[Epidural lipomatosis : management proposal]. / Comment je traite la lipomatose épidurale.

Epidural lipomatosis is a rare condition characterized by excessive accumulation of normal fat in the epidural space. This paper presents the results of a retrospective study of the charts of 20 patients. The 20 patients - 17 men and 3 women - were on average 64 years old. They suffered from radiculopathy and/or neurogenic claudication. Lipomatosis was idiopathic in 6 patients and secondary in 14 patients. Lipomatosis was MRI grade 2 in 30 % of cases and grade 3 in 70 % of cases. The patients have all been improved thanks to decompressive surgery by laminectomy and resection of epidural fat. According to our experience and to the literature, surgical decompression is an effective and safe procedure for patients with symptomatic lumbar epidural lipomatosis in case of failure of conservative treatment or in case of neurological deficits. We present a decision tree that can help in the management of this disease.

La lipomatose épidurale est une affection rare caractérisée par une accumulation excessive de graisse normale dans l'espace épidural. Ce travail présente les résultats d'une étude rétrospective des dossiers de 20 patients. Les 20 patients, 17 hommes et 3 femmes, étaient âgés en moyenne de 64 ans. Ils souffraient d'une radiculopathie et/ou d'une claudication neurogène. La lipomatose était idiopathique chez 6 patients et secondaire chez 14 patients. L'IRM a démontré une lipomatose de grade 2 dans 30 % des cas et de grade 3 dans 70 % des cas. Les patients ont tous été améliorés grâce à la chirurgie de décompression par laminectomie et résection du tissu épidural. D'après notre expérience et selon la littérature, la décompression chirurgicale est une procédure efficace et sûre pour les patients présentant une lipomatose épidurale lombaire symptomatique en cas d'échec du traitement conservateur ou en cas de déficits neurologiques. Nous présentons un arbre décisionnel pouvant aider à la prise en charge de cette pathologie.

[Which complementary examination does replace a bad clinical examination ? A good clinical examination ! A mood ticket...] / Quel examen complémentaire remplace un mauvais examen clinique ? Un bon examen clinique ! Billet d'humeur

The writer rebels in a mood ticket on the dictatorship of the complementary examinations at the expense of the clinical approach. She comments on the multiple reasons, medical and medicolegal, which in the 21st century still encourages a good history taking and a good clinical examination.

L'auteure s'insurge, dans un billet d'humeur, sur la dictature des examens complémentaires aux dépens de la clinique. Elle commente les multiples raisons, médicales et médicolégales qui doivent, au XXIème siècle, toujours inciter à une bonne anamnèse et un bon examen clinique.

Refractory neuropathic pain from a median nerve injury: spinal cord or peripheral nerve stimulation? A case report.

Spinal cord stimulation (SCS) is the most frequently used neuromodulation technique even for neurogenic pain from a peripheral nerve injury although peripheral nerve stimulation (PNS) has been designed for this purpose. PNS appears less invasive than SCS or deep brain stimulation. It provides greater and specific target coverage and it could be more cost-effective than SCS because low electrical stimulation is exclusively delivered to the precise painful territory. We report a case of excellent result following median nerve stimulation at arm level after SCS failure and a 10-year history of intense pain. PNS would certainly have been considered much earlier if it was accepted and reimbursed by the Belgium National Insurance. PNS is a safe, simple, and efficient technique available for decades but it is still considered as experimental and underemployed. Belgian National Insurance fears an explosion of indications on neuromodulation if PNS was reimbursed. We consider that PNS aside SCS and other neuromodulation techniques should be made available in Belgium in case of peripheral chronic neuropathic pain.

[Paralysing lumbar disc herniation: a surgical emergency? Reflexion about a series of 24 patients and literature data]. / La hernie discale lombaire paralysante : une urgence chirurgicale ? Réflexion à propos d'une série de 24 patients et des données de la littérature.

BACKGROUND AND PURPOSE: Paralysing lumbar disc herniation (LDH): what and when to do? Few studies have analyzed the optimal timing of surgery in case of paralysing LDH. METHODS: Twenty-four charts were retrospectively reviewed of patients suffering of LDH with severe motor deficit. RESULTS: There were 16 men and eight women. Mean age was 45.1 years. Seventeen patients suffered of lumbar pain, 15 of radicular pain and all of a severe motor deficit, implying mostly the ankle flexion (17 patients). LDH was most frequently located at L4/L5 or L5/S1 level. Surgery was proposed to all patients at the end of the consultation. Nine patients were operated within 48 hours. The mean interval between onset of motor deficit and operation was 20 days. The statistical analysis did not reveal any significant difference among different prognostic factors between the 17 patients with good motor recovery and the seven patients with poor motor recovery. In particular the operative delay did not appear to influence the degree of motor recovery. Literature review on paralysing LDH provides five published series since 1996, including 28 to 116 patients. Two series, including the single prospective one, conclude that the degree of recovery of motor function is inversely related to the degree and duration of motor deficit. CONCLUSIONS: Our retrospective series of 24 operated paralysing LDH did not reveal any prognostic factor for motor recovery. There is no evidence based medicine data in the literature about the optimal timing of decompressive surgery. A relative consensus exists among spine surgeons for paralysing LDH: since operative indication is obvious, surgery should be done as soon as possible.

