[Evaluation of the clinical and radiological results of cervical longitudinal median somatotomy without graft]. / Evaluation des résultats cliniques et morphologiques de la somatotomie cervicale médiane longitudinale sans greffe.

OBJECTIVES: To evaluate the clinical and radiological results of cervical longitudinal median somatotomy without graft, used for the treatment of cervical myelopathy and radiculopathy, and compare it to techniques with graft and to laminectomies. MATERIAL AND METHOD: Thirty-four patients (25 males and nine females), with a mean age over 60 years, were included in a study comparing pre- and postoperative clinical status on the Japanese Orthopaedic Association (JOA) functional scale and radiological status with evaluation of the cervical curve on plain films and dynamic tests in flexion and extension. RESULTS: No significant difference was found with the clinical and anatomical results published in the literature concerning median somatotomies performed with graft and/or osteosynthesis and laminectomies and their variants. CONCLUSIONS: The cervical longitudinal median somatotomy without graft is an easy and reliable technique that can be proposed as first-line treatment for cervical spondylotic myelopathy related to anterior compression. It decreases the cost and the duration of the surgical procedure, it protects the patient from the complications and sequelae related to graft harvesting and the use of implants. It should be limited to patients without preoperative kyphosis who are over 50 years old.

[Non traumatic spinal epidural hematomas. Report of twenty cases. Review of the literature and outcome aspects]. / Hématomes épiduraux non traumatiques du rachis. Présentation de 20 cas. Revue de la littérature et étude des aspects évolutifs.

BACKGROUND AND PURPOSE: We report a personal series of 20 non traumatic spinal epidural hematomas and study outcome aspects with a review of data in the literature. METHOD: Clinical presentation of non-traumatic spinal epidural hematomas observed between January 1980 and December 1998 was acute in 17 cases (85%) and chronic in 3 (15%). Symptoms were spinal and/or radicular pain, sensorimotor and sphincter dysfunction. Radiological evaluation consisted in myelography (n=6), myelography-CT scan (n=5), CT scan (n=1) and MRI (n=9). Patients underwent surgery in 15 cases, between 8 hours and 2 months after the first symptoms. All our patients were clinically reevaluated between 2 and 4 months after either surgery or admission for cases of spontaneous resolution. RESULTS: Good results (complete neurological resolution or moderate sequelae) were observed in 14 patients (70%). A partial recovery with major persistent neurological impairment was observed in 1 patient (5%), an initial persistent neurological impairment in 1 (5%). Three patients (15%) died and 1 (5%) was lost to follow-up. Complete spontaneous resolution were observed in four patients. CONCLUSION: Postsurgical outcome is mainly related to the preoperative neurological impairment, the duration of spinal cord compression and the time interval between the onset of symptoms and maximal deficit. A prompt laminectomy is necessary except in the cases where a spontaneous resolution can be expected from the early neurological course.

[Clinical recurrence of Cushing syndrome without evidence of tumor recurrence: radical hypophysectomy?]. / Les récurrences cliniques de la maladie de Cushing sans récidive tumorale documentée: hypophysectomie radique.

Outcome following radiation therapy for hormonally-active Cushing adenoma is reported. Conventional radiation using 20 to 30 grays improved mass and hormone level in 30 to 80% of the patient. Gamma-knife radiosurgery was at least as effective. These results are discussed in this review.

Phase II study of a radiotherapy/etoposide combination for patients with newly malignant gliomas.

PURPOSE: Etoposide, a semisynthetic derivative of podophyllotoxine, is a topoisomerase II inhibitor. This drug is currently used in several types of human cancer. The aim of this study was to evaluate the efficacity and tolerance of a near-concurrent association of radiotherapy and etoposide for newly malignant gliomas. METHODS: From May 1995 to December 1996, 30 malignant glioma patients were included in this phase II study; 16 patients underwent surgical tumor resection, and a stereotactic biopsy was performed in 14 patients. Standard cranial irradiation and six courses of etoposide (100 mg/m2, x days 1-3) were administered. The first course of etoposide was administered on days 1-3 of radiotherapy and was resumed in the week following the end of radiotherapy. Treatment was consolidated by further courses of etoposide every 4 weeks. RESULTS: Only 26 patients could be evaluated for the purpose of our study. The median age was 60.1 years, and the median Karnofsky performance score (KPS) was 80.2. The rate of objective response for evaluable patients was 34.6%, and four complete responses (CR) and five partial responses (PR) were noted. The median survival (MST) was 12 months, and the average overall survival was 12.5 months. Hematological toxicity was mild, and grade 3 or 4 neutropenia (white blood cell count < 1500/ml) was noted in three patients, without any sepsis or bleeding. CONCLUSIONS: The results obtained in this study are comparable to the best reported results on the combination of radiotherapy and nitrosoureas. The near-concurrent combination of radiotherapy and etoposide seems to be effective and well tolerated in the treatment of newly malignant gliomas.

