Results of a French pilot database of standard of care of chronic subdural hematoma.

BACKGROUND: A registry of chronic subdural hematoma does not exist in France yet. OBJECTIVE: To present a monocentric pilot project of a French registry of surgical management of chronic subdural hematoma. METHOD: A monocentric pseudonymized formal database was created. From May 2020 to May 2021, all patients undergoing surgical evacuation of chronic subdural hematoma were entered into the database. RESULTS: One hundred and twenty four surgeries from 113 patients were entered in the database. Patients' demographic and surgical data as well as follow-up are described. CONCLUSION: A local database is easy to implement. We propose a national registry of chronic subdural hematoma management.

Security and reliability of CUSTOMBONE cranioplasties: A prospective multicentric study.

BACKGROUND: Repairing bone defects generated by craniectomy is a major therapeutic challenge in terms of bone consolidation as well as functional and cognitive recovery. Furthermore, these surgical procedures are often grafted with complications such as infections, breaches, displacements and rejections leading to failure and thus explantation of the prosthesis. OBJECTIVE: To evaluate cumulative explantation and infection rates following the implantation of a tailored cranioplasty CUSTOMBONE prosthesis made of porous hydroxyapatite. One hundred and ten consecutive patients requiring cranial reconstruction for a bone defect were prospectively included in a multicenter study constituted of 21 centres between December 2012 and July 2014. Follow-up lasted 2 years. RESULTS: Mean age of patients included in the study was 42±15 years old (y.o), composed mainly by men (57.27%). Explantations of the CUSTOMBONE prosthesis were performed in 13/110 (11.8%) patients, significantly due to infections: 9/13 (69.2%) (p<0.0001), with 2 (15.4%) implant fracture, 1 (7.7%) skin defect and 1 (7.7%) following the mobilization of the implant. Cumulative explantation rates were successively 4.6% (SD 2.0), 7.4% (SD 2.5), 9.4% (SD 2.8) and 11.8% (SD 2.9%) at 2, 6, 12 and 24 months. Infections were identified in 16/110 (14.5%): 8/16 (50%) superficial and 8/16 (50%) deep. None of the following elements, whether demographic characteristics, indications, size, location of the implant, redo surgery, co-morbidities or medical history, were statistically identified as risk factors for prosthesis explantation or infection. CONCLUSION: Our study provides relevant clinical evidence on the performance and safety of CUSTOMBONE prosthesis in cranial procedures. Complications that are difficulty incompressible mainly occur during the first 6 months, but can appear at a later stage (>1 year). Thus assiduous, regular and long-term surveillances are necessary.

Impact of malpractice liability among spine surgeons: A national survey of French private neurosurgeons.

PURPOSE: In the general context of medical judicialization, spine surgeons are impacted by the part that medical responsibility and the risk of malpractice play in their actions and decisions. Our aim was to evaluate possible shifts in practices among private neurosurgeons who are highly exposed to this judicial risk and detect alterations in their pleasure in exercising their profession. We present the first national survey on French physicians' perception of surgical judicialization and consequences on their practice. METHODS: An online survey was submitted to the 121 members of the French Society of Private Neurosurgery, who represent 29.1% of the total number of spine surgeons and perform 36.0% of the national total spine surgery activity. The French law (no-fault out-of-court scheme) significantly impacts these surgeons in the event of litigation. RESULTS: A total of 78 surveys were completed (64.5% response rate): 89.7% of respondents experienced alteration of doctor-patient relationship related to judicialization and 60.2% had already refused to perform risky surgeries. Fear of being sued added negative pressure during surgery for 55.1% of respondents and 37.2% of them had already considered stopping their practice because of this litigation context. CONCLUSION: The increasing impact of medical liability is prompting practitioners to change their practice and perceptions. The doctor-patient relationship appears to be altered, negative pressure is placed on physicians and defensively, some neurosurgeons may refuse high-risk patients and procedures. This situation causes professional disenchantment and can ultimately prove disadvantageous for both doctors and patients.

Spinal cord injury associated with cervical spinal canal stenosis: Outcomes and prognostic factors.

