Intraspinal meningiomas: review of 54 cases with discussion of poor prognosis factors and modern therapeutic management.

INTRODUCTION: Intraspinal meningiomas account for 25%-46% of primary spinal cord tumors. Technical advances in magnetic resonance imaging (MRI) and surgical procedures (ultrasonic cavitation aspirators [CUSA], lasers) have brought about better clinical results. In spite of these new techniques, a small percentage of patients still present with poor postoperative results and/or a recurrence. The authors tried to determine which data could influence clinical outcome and what therapeutic modalities could limit recurrence rate. MATERIALS AND METHODS: We reviewed 54 patients who from 1963 to 1994, each had surgery for an intraspinal meningioma. There were 43 females and 11 males, aged 8 to 85 years old. Thirty-six (66.6%) patients were ambulatory on admission; only 2 presented with a paraplegia. Tumor location was cervical in 10 cases, thoracic in 43 cases, lumbar in 1 case. Forty-seven tumors were intradural, 5 epidural, 2 epidural and intradural. Thirty patients underwent a myelography, 10 a computed tomography (CT) scan, and 14 an MRI. Twenty-three spinal angiographies were performed before surgery. Complete removal was achieved in 50 patients (92.6%). Ultrasonic cavitation was used 10 times for debulking the tumor, and laser was used in 12 surgical procedures to perform hemostasis of the meningioma and to coagulate the dural attachment. RESULTS: The majority of the neoplasms were meningothelial (N = 24) or psammomatous (N = 11). No mortality was noted. Morbidity concerned five patients: two pulmonary embolisms, one definitive paraplegia, one transient deficit, and one epidural suppuration, which necessitated a second operation. Mean follow-up was 28 months. Final functional results were very good in 85% and good in 13%; one patient (2%) worsened. Two recurrences were noted: one with clinical signs and the other with only CT-scan modifications. Both patients underwent complementary radiotherapy. DISCUSSION AND CONCLUSION: The authors discuss factors influencing functional results. Sex, pregnancy, pathologic diagnosis, and recurrence do not seem to have any influence. Calcification of the meningioma, as well as an anterior dural attachment, are pejorative factors. They insist on preoperative angiography and point out the advantage of using a CUSA and/or a laser to debulk and coagulate the tumor itself and its dural attachment. They propose radiation therapy as an adjuvant treatment or an alternative to reoperation, which could be hazardous for some patients when, for instance, a recurrence is located in a critical area or when the patient's general status is fragile.

[Mature lumbar multi-tissue dysembryoma of the spinal cord with sacral spina bifida occulta]. / Dysembryome pluritissulaire mature médullaire lombaire avec spina bifida occulta sacré.

The authors report the case of a 28-year-old woman who presented with L5 bilateral sciatica associated with perineal sensory disorders. During surgery, a mature pluritissular dysembryoma originating in a tethered spinal cord was discovered at the level of the L2-L3 intervertebral space. Following removal of the lesion, all symptoms disappeared. Mature pluritissular dysembryomas of the spinal cord result from the inclusion of neuroectodermal and mesodermal tissue which has not followed normal evolutive embryonic organization.

Treatment of severe traumatic lesions of the dorsolumbar spine using Roy-Camille's apparatus. A clinical study of 121 cases together with technical considerations.

The authors report 121 cases of surgically treated severe lesions of the dorsolumbar spine. One single technique has been used: posterior osteosynthesis using Roy-Camille's plates.

Odontoid process fracture osteosynthesis with a direct screw fixation technique in nine consecutive cases.

The authors present their experience with surgical treatment of odontoid process fractures using a direct screw fixation technique via an anterolateral retropharyngeal approach. Nine consecutive patients have been operated on with this technique. There were two deaths unrelated to the surgery, and anatomical union with conservation of the craniospinal hinge mobility was achieved in the remaining seven patients. The direct screw fixation technique appears feasible, efficient, and logical.

[Cervical Pott's disease. Technical considerations apropos of a surgically treated case]. / Mal de Pott cervical. Considérations techniques à propos d'un cas opéré.

The authors report one case of cervical Pott's disease located in C5 and associated with neurological disorders. Following corrections of the spinal disaxation, they advocate a per priman posterior fixation which will ensure spinal stability. This will be followed secondarily by an operation through an anterior approach.

Treatment of severe lesions of the lower cervical spine (C3-C7). A clinical study and technical considerations in 102 cases.

The authors report 102 cases of severe lesions of the lower cervical spine, in which operation was mandatory. The characteristics of these fractures are discussed, together with the different operative procedures. Posterior osteosynthesis using Roy-Camille's plates was preferred.

[Osteosynthesis of fractures of the odontoid process by direct screwing. Preliminary reflections on 2 surgically treated cases]. / Ostéosynthèse des fractures de l'odontoïde par vissage direct Réflexions préliminaires à propos de 2 cas opérés.

Following surgical treatment of 2 cases of odontoïd base fracture, the authors describe the direct screw fixation technique through an anterolateral approach. This technique allows for good access and is very efficient. It results in an anatomical union with conservation of the craniospinal hinge mobility.

