Ausgepragte Knochenschmerzen, eine schwere Demineralisierung des Skeletts, Frakturen der Darmbeinschaufeln, des Sitz- und Schambeins sowie ausgedehnte Loosersche Umbauzonen in diesen Bereichen fuhrten bei einer 38jahrigen Patientin zur Diagnose einer hypophosphatamischen Osteomalazie. Die computergesteuerte Osteodensitometrie zeigte eine um 31 % reduzierte Hydroxylapatitdichte des Achsenskelettes. Histologisch war ein groser Anteil des Knochens nicht mineralisiert, Osteoklasten fehlten fast vollstandig. Klinisch-chemisch fanden sich eine ausgepragte Hypophosphatamie (0,48 mmol/l), eine erhohte Phosphat-Clearance (36 ml/min), eine verminderte renal-tubulare Phosphatruckresorption (73 %) und eine erhohte alkalische Phosphatase (355 U/l). Parathormon und 1,25-Dihydroxycholecalciferol waren normal. Angeborene Storungen des Calciumstoffwechsels wie auch eine Paraneoplasie konnten ausgeschlossen werden. Eine Behandlung mit Calcitriol (0,25µg/d) und Phosphatsubstitution (1200 mg/d) wurde eingeleitet. Kontrolluntersuchungen nach 6 Monaten liesen erkennen, das damit zumindest ein weiteres Fortschreiten der Erkrankung verhindert werden konnte. Hypophosphataemic osteomalacia occurred in a 38-year-old woman. The leading clinical symptom was severe bone pain. X-ray studies demonstrated fractures of the iliac crest and pubic and ischiadic bone, as well as Looser's zones and demineralization of the skeleton. Computerized densitometry of the bone revealed a 31 % reduction of hydroxyapatite. Histological evaluation showed nearly absence of osteoclasts and extensive demineralisation of the bone. Hypophosphataemia (0.48 mmol/l), increased urinary phosphate clearance (36 ml/min), reduced renal-tubular reabsorption for phosphate (73 %) and increased alkaline phosphatase (355 U/l) were present. Parathyroid hormone and 1,25-dihydroxyvitamin D were normal. No inborn errors, disturbances of the calcium metabolism or paraneoplastic signs could be detected. Defective renal tubular reabsorption of phosphate is likely to be the underlying cause of the disease. Phosphate supplementation and intermittent vitamin D administration remains the therapy of choice.

The spontaneous intracranial hypotension syndrome is a rare event but with increasing tendency. The clinical characteristics are comparable to those occurring after dural puncture and the most important clinical finding is the postural headache. The syndrome results from cerebrospinal fluid leakage but its etiology is still nearly unknown. The leaks are mainly located cervically or at the cervicothoracic junction. The syndrome may be associated with cranial subdural fluid build-up. Magnetic resonance imaging of the brain typically reveals diffuse pachymeningeal enhancement, frequently in association with displacement of the brain. Knowledge of this can be helpful to facilitate the diagnosis. Although conservative measures are often initially undertaken, placement of an epidural blood patch is the treatment of choice. Because of its similarity to postdural puncture headache, anaesthesiologists and pain therapists are increasingly involved in diagnosis and therapy. We report 2 patients with spontaneous intracranial hypotension. In addition to the cardinal feature of a postural headache, the patients suffered from subdural fluid build-up demonstrated by cranial magnetic resonance imaging.

Das spontane Liquorunterdrucksyndrom (SLUDS) ist ein noch seltenes Krankheitsbild mit allerdings zunehmender Tendenz. Die klinischen Symptome sind mit denen des postspinalen Punktionssyndroms vergleichbar. Leitsymptom ist der lageabhängige Kopfschmerz. Die Ursache des SLUDS ist eine Liquorleckage, die zumeist zervikal oder zervikothorakal lokalisiert ist. Seine Ätiologie ist noch weit gehend unbekannt. Als mögliche Komplikation treten kraniale subdurale Hämatome auf. Magnetresonanztomographien des Schädels zeigen häufig typische diffuse Kontrastmittelanreicherungen der Dura, oft auch in Verbindung mit Kaudalverlagerungen des Hirnstamms. Kenntnis dieser radiologischen Befundkonstellation kann sehr hilfreich bei der Diagnosefindung sein. Obwohl konservative Behandlungsmaßnahmen häufig zuerst durchgeführt werden, ist die Anlage eines epiduralen Blutpatches die Therapie der Wahl. Aufgrund der klinischen Symptomatik mit der Ähnlichkeit zum postspinalen Punktionssyndrom werden zunehmend Anästhesisten und Schmerztherapeuten in Diagnosefindung und Behandlung miteinbezogen. Wir berichten über 2 Patienten mit dem Krankheitsbild eines SLUDS, die neben dem Leitsymptom des lageabhängigen Kopfschmerzes auch magnetresonanztomographisch nachgewiesene kraniale epidurale Flüssigkeitsansammlungen aufweisen.