[Bilateral peroneal neuropathy following bariatric surgery]. / Neuropathie bilatérale du nerf fibulaire commun après chirurgie bariatrique.

We report the case of bilateral peroneal neuropathy following massive weight loss after bariatric surgery. A few months after a gastric by-pass, the patient developed sequentially within 6 months a L2-L3 herniated disc that required surgery, a severe right peroneal nerve palsy that led to decompressive surgery and finally contralateral peroneal nerve palsy also operated. The electrophysiological analysis confirmed the clinical suspicion of peroneal nerve compression at the fibular head. Postoperative course was favorable. Literature reports peroneal nerve palsy after slimming, mostly when weight loss is fast and marked although the issue is rarely bilateral.

Determinants of weight loss in an interdisciplinary long-term care program for childhood obesity.

Background. Efforts are needed to improve the long-term efficiency of childhood obesity treatment. To adapt strategies, the identification of subgroups of patients with a greater weight loss may be useful. Objective. To analyze the results of a chronic care program for childhood obesity and to determine baseline factors (medical, dietary, and psychosocial) associated with successful weight loss. Subjects and Method. We set up a family-targeted and individually adapted interdisciplinary long-term care program. We reviewed the medical files of 144 children (59 boys and 85 girls; 10.5 ± 3.1 y; mean BMI-z-score: 2.73 ± 0.62) who had ≥2 interdisciplinary visits and ≥1-year treatment. Results. Mean treatment length was 2.2 y (1-6.7 y) with 3 ± 1 visits/year. The duration of treatment did not depend on the initial weight loss, but this was predictive of the weight change over time. Furthermore any additional weight loss was observed with time whatever the initial weight change. High levels of physical activity and daily water intake from baseline conditions were associated with a greater weight loss after 9 months of intervention. In contrast, a high baseline consumption of soft drinks resulted in lower weight loss. Family specific factors such as being a single child or the child's family support were identified as baseline factors which may contribute to better results. Conclusion. Our study suggests that the benefit of a chronic weight control program supports the need for its integration into the current concept of treatment. Better prevention policy and parental support may improve the success of the childhood obesity treatment.

[Two post-traumatic "Gilliatt-Sumner hands" from decompensation of thoracic outlet syndrome]. / A propos de deux "mains de singe" post-traumatiques sur décompensation d'un syndrome de défilé cervico-thoracique.

The clinical picture of hand atrophy related to a cervical rib has been well described in 1970 by Gilliatt and Sumner. These authors reported a series of nine patients whose motor status was stabilized following decompressive surgery of the brachial plexus. We report two young patients decompensating a predisposed thoracic outlet (rudimentary cervical rib), following a scapular or cervical trauma. After several years of neck and arm painful complaints, the two patients progressively developed hand atrophy. One patient had been operated both at cervical (double discectomy and disc prosthesis) and elbow (ulnar nerve neurolysis) levels, before the diagnosis of thoracic outlet syndrome (TOS) was attained. Decompression of the brachial plexus by anterior approach has improved the painful symptoms and stabilized the motor status of our two patients. The diagnosis of plexus disease was reached in our two patients at the "true" neurogenic TOS stage (hand atrophy), evolving several years after a "disputed" neurogenic TOS (subjective complaints). These cases remind us to keep in mind the diagnosis of TOS in front of a cervicobrachialgia not or insufficiently explained by a cervical pathology.

[Gilliatt-Sumner hand or true neurogenic thoracic outlet syndrome. A report on seven operated cases]. / La main de Gilliatt-Sumner ou le syndrome de défilé cervicothoracique neurogène vrai. À propos de sept cas opérés.