Treatment of pedicular fractures of the axis. A clinical study and screw fixation technique.

The authors report 18 cases of pedicular fractures of C-2. The characteristics of these fractures are discussed, and the authors conclude that these lesions are more correctly called "pedicular-isthmus" fractures. A technique of screw fixation of the pedicle is presented. This was found to be a simple and safe method of repair, giving consistently good anatomical and functional results.

[Cervical spine injuries in children]. / Les traumatismes du rachis cervical chez l'enfant.

Cervical spine injuries in children are usually benign, severe traumatism being exceptional. The authors report 4 observations of severe traumatisms, 2 of which have required surgical treatment. Moreover they insist on the interest of acupuncture in the treatment of torticollis and of pain in the cervical spine after injury. The authors also point out the frequent aspect of anterior pseudo-subluxation C2-C3 which corresponds to a genuine medio-cervical physiological hinge.

[Traumatic bitemporal hemianopsia (author's transl)]. / L'hémianopsie bi-temporale traumatique.

The authors report a case of traumatic bitemporal hemianopsia, without any macroscopic lesion in the chiasma. At this juncture, they argue about the different mechanisms which may occur in the pathogenesis of these lesions, and they dwell on the indirect mechanism of the quartering of the optic nerves, which is responsible for a tear in the chiasma.

[A clinical study in neurosurgical diseases. A report on eighty cases (author's transl)]. / Essai thérapeutique en neurochirurgie. A propos de quatre-vingts observations.

The authors describe 80 patients with neurosurgical disorders treated with tiapride, either during neurosurgical investigations including radiological examinations after removal of cerebrospinal fluid, or for agitation following alcoholism or meningeal haemorrhage. The authors stress the value of tiapride for patients undergoing radiculography and especially gas myelography procedures. The effect of tiapride on the various manifestations of agitation was also spectacular and rapid, and the authors confirm the excellent tolerance of the product.

[Diagnostic problems in the disseminated intraparenchymatous form of cerebral cysticercosis. A report on two cases (author's transl)]. / Problèmes diagnostiques posés par la forme intraparenchymateuse disséminée de la cysticercose cérébrale. A propos de deux cas.

The authors report 2 cases of brain localisation of cysticercosis due to Cysticercus cellulosae. In both cases epilepsy was found but only later was its origin proved by the finding of caracteristic ellipsoidal calcifications of cysticerci on the roentgenogram. The authors also recall the various possible symptoms; insist on the fact that early positive diagnosis is difficult and that the mode of treatment by surgery is exceptional. Though cysticercosis is rare in France, it should be remembered when a diagnosis of epilepsy is made and no apparent cause is found: further research of etiology should thus be made in such cases.

[Large aneurysms of the internal carotid artery in its infraclinoidal intracranial portion (author's transl)]. / Les anévrismes géants de la carotide interne, intra-cranienne infra-clinoidienne.

Two new cases of large aneurysms of the infraclinoidal intracranial portion of the internal carotid artery are reported. After a survey of the literature, the authors emphasize the rarity of these malformations, their particular clinical picture with involvement of the cranial nerves. Among the various surgical techniques which were suggested for the management of these large aneurysms, the ligation of the internal carotid artery in the neck is favoured by the authors as the best procedure.

[Cerebral cysticercosis. About two cases of brain localisation (author's transl)]. / La cysticercose cérébrale: à propos de 2 cas d'infestation intra-parenchymateuse disséminée.

The authors report 2 cases of brain localisation of cysticercosis due to Cysticercus cellulosae. In both cases epilepsy was found but only later was its origin proved by the finding of characteristic ellipsoidal calcifications of cysticerci on the roentgenogram. The authors also recall the various possible symptoms ; insist on the fact that early positive diagnosis is difficult and that the mode of treatment by surgery is exceptional. Though cysticercosis is rare in France, it should be remembered when a diagnosis of epilepsy is made and no apparent cause is found : further research of etiology should thus be made in such cases.

[Autochthonous cases of cranial echinococcosis]. / Un cas autochtone d'échinococcose du crâne.

The above case-report of Echinococcosis involving the vault presents some noteworthy features, namely:--its occurence in a patient who has never left continental France;--it represents a vault localisation in which, despite the large size attained by the cyst, the latter has remained well-circumscribed;--X-ray examination revealed important condensation reactions without newbone formation and calcification of the cyst wall.

[Right lumbo-crural sciatica due to a vertebral osteochondroma]. / Lombo-cruro-sciatique droite due à un ostéochondrome vertébral

The above case-report is about unilateral lumbar-crural-sciatalgie which has led to the finding of a spinal tumour situated within the articular block on the right side of the third and fourth lumbar vertebrae. The clinical picture produced by this slowly growing tumour was that of spinal root compression which has called for its surgical removal. Histological examination of the tumour revealed an osteochondroma, the original aspects of which lie in its localization, the presenting symptoms, the age of the patients an in its course.