OBJECTIVES: To specify outcomes and identify prognostic factors of neurologic and functional recovery in patients with an acute traumatic spinal cord injury (SCI) associated with cervical spinal canal stenosis (SCS), without spinal instability. METHODS: A retrospective study was conducted using data from a Regional Department for SCI rehabilitation in France. A description of the population characteristics, clinical data and neurological and functional outcomes of all patients treated for acute SCI due to cervical trauma associated with SCS was performed. A statistical analysis provided insights into the prognostic factors associated with the outcomes. RESULTS: Sixty-three patients (mean age 60.1 years) were hospitalized for traumatic SCI with SCS and without instability between January 2000 and December 2012. Falls were the most frequent cause of trauma (77.8%). At admission, most patients had an American Spinal Injury Association Impairment Scale (AIS) grade of C (43.3%) or D (41.7%) and the most frequent neurological levels of injury were C4 (35.7%) and C5 (28.6%). Clinical syndromes were frequently identified (78.6%), with the most frequent being the Brown-Sequard plus syndrome (BSPS) (30.9%), followed by central cord syndrome (CCS, 23.8%). Almost 80% of survivors returned to the community, 60% were able to walk and 75% recovered complete voluntary control of bladder function. Identified prognostic factors of favourable functional outcomes were higher AIS at admission, age under 60 years and presence of BSPS or CCS. CONCLUSION: Traumatic SCI, associated with SCS results mostly in incomplete injuries, can cause various syndromes and is associated with favourable functional outcomes.

Managing spine surgery referrals: The consultation of neurosurgery and its nuances.

INTRODUCTION: Spinal disorders, particularly low back pain, are among the most common reasons for general practitioner (GP) consultation and can sometimes be a source of professional friction. Despite their frequency and published guidelines, many patients are still mistakenly referred by their GP to specialists for spinal surgery consultation which can create colleague relationship problems, suboptimal or unnessary delayed care, as well as the financial implications for patients. PURPOSE: To assess the management of GP lumbar spine referrals made to 4 neurosurgeons from 3 neurosurgical teams specialized in spinal surgery. METHODS: All patient's medical records relating to 672 primary consultants over a period of two months (January and February 2015) at three institutions were retrospectively reviewed. Medical referral letters, clinical evidence and imaging data were analyzed and the patients were classified according the accuracy of surgical assessment. The final decisions of the surgeons were also considered. RESULTS: Of the 672 patients analyzed, 198 (29.5%) were considered unsuitable for surgical assessment: no spinal pathology=10.6%, no surgical conditions=35.4%, suboptimal medical treatment=31.3%, suboptimal radiology=18.2% and asymptomatic patients=4.5%. CONCLUSION: Unnecessary referrals to our consultation centers highlight the gap between the reason for the consultation and the indications for spinal surgery. Compliance with the guidelines, the creation of effective multidisciplinary teams, as well as the "hands on" involvement of surgeons in primary and continuing education of physicians are the best basis for a reduction in inappropriate referrals and effective patient care management.

Neurotomy of the rectus femoris nerve: Short-term effectiveness for spastic stiff knee gait: Clinical assessment and quantitative gait analysis.

BACKGROUND: Stiff knee gait is a troublesome gait disturbance related to spastic paresis, frequently associated with overactivity of the rectus femoris muscle in the swing phase of gait. OBJECTIVE: The aim of this study was to assess the short-term effects of rectus femoris neurotomy for the treatment of spastic stiff-knee gait in patients with hemiparesis. PATIENTS AND METHODS: An Intervention study (before-after trial) with an observational design was carried out in a university hospital. Seven ambulatory patients with hemiparesis of spinal or cerebral origin and spastic stiff-knee gait, which had previously been improved by botulinum toxin injections, were proposed a selective neurotomy of the rectus femoris muscle. A functional evaluation (Functional Ambulation Classification and maximal walking distance), clinical evaluation (spasticity - Ashworth scale and Duncan-Ely test, muscle strength - Medical Research Council scale), and quantitative gait analysis (spatiotemporal parameters, stiff knee gait-related kinematic and kinetic parameters, and dynamic electromyography of rectus femoris) were performed as outcome measures, before and 3 months after rectus femoris neurotomy. RESULTS: Compared with preoperative values, there was a significant increase in maximal walking distance, gait speed, and stride length at 3 months. All kinematic parameters improved, and the average early swing phase knee extension moment decreased. The duration of the rectus femoris burst decreased post-op. CONCLUSION: This study is the first to show that rectus femoris neurotomy helps to normalise muscle activity during gait, and results in improvements in kinetic, kinematic, and functional parameters in patients with spastic stiff knee gait.

[Vascular relationships of the right great splanchnic nerve in the thorax]. / Rapports vasculaires thoraciques du nerf grand splanchnique droit.