BACKGROUND AND PURPOSE: The clinical picture of hand atrophy related to a cervical rib or elongated C7 transverse process was well described in the modern literature by Gilliatt and Sumner; in 1970, they reported a series of nine patients whose motor status was stabilized following brachial plexus decompression. We report here seven patients suffering from thoracic outlet syndrome (TOS), who developed hand atrophy, sometimes because of diagnostic delay. METHODS: The patient's charts were analysed retrospectively. RESULTS: The seven patients were all female; the mean age was 43 years. The first complaints were arm pain and paresthesias lasting six months to 5 years. Three patients were treated with C56/C67 discectomy plus disc prosthesis (one patient), ulnar neurolysis at the elbow (the same patient), carpal tunnel release (one patient), and intravenous immunoglobulins (one patient) before TOS diagnosis. Hand atrophy, severe in five patients, was present at presentation. All patients underwent brachial plexus decompression by the anterior (four), posterior (two), or transaxillary (one) approach. This last approach was completed 18 months later by brachial plexus neurolysis via the anterior approach. Postoperatively, motor deficit was improved in two patients and stabilized in five patients. CONCLUSIONS: Physicians' unfamiliarity with TOS diagnosis or their reluctance to accept the diagnosis without electrical confirmation can lead to hand atrophy. Brachial plexus decompression at this stage usually stabilizes the deficit.

[Clinical case of the month. Traumatic bilateral orbital encephalocele]. / Le cas clinique du mois. Encéphalocèle orbitaire post-traumatique bilatéral.

Acute traumatic orbital encephalocele is a rare entity, with less than 25 cases reported. We hereby describe the first bilateral orbital encephalocele through a blow-in orbital fracture after a blunt cranial traumatism. Early treatment of the orbital traumatic encephalocele is necessary in order to avoid the increase of the intra orbital pressure that might damage the optic nerve. Repairing the orbital roof has to be performed in a rigid manner in order to avoid the transmission of the intracranial pressure variation to the orbit. In the present case, the reconstruction of orbital roof was performed using a subfrontal approach supported by a titanium mesh fixed with screws and a mixture of bone powder mixed and fibrin glue.

[Thoracic outlet syndrome]. / Le syndrome du défilé cervico-thoracique.

Thoracic outlet syndrome (TOS) is due to compression/irritation of brachial plexus elements ("neurogenic TOS") and/or subclavian vessels ("vascular TOS") in their passage from the cervical area toward the axilla. The usual site of entrapment is the interscalenic triangle. TOS is a highly controversial subject in regard to its incidence, diagnostic criteria and optimal treatment. Constitutional factors--osseous or more often fibromuscular--and external factors such as trauma predispose to the development of TOS. Various clinical pictures include pain in the cervical region and arm, paresthesias, aggravated by overhead positions of the arms, hand intrinsic muscle deficit/atrophy, easy fatiguability, paleness, coldness of hand. The clinical examination may be entirely normal or show cervical and scapular muscle spasm, tenderness of supraclavicular area, radial pulse attenuation upon positional maneuvers, sensory and/or motor deficit, usually of C8/T1 distribution. The diagnosis is based on clinical evaluation and absence of other relevant pathology. Sometimes TOS can enhance symptoms consecutive to cervical or supraclavicular lesions. Cervical spine and distal peripheral nerves are investigated by radiological and electrophysiological studies. Unless there is significant motor deficit or subclavian artery compression, the treatment should be kept conservative as long as possible, by adapted physical therapy. In case of neurological deficit or symptoms unresponsive to medical treatment, the patients will--like in other nerve entrapment syndromes--be helped by decompressive surgery, nowadays preferably performed via an anterior supraclavicular approach.

Sciatic nerve regeneration through venous or nervous grafts in the rat.

This study analyses the interest of isologous venous grafts filled with saline or with Schwann cells versus nerve grafts as guides for regeneration of the sciatic nerve in 35 Wistar rats. Electrophysiological parameters (conduction velocities and distal latencies of motor responses) and the functional index of De Medinacelli were measured several times from 1 month to 1 year after surgery. An histological analysis was performed on 2 control rats and on 3 rats killed 6 or 12 months after surgery: the total number of fibers was counted on a montage photoprint of the whole nerve, and the diameters of axons and the thickness of the myelin sheath were measured on digitized images. With a portion of nerve as guide, the regeneration is faster than with a vein. However, regeneration after 6 months is at least as good with a venous graft filled with Schwann cells, as assessed by electrophysiological, functional, and histological analysis. The addition of Schwann cells in grafted veins allows the nerve to regenerate through longer gaps than previously described (25 vs 15 mm). In order to assess the quality of nerve regeneration, functional, electrophysiological, and histological analysis are complementary.

Predegenerated nerve allografts versus fresh nerve allografts in nerve repair.