[Solitary fibrous tumor of the meninges]. / Tumeur fibreuse solitaire des méninges.

We report a case of solitary fibrous tumor (SFT) of the meninges. SFTs have been initially described in the pleura. SFTs show similar histological findings as in other locations. SFTs show a diffuse positive staining for vimentin and CD34. Meningeal SFTs have usually a favourable outcome. These tumors have to be essentially distinguished from hemangiopericytomas and fibrous meningiomas. Immunostaining for CD34 is of value for this purpose. CD34 expression is often patchy and weaker in hemangiopericytomas whereas it is rarely observed in fibrous meningiomas. It is of great interest to isolate SFTs from hemangiopericytomas because of their favourable outcome.

Aggressive treatment with complete remission in primary diffuse leptomeningeal gliomatosis--a case report.

Primary leptomeningeal gliomatosis is rare, and the diffuse form (PLDG) is even more unusual. The following report is an example. A 17 year-old man developed a syndrome characterized by extensive basal and chronic spinal meningitis. Routine biological tests showed elevated levels of CSF proteins, and moderate mononuclear pleocytosis, with no direct evidence of neoplasia, leading to a diagnosis of chronic meningitis. A second meningeal biopsy, guided by MRI and performed in the left frontal region, led to the specific diagnosis of primary diffuse leptomeningeal gliomatosis. Treatment including ventricular and lumbar shunting, a course of cortico-spinal radiation, and three courses of an eight-drug systemic chemotherapy with intrathecal methotrexate lead to complete remission over 15 months. We believe that this is the first report of such a remission in the literature.

[Adenoid cystic carcinomas of the maxillary sinus with intracranial invasion. Review of the literature, apropos of a case]. / Les carcinomes adénoïdes kystiques du sinus maxillaire à développement intracrânien. Revue de la littérature, à propos d'un cas.

We report a case of adenocystic carcinoma (cylindroma) of the maxillary sinus with intracranial extension in a 35-year-old man with no previous clinical history. The patient underwent primary neurological and maxillofacial surgery. He then developed two successive recurrences of the tumor in the temporo-parietal area of the brain treated by surgery and radiotherapy for the first one and surgery alone for the second. The patient finally died 4 years and 2 months after the diagnosis. Adenoid cystic carcinomas are malignant epithelial neoplasms that arise mainly from salivary glands (14% of the salivary tumors), and less frequently from other structures. Their histological pattern can be either tubular, cribriform or solid, with different prognosis. They invade local areas (perineural spaces) and also metastasize to the lung, liver, bone, regional lymph nodes. Treatment mainly consists in combined surgery and radiation therapy. Chemotherapy might be also used.

[Acute pituitary necrosis after multiple pituitary stimulation test]. / Nécrose hypophysaire aiguë après test de multistimulation hypophysaire.

Iatrogenic necrosis of the pituitary gland is well-known but rarely caused by stimulation tests used to investigate pituitary adenomas; 26 cases have been reported in the literature. We report 2 new cases where the chronology of the events suggests the sudden necrosis resulted from stimulation tests. Several mechanisms have been proposed. It is not possible to define increased risk as a function of the adenoma histology. In most cases, voluminous tumors are revealed by visual dysfunction. These accidents should not overshadow the role of function tests in neurosurgical situations. Outcome is usually favorable after acute necrosis.

[Spontaneous spinal epidural hematoma: 2 cases]. / Hématome épidural rachidien spontané: 2 cas.

The authors report on two cases of spontaneous spinal epidural hematomas with atypical subacute clinical presentation and good recovery after surgical treatment. Etiologies, physiopathology, early diagnosis and treatment are considered through a brief review of the literature.

[Preservation of procedural memory in 18 patients operated for aneurysm of the anterior communicating artery]. / Préservation de la mémoire procédurale chez dix-huit patients opérés d'un anévrisme de l'artère communicante antérieure.