AIM: The surgical assumption of responsibility of the pancreatic pain requires either a truncular coelioscopic or radicular neurectomy of greater splanchnic nerves (gsn). The goal of our work is to describe the way and relations of the right gsn which are variable and rarely described. This constitutes an undeniable peroperational hemorrhagic risk during splanchnicectomy. MATERIAL AND METHODS: After a double side thoracotomy and a bilateral sterno-clavicular desarticulation on 15 adult cadaveric subjects preserved by method of Winckler we removed the sterno-costal drill plate as well as the ventral rib arch and proceeded to a mediastinal evisceration of the thorax. Then we respected only the thoracic aorta and the oesophagus, the azygos venous system, the thoracic duct and the thoracic sympathetic chain. In some of the subjects, the azygos vein was injected (after catheterization of its stick) using gelatine coloured with blue paint. We studied the way and vascular relations of the right gsn. We measured the transverse distances between the origin of the gsn on one hand and the longitudinal axes of the azygos vein and the thoracic duct on the other hand. RESULTS: The relations of the right gsn trunk during its way related to the azygos vein in particular its constitutive origin and its affluents: ascending lumbar vein and twelfth intercostal vein. Sometimes the thoracic duct even a lymphatic node was near the gsn in the posterior infra-mediastinal space. A classification of the way and vascular relations of the right gsn in the thorax identified 3 anatomical types. The average distances separating the right gsn on one hand from the azygos vein and the thoracic duct on the other hand were respectively 5.7 mm and 11.2 mm. CONCLUSION: The vascular relations of the right gsn are very variable from one subject to another but primarily venous, sometimes lymphatic. They concerned the great thoracic vessels whose respect is essential in particular at the time of mini-invasive access procedure for a cœlioscopic splanchnicectomy.

[New recommendations for the management of children after minor head trauma]. / Actualisation des recommandations pour la prise en charge du traumatisme crânien léger chez l'enfant.

Minor head trauma is a common cause for pediatric emergency department visits. In 2009, the Pediatric Emergency Care Applied Research Network (PECARN) published a clinical prediction rule for identifying children at very low risk of clinically important traumatic brain injuries (ciTBI) and for reducing CT use because of malignancy induced by ionizing radiation. The prediction rule for ciTBI was derived and validated on 42,412 children in a prospective cohort study. The Société Française de Médecine d'Urgence (French Emergency Medicine Society) and the Groupe Francophone de Réanimation et Urgences Pédiatriques (French-Language Pediatric Emergency Care Group) recommend this algorithm for the management of children after minor head trauma. Based on clinical variables (history, symptoms, and physical examination findings), the algorithm assists in medical decision-making: CT scan, hospitalization for observation or discharge, according to three levels of ciTBI risk (high, intermediate, or low risk). The prediction rule sensitivity for children younger than 2 years is 100 % [86.3-100] and for those aged 2 years and older it is 96.8 % [89-99.6]. Our aim is to present these new recommendations for the management of children after minor head trauma.

[Occipitalization of the atlas. Radiological diagnosis and clinical significance]. / Occipitalisation de l'atlas. Diagnostic radiologique et implication clinique.

INTRODUCTION: Occipitalization of the atlas is the most common malformation of the craniovertebral junction. It can be diagnosed on lateral teleradiography and its finding imposes screening for associated atlantoaxial instability. In case of instability, brisk movements of the cervical spine during surgery may result in compression and distortion of the spinal chord and vertebro-basilar vascular system. OBSERVATION: An 18 year-old female patient was referred to our department for facial dysmorphosis and extraction of the third molars. A lateral teleradiography revealed an occipitalization of the atlas and the fusion of the second and third cervical vertebral body. Further pre-operative investigations allowed ruling out any joint instability or associated craniovertebral junction malformations. DISCUSSION: Occipitalization of the atlas is not usually well-known by maxillofacial surgeons. It may be diagnosed with a lateral teleradiography. Its diagnosis imposes screening for other spinal malformations (spinal fusion, hemivertebra, spina bifida occulta). The major risk is compression and distortion of the spinal chord and vertebro-basilar vascular system, during surgery or anesthesia.

[Post-traumatic syringomyelia: What should know the urologist?]. / Syringomyélie post-traumatique : ce que doit savoir l'urologue ?