This study reevaluated the possibility of using predegenerated nerves as donor nerve allografts for nerve repair and compared the results of functional recovery to those obtained after standard, fresh nerve allograft repair. Twenty donor rats underwent a ligature/ section of the left sciatic nerve 4 weeks before nerve graft harvesting. Forty recipient rats underwent severing of the left sciatic nerve leaving a 15-mm gap between the nerve stumps. Graft repair was undertaken using either the predegenerated left sciatic nerve of the 20 donor rats (predegenerated group, 20 recipient rats) or the normal right sciatic nerve of the 20 donor rats (fresh group, 20 recipient rats). Recovery of function was assessed by gait analysis, electrophysiologic testing and histologic studies. Walking tracks measurements at 2 and 3 months, electromyography parameters at 2 and 3 months, peroperative nerve conduction velocity and nerve action potential amplitude measurements at 3 months, as well as assessments of myelinated nerve fiber density and surface of myelination showed that fresh and predegenerated nerve grafts induced a comparable return of function although there was some trend in higher electrophysiologic values in the predegenerated group. The only slight but significant difference was a larger mean nerve fiber diameter in the nerve segment distal to a predegenerated nerve graft compared to a fresh nerve graft. Although our study does not show a dramatic long-term advantage for predegenerated nerve grafts compared to fresh nerve grafts, their use as prosthetic material is encouraging.

Recurrent ganglion cyst of the peroneal nerve: radiological and operative observations. Case report.

This 34-year-old man presented with right leg pain and foot drop of 1-month duration. The preoperative diagnosis of a 10-cm-long ganglion cyst of the peroneal nerve was achieved using ultrasonography (US), computerized tomography and, particularly magnetic resonance (MR) imaging. Surgical exploration disclosed a lobulated cystic mass filled with gelatinous material, which intermingled with the nerve substance of the deep peroneal nerve. The lesion was completely resected, with the sacrifice of some electrically nonfunctioning fascicles. No connection with the knee joint was found. A good postoperative recovery of motor function was obtained. However, routine postoperative MR imaging disclosed a recurrent ganglion cyst that was slightly less extensive than the original. A careful radiological examination of the knee joint was performed, including arthrography. A communication of the cyst with the tibiofibular joint was clearly demonstrated and was meticulously closed at reoperation. The patient's postoperative course was uneventful, and a third MR image, obtained 5 months after reoperation, showed no sign of cyst recurrence. The patient remained free of symptoms 11 months postoperatively. This case illustrates the value of US and MR in diagnostic imaging. The diagnostic efficacy of US and MR imaging in identifying and characterizing a ganglion cyst is described. Close contact between a ganglion cyst and the tibiofibular joint should raise the possibility of an existing cyst-joint communication and lead to an aggressive radiological workup and/or a surgical search for such a communication.

Posterior subscapular approach to the brachial plexus. Report of 102 patients.

A 15-year operative experience with 105 posterior subscapular approaches to the brachial plexus in 102 patients is presented. The procedure is indicated in carefully selected cases, especially where the proximal portions of lower spinal nerves are involved. Its main advantage is proximal exposure of the plexus spinal nerves, particularly at an intraforaminal level. The indications in this series were thoracic outlet syndrome (TOS) in 51 carefully selected procedures, brachial plexus tumor involving proximal roots in 22 patients, post-irradiation brachial plexopathy in 14 cases, and proximal traumatic brachial plexus palsy in 18 patients. Thoracic outlet syndrome associated with neurological loss, recurrent TOS after a prior operation, or proximal brachial plexus surgical lesions involving the spinal nerve(s), especially at an intraforaminal level, can be approached advantageously by such a posterior subscapular approach. The technique should also be considered when prior operation, trauma, or irradiation to the neck or anterior chest wall make a posterior exploration of the plexus easier than an anterior one. Anterior exposure of the plexus is the preferable approach for the majority of lesions needing an operation, but the posterior subscapular procedure can be useful in well-selected cases.

Sciatic nerve regeneration across gaps within collagen chambers: the influence of epidermal growth factor.

The effects of Epidermal Growth Factor (EGF) on axonal regeneration of a sectioned sciatic nerve within collagen tubes were investigated in 15 rats. Following baseline electrophysiologic assessment, bilateral 7-mm nerve gaps were created and repaired by interposition of collagen tubes, into which EGF (left side) or type I collagen (right side) was instilled. After 4 or 8 weeks, axonal regeneration, measured by electrophysiologic and histologic means, was identical for the EGF and control legs. The conclusion is that EGF does not influence nerve regeneration within a collagen chamber.