The hypothenar hammer syndrome (HHS) is characterized by lesions of the ulnar artery secondary to repetitive trauma to the hypothenar eminence. We report the case of an orthopedic surgeon with HHS due to his occupational practice. Angiography and MRI confirmed an aneurysm of the ulnar artery and embolic occlusions of his carpal and digital arteries. Patency was reestablished with regional thrombolysis using rt-PA. So far there have been no reports on thrombolysis with rt-PA in HHS.

In a prospective study, we examined 34 patients with shoulder instabilities and 5 patients with unclear chronic shoulder pain (4 females, 35 males; 18-56 years of age, median 28 years) by CT arthrography and MRT arthrography from August 1994 through December 1995. No complications were seen when gadolinium-DPTA was applied intra-articularly. Twenty-three patients were followed up by operation and/or arthroscopy; 20 patients underwent a modified, open Bankart operation. In this paper, we present a new classification for damage of the anterior capsule and labrum. MRT arthrography showed better results in judging the anterior labrum and in determining the degree of damage to the labrum (sensitivity, specificity and accuracy 100%) in comparison with CT arthrography (sensitivity 90%, specificity 100%, accuracy 91%). Furthermore, MRT arthrography gave clearer results than CT arthrography regarding SLAP and cartilage lesions. Thus, MRT arthrography has proved to be a very exact method for diagnosing shoulder instabilities and is superior to CT arthrography in diagnostic accuracy.

PURPOSE:Evaluation of dacryocystography in the preoperative localisation of stenosis of the lacrimal passage.METHOD:The lacrimal system of 20 patients (25 eyes) suffering from lacrimal passage obstruction was examined either by conventional (n = 20) or by digital (n = 5) technique. Diagnostic imaging was evaluated concerning topographic Information of the pathologic lacrimal system, localisation of the level and differential diagnosis of the cause of the obstruction.RESULTS:Cause of the obstruction was chronic dacryocystitis (n = 16), dacryolithiasis (n = 1), atresia of the lacrimal duct (n = 2), posttraumatic lesions (n = 3), rhinosinusitis (n = 1) and carcinoma of the maxillary sinus (n = 1). In 23 of 25 cases (92%) we found an exact correlation between dacryocystography and the intraoperative findings. The variation of stenosis types as well as different examination techniques are presented and compared with literature findings.CONCLUSION:Dacryocystography is a valuable method in the diagnosis and preoperative planing in lacrimal system obstruction.

In a prospective study, we examined 34 patients with shoulder instabilities and 5 patients with unclear chronic shoulder pain (4 females, 35 males; 18 - 56 years of age, median 28 years) by CT arthrography and MRT arthrography from August 1994 through December 1995. No complications were seen when gadolinium-DPTA was applied intra-articularly. Twenty-three patients were followed up by operation and/or arthroscopy; 20 patients underwent a modified, open Bankart operation. In this paper, we present a new classification for damage of the anterior capsule and labrum. MRT arthrography showed better results in judging the anterior labrum and in determining the degree of damage to the labrum (sensitivity, specificity and accuracy 100%) in comparison with CT arthrography (sensitivity 90%, specificity 100%, accuracy 91%). Furthermore, MRT arthrography gave clearer results than CT arthrography regarding SLAP and cartilage lesions. Thus, MRT arthrography has proved to be a very exact method for diagnosing shoulder instabilities and is superior to CT arthrography in diagnostic accuracy.

Intimointimal intussusception is a rare type of aortic dissection. The intimal tear occurs circumferentially with intussusception of the intimal flap downstream into the aortic arch causing obstruction of the great supraaortic vessels. A CT diagnosis has only once been reported. CT and angiographic findings of this rare complication of aortic dissection are described.