Organic amnesia is typically associated with lesions in either the diencephalic or medial temporal regions of the brain. However, amnesia can result from other kinds of lesions, in particular those resulting from an aneurysm of the anterior communicating artery (ACoA). In the present study, 7 patients who became amnesic following a ruptured and operated ACoA aneurysm were comparated neuropsychologically with 11 patients with ruptures but no cognitive complaints and 18 normal control subjects. They were submitted to explicit and implicit memory tests and to tests claimed to be sensitive to frontal lobe dysfunction. The performance of the 11 ACoa patients without cognitive complaints revealed evidence for a functional frontal dysfunction (test of Stroop) and a partial deficit of explicit memory (free recall and long-term recall). The performance of the 7 ACoa amnesics revealed evidence for a functional frontal dysfunction and a deficit of explicit memory (safe in recognition). Anosognosia was also observed. The performance of all patients revealed the preservation of implicit memory in procedural tasks (serial reaction time and mirror reading) as diencephalic and temporal amnesia. The functionnal nature of the syndrome is discussed.

[Complications of lumboperitoneal shunts. A retrospective study of a series of 195 patients (214 procedures)]. / Complications des dérivations lombo-péritonéales. Etude rétrospective d'une série de 195 patients (214 interventions).

BACKGROUND AND PURPOSE: We report our experience with the lumboperitoneal shunt (LPS) in 195 patients. The aim of this retrospective study was to assess and compare the rate of complications and to discuss 4 indications. MATERIAL AND METHOD: Between January 1983 and July 1994, 195 patients including 14 pediatric cases were treated with a LPS. Sex ratio was 1.24. The mean age at insertion was 59.5 years (from 6 months to 88 years) and the follow-up in this series was from 6 months to 12.5 years. The indications for a LPS were: chronic idiopathic hydrocephalus (115 cases), post-hemorrhagic hydrocephalus (37 cases), cerebrospinal fluid fistula (11 cases), post-traumatic hydrocephalus (9 cases), post-surgical hydrocephalus (8 cases), hydrocephalus of the child (6 cases), post-meningitis hydrocephalus (4 cases), benign intracranial hypertension (4 cases), post-radiotherapy hydrocephalus (1). Forty patients (20.5%) presented with at least one complication. A total of 47 complications were observed: chronic subdural effusion (8 cases), meningitis (10 cases), mechanical failures (28 cases), acquired Chiari abnormality (1 case). Mechanical complications varied with the type of shunt. CONCLUSION: Complications of LPS in adults are less frequent than is usually reported after ventricular atrial or peritoneal shunting. In adults, LPS can be used as the first valuable treatment in case of chronic communicating hydrocephalus. LPS is also valuable in the treatment of benign intracranial hypertension or recurrent CSF fistulae. Conversely, in the pediatric cases general and specific complications are frequent, so an indication for LPS must be strictly discussed.

[Anterior and anterolateral surgery of the lower cervical spine (25 years after H. Verbiest). I: Technical bases]. / Chirurgie antérieure et antéro-latérale du rachis cervical inférieur. (Vingt-cinq ans après H. Verbiest). Première partie: les bases techniques.

The anterior approach to the cervical spine is currently a worldwide traditional surgical technique used by neurosurgeons or orthopedists in the treatment of traumatic, degenerative or tumoral cervical spinal lesions. Many original rules of these techniques were raised by pioneers as R. Cloward and H. Verbiest, and are still valid. Advances in the surgical armentarium and in bio-materials markedly improved the original technique and subsequently improved the clinical results. The present course was organized for the neurosurgery trainees by the French Speaking Neurosurgical Society, and was helded during the winter meeting in December 1995. The aim of this course is to recall the basic technical principles of the microsurgical anterior cervical approach, and to discuss the main indications of this surgical treatment. Many theoretical points are strengthened by the author's personal experience and comments. Part I presents the different anterior or antero-lateral approaches which any surgeon involved in cervical spine surgery actually needs to know. Secondly, the materials and technical basis needed to achieve an interbody graft or fusion or fixation are described. Lastly, some practical applications are detailed as a microdiscectomy, a medial or lateral cervical spine decompression, and the use of acrylic plastic or prothesis for a cervical vertebral replacement.

[Anterior and antero-lateral surgery of the lower cervical spine (25 years after H. Verbiest). 2: Indications, results, complications)]. / Chirurgie antérieure et antéro-latérale du rachis cervical inférieur. (Vingt-cinq ans après H. Verbiest).Deuxième partie: Indicaions, rèsultats, complications.

The present course on the anterior and antero-lateral surgical approach of the lower cervical spine was organized for the neurosurgery trainees by the French Speaking Neurosurgical Society, and was held during the winter meeting in December 1995. The aim of this course was to recall the basic technical principles of the microsurgical anterior cervical approach, and to discuss the main indications of this surgical treatment. Many theoretical points were strengthened by the author's personal experience and comments. In Part I, the technical bases of the different anterior or antero-lateral approaches were presented (1996, 42 : 105-122). In the present Part II, the main indications of the anterior surgical approach to the cervical disk or the vertebral body are detailed, and the requirement of a bone graft and/or an osteosynthesis are discussed with their consequences on the final results. Secondly, variants of the surgical technics in use in case of cervical spinal instability are commented. Then various approaches to the cervical spinal tumors and to the vertebral artery are detailed and commented. Lastly, general and specific complications of the anterior cervical approach are listed with their rate of occurrence, and their prevention and management are discussed.

Cervical root compression by a loop of the vertebral artery: case report.

A case of an abnormal loop of the extracranial vertebral artery enlarging the intervertebral foramen at C5-C6 and the transverse foramen at C5 is reported. This occurrence is rare and was associated with cervicobrachial neuralgia caused by neurovascular compression of the C6 root. The patient was cured by microvascular decompression.

[Anterior osteosynthesis of the cervical spine by phusiline bioresorbable screws and plates. Initial results apropos of 5 cases]. / Ostéosynthèse antérieure du rachis cervical par vis et plaques biorésorbables en Phusilines. Résultats préliminaires à propos de cinq cas.

The authors have designed a biocompatible and bioresorbable plate (1) in Phusilines* for anterior cervical interbody stabilization. Phusilines* are polymer of alpha hydroxyacid (poly lactic acid), and their in vivo degradation (in lactic acid and via the Krebs circle, in water and carbon dioxide), is complete within 18 months. Screws are available in the same material. Phusilines* are radiotransparent and do not interfere with MRI. The size and shape of the plate have been determined with three dimensional computed tomography, their thickness and their molecular weight and chemical structure have been determined to obtain the best compromise in mechanical properties and time of resorption. Biomechanical studies have been performed in cadaver, and have showed a good quality of the osteosynthesis. Five patients with anterior cervical disco-ligamental instability were operated on according the french law of bioethic (Huriet Law). In these five cases the operation was performed via antero lateral approach, and it consisted in a interbody xenograft with Surgibone (2) and interbody osteosynthesis with a plate and four screws of 16 mm of length and 4 mm of diameter. Clinical and radiological examinations were realised during 18 months. In all cases, clinical results in rachialgia and neurological signs were excellent, in four case the tolerance was excellent, in a case inflammatory phenomens were observed the 8th and the 14th month successfully treated with non steroid anti-inflammatories. Anatomical results were excellent in two cases, good in two cases and incomplete in one case. Reasons of these incomplete results are discussed. These preliminary results are sufficient to continue these implantations.

[Post-traumatic syringomyelobulbia and inferior vertical nystagmus]. / Syringomyélobulbie post-traumatique et nystagmus vertical inférieur.

A case of post-traumatic cervico-thoracic syringomyelia was complicated, 3 years after the injury, by a bulbar extension manifested by a downbeat vertical nystagmus which became a source of disabling oscillopsia. The syringobulbia was visualized at MRI. The usefulness of syringostomy in such a case is discussed.

[Anterior sacral meningocele with urologic manifestations. Report of 3 cases]. / Méningocèle sacrée antérieure à expression urologique. A propos de 3 observations.

Anterior sacral meningocele is defined as a spinal fluid-filled thecal sac in the pelvis communicating with the spinal subarachnoid space through a defect in the anterior sacral wall. Since scimitar shape of the sacrum is characteristic, diagnosis is easily confirmed by echography and myelography. The sac very often contains benign tumors and a thickened filum terminale which can achieve a tethered cord syndrome. This congenital malformation, whose autosomal inherited condition has been proposed, has usually few characteristic symptoms but can present itself as a neurogenic bladder from tethered cord origin. Neurosurgical treatment can prevent rupture of the meningocele with meningitis. In addition to symptomatic treatment of the neurogenic bladder, the urologist must advise neurosurgical operation to preserve potency and cure specific bladder dysfunction secondary to tethered cord syndrome.