The incidence of post-traumatic syringomyelia (PTS) is estimated according to recent studies at 25 to 30% of patients with traumatic spinal cord injuries in magnetic resonance imaging (MRI), which remains the gold standard exam for syringomyelia diagnosis and monitoring. Syringomyelia is translated by an increased cord signal (similar to CSF) with low-density T1-weighted image and high-density T2-weighted image, which extends beyond site of initial lesion at least to two vertebral segments. Two conditions are required for development of PTS: traumatic spinal cord injury and blocked the flow of CSF epidural. The mean interval from spinal cord injury to diagnosis SPT was 2.8years (range, 3months to 34years). The commonest symptoms are pain and sensory loss. PTS should be suspected if the patient has new neurological symptoms above level of injury, such as dissociated sensory injuries, reflexes abolition, and motor deficit, after the neural function becomes stable for certain time. In urologic practice, new neurological symptoms could be bladder and/or erectile dysfunction. The medical management based on prevention efforts with closed-glottis pushing, which could aggravate the syrinx cavity. In urology, extracorporeal shockwave lithotripsy, and laparoscopic or robotic surgery could extend the syrinx cavity for the same reason (increase abdominal pressure). The indications for surgical intervention and optimal surgical treatment technique for patients with PTS are not consensual. The literature demonstrated that surgery PTS is effective at arresting or improving motor deterioration, but not sensory dysfunction or pain syndromes.

Perilesional myeloradiculopathy with tethered cord in post-traumatic spinal cord injury.

STUDY DESIGN: A retrospective series of cases. OBJECTIVE: To identify, among post-traumatic myelopathies, a specific entity in which clinical and radiological features are not extensive but are strictly limited to the perilesional zone. SETTING: The data set of the Regional Spinal Cord Injury Department of Nantes, France. METHODS: A systematic analysis of all traumatic spinal cord injury (SCI) patients who presented with a neurological aggravation delayed from initial injury, without syringomyelia or extensive myelomalacia. RESULTS: Twelve patients presenting with this type of complication were identified (that is, four tetraplegics and eight paraplegics). The neurological worsening consisted in weakness of the muscles close to the motor level in five patients, and in isolated at-level neuropathic pain in seven patients. A tethered cord was evidenced by the magnetic resonance imaging (MRI) results in all of the patients. Roots were involved by the tethering on the MRI results in eight cases. Surgery, with untethering and expansile duraplasty, was performed in all cases. Surgery allowed motor recovery in patients who presented with a motor loss (motor score gain range=1-7 points; median=3) and decreased pain in all pain patients (decrease on the 10-point numerical rating scale: range=1-6 points; median=4). CONCLUSIONS: In traumatic SCI patients, a tethered cord could be responsible for clinical and radiological changes, which are strictly localised to the perilesional area. The term perilesional myeloradiculopathy is proposed for this complication, which requires cord release surgery.

[Familial colloid cyst of the third ventricle: case report and review of the literature]. / Kystes colloïdes familiaux du troisième ventricule : cas clinique et revue de la littérature.

Colloid cysts of the third ventricle are rare benign lesions. We report here an exceptional familial case defined by the evidence of two colloid cysts in two relatives of the first degree, a mother and her daughter in our description. Only 15 cases are reported in the literature. The main differences compared with sporadic cases are an earlier age of discovery and a female predominance. In case of familial colloid cyst, we have to recover a brain MRI screening of all the relatives of the first degree.

Arterial supply to the tibial tuberosity: involvement in patellar ligament transfer in children.

PURPOSE: The aims were to study arterial blood supply of the tibial tuberosity, and to evaluate its remaining blood supply after patellar ligament transposition in children. METHODS: The anatomic study was carried out on 15 lower limbs after latex injection, and on two fetuses after diaphanization. RESULTS: Tibial tuberosity was vascularized by an arterial network mainly supplied by anterior tibial recurrent artery. Other arteries from the popliteal artery or its branches were also involved in the tibial tuberosity blood supply. CONCLUSIONS: Our findings confirm the safety of transposition of patellar ligament in children due to dense arterial network supplying tibial tuberosity.

Anatomical basis of digital rectal examination.

PURPOSE: Rectal examination is difficult to carry out by students because of their lack of knowledge and fear. It is therefore necessary to search for methods in order to facilitate its practice. This work mainly focuses on the palpation of the posterior lateral area of the rectum. METHODS: This work bases itself on the study of the average length of indexes and on the anatomical study of the dissection and prints of two pelvises. In the lithotomy position, we can identify three successive levels of exploration of the posterior and lateral area of the rectum. These three levels are defined by the extremity of the index, and the distal and proximal interphalangeal articulations placed successively on the tip of the coccyx. A 180° rotation of the hand enables at each level to identify the parietal structures that the pad of the index comes across, but excludes the palpation of genital organs and rectum. RESULTS: The first level corresponds to the higher part of the anal canal, the ischioanal fossa and the ischium. The second level corresponds to the levator ani muscle, the ischioanal fossa and the pudendal canal. The third level corresponds to the sacrospinous ligament, the ischiatic spine and the internal obturator muscle. CONCLUSIONS: In spite of the significant differences between the lengths of the indexes, the use of these landmarks will facilitate the identification of parietal anatomical structures. The internal organs' palpation will depend on the patient's position, his efforts in pushing, the length of the index, and the way the examiner presses on the perineum.