Die CT-Diagnose einer seltenen Form einer Aortendissektion, die intimointimale Invagination bei zirkulärer Dissektion der Aorta ascendens, wird vorgestellt. Bei diesem Typ der Aortendissektion liegt ein zirkulärer Intimariß mit Einstülpung des Intimaschlauches in den Aortenbogen vor. Dabei erscheint der in das Aortenlumen invaginierte Intimaschlauch in axialer Schnittführung als Ringfigur im Aortenlumen. Neben den typischen CT-Befunden wird auch das angiographische Erscheinungsbild der intimointimalen Invagination beschrieben.

Malignant schwannomas are rare. These malignomas are primary nerve sheath tumors that usually arise from a peripheral nerve. They appear most frequently in the lower extremities, including the hips and buttocks (34.8%), the upper extremities (23.4%), and in the trunk (17%). To the best of our knowledge, this is the first reported case of a malignant schwannoma of the rectum. We describe the rare disease with reference to the literature.

Maligne Schwannome haben einen Anteil von 10 % an den malignen Weichteiltumoren, welche nur 1 % aller bösartigen Neubildungen ausmachen. Am häufigsten treten die malignen Schwannome im Bereich der unteren Extremitäten einschließlich Hüfte und Gesäß (34,8 %), im Bereich der oberen Extremitäten (23,4 %) und im Rumpf (17 %) auf. Unseres Wissens ist dies der erste Fall eines malignen Schwannoms des Rektums, der in der Weltliteratur beschrieben wird. Wir berichten über das seltene Krankheitsbild und geben einen Überblick über die Literatur.

Sarcoma of the pulmonary artery is a rare tumor. The histopathologic features of these tumors differ widely, with leiomyosarcomas representing less than 20 % of all pulmonary sarcomas. Diagnosis is very difficult because most of the cases have no specific clinical signs: the major differential diagnosis is that of pulmonary thromboembolism. We report the case of a 45-year-old woman, who was first treated for pulmonary thromboembolism until the diagnosis of an intravascular growing tumor was made by means of computed tomography, pulmonary angiography and nuclear magnetic resonance tomography. The patient underwent right pneumonectomy and microscopically a leiomyosarcoma of the right pulmonary artery was found.

The formation of an epidural or subdural haematoma is a well-known but very rare complication when anaesthetic procedures are conducted near the spinal cord. The major reasons are impaired blood coagulation and the trauma of puncture, which represents the initiating factor and determines the extent of the vascular lesion, while defective coagulation may cause the bleeding to continue. We report on a 30-year-old slender female patient of ASA group II undergoing epidural anaesthesia at L3/4 with a 19-gauge Crawford needle for an ankle joint injury. Unexpected puncture difficulties made several approaches necessary. Prevention of thrombosis with low-molecular heparin was not started preoperatively but 8 h following the intervention. On the first postoperative day the patient was mobilized and, in spite of the repeated punctures, there were no complaints until the fourth postoperative day. Subsequently, sudden significant complaints occurred, first suggesting infection near the spinal cord. Immediate magnetic resonance imaging revealed an epidural haematoma, which did not require intervention. Puncture of the spinal fluid was not performed. Laboratory analysis of coagulation showed a prothrombin time of 56%; PTT was normal with 36 s. Following three days of symptomatic therapy, the complaints had improved markedly, so that mobilization could be started again. For another 10 days the patient had a minor diffuse sensation of pressure when moving the lumbar spine in this region. Subsequently, there were no complaints at all, as proved by an investigation one year later. Unfortunately, the patient refused to undergo another MRT at that time. In the present case the haematoma was caused by tissue trauma due to several puncture attempts. The prognosis largely depends on early recognition of the symptoms, which in our case became manifest only after several days, as well as the immediate employment of special diagnostic procedures and, if necessary, surgical intervention. At present, it is not possible to conduct a statistical analysis on the question of whether there is a higher incidence of haematoma in single-shot anaesthesia than in continuous anaesthesia.

Aortic arch anomalies are rare. They arise as a failure of the normal development of the left fourth dorsal arch. Cervical aortic arches are believed to result from persistence of the third dorsal arch, which re-routes the aortic arch in the cervical region. We describe a case of a left-sided cervical aortic arch in which the diagnosis was confirmed, and the anatomy defined. using magnetic resonance tomography.

Fractures of the talus have a relatively low incidence, accounting for 0.3% of all bone fractures and 3.4% of fractures of bones in the foot. These injuries affect the neck of the talus more frequently than its head or body. Because of the combined traumatic mechanism, sagittal fracture of the talar body is extremely rare; the literature contains only a few case reports, all with severe dislocation of the fragments. Plain film radiographs and CT pictures recorded in a rare case of nondisplaced fracture of the talar body are presented.