerative lumbar instability with spinal stenosis.