[Pudendal nerve surgery in the management of chronic pelvic and perineal pain]. / La chirurgie du nerf pudendal dans la prise en charge thérapeutique des douleurs pelvipérinéales chroniques.

OBJECTIVE: To define the place of pudendal nerve surgery in pudendal nerve entrapment syndromes. MATERIALS AND METHODS: Description of the various surgical techniques and published results. RESULTS: The original surgical technique, which remains the reference technique, consists of performing surgical release of the pudendal nerve from the infrapiriformis foramen to Alcock's canal via a transgluteal approach. This surgical procedure is safe and gives encouraging results validated by a prospective, randomized protocol: 66 to 80% of patients are improved. Other transvaginal or transperineal approaches have also been proposed. CONCLUSION: Pudendal nerve surgery is a reasonable treatment option when all other treatments have failed. However, the various techniques proposed and their respective criticisms must be carefully evaluated.

Chronic neuropathic pain in spinal cord injured patients: what is the effectiveness of surgical treatments excluding central neurostimulations?

OBJECTIVES: Analyzing the literature and elaborating recommendations on the following topics: relevance of dorsal root entry zone (DREZ) lesions, surgical treatment for posttraumatic syringomyelia, other therapeutic approaches (peripheral nerve root pain, nerve trunk pain and Sign Posterior Cord [SCI] pain). MATERIAL AND METHODS: The methodology used, proposed by the French Society of Physical Medicine and Rehabilitation (SOFMER), includes a systematic review of the literature, the gathering of information regarding current clinical practices and a validation by a multidisciplinary panel of experts. RESULTS: Ninety-two articles were selected, 10 with a level of evidence at 2, 82 with a level of evidence at 4. Some articles lacked information on the type of injury, the pain characteristics and the symptoms' evolution over time. DREZ: This type of procedure has been validated for its effectiveness on pain at the level of injury (transitional zone pain), but is inefficient for pain located below the level of injury. Posttraumatic syringomyelia (PTS): suspected when there is an increased neurological impairment, changes below the level of injury (mainly bladder dysfunctions) or a sudden onset of pain. The surgery associates arachnoid grafting, cyst drainage, expansile dural plasty (same treatment for posttraumatic tethered spinal cord and posttraumatic myelomalacia). PERIPHERAL NERVE ROOT, NERVE TRUNK OR TRANSITIONAL ZONE PAIN: Surgical implants (screws or clips) can generate radicular pain caused by inflammation and they can even move around with time. The material-induced constraints can also trigger pain. Surgical removal of osteosynthesis material (with an eventual saddle block) remains a simple procedure yielding good results. Correcting surgeries can also be performed (malunion and nonunion). Finally, compressive neuropathies (carpal tunnel syndrome, ulnar nerve entrapment) already have a well-defined treatment. CONCLUSION: The literature review can define the relevance of surgical treatments on some types of SCI pain. However, the results of many articles are difficult to analyze, as they do not report clinical or follow-up data.

[The pudendal nerve: clinical and therapeutic morphogenesis, anatomy, and physiopathology]. / Le nerf pudendal: morphogenèse, anatomie, physiopathologie, clinique et thérapeutique.

The pudendal is the king of the perineum. Most often originating in the S3 root, it is responsible for the teguments of the perineum (glans penis, clitoris, scrotum, and the labia majora, the skin of the central fibrous perineal body, anus), but also the erector muscles and the striated sphincters. The social nerve, it controls erection and the voluntary sphincters. It is also the nerve of the beginnings of sexual sensation and masturbation. Its injury is expressed in perineal pain, which, when positional, suggests a tunnel syndrome. The compression points have become well known: ligament pinching between the sacrotuberous and sacrospinous ligaments, the falciform process and the pudendal canal (Alcock canal). The data from questioning the patient, the results of the neurological exam, and the at least momentary response to infiltration define the Nantes criteria, which confirm the diagnosis. Treatment is medical, physical therapy, infiltration, and, as a last resort, surgery. The results have improved because of new technical norms, with 75% of operated patients benefiting from surgery. This disorder has become well known and should be remembered, thus sparing the patient from years of suffering and needless consultations for patients who do not present with organ disease, too often implicated instead of a true canal neuropathy, whose clinical manifestation and treatment have now been validated.

[Somatic perineal pain other than pudendal neuralgia]. / Les douleurs périnéales somatiques autres que les névralgies pudendales.

In addition to the well-established syndrome of pudendal compression, and given the rich nerve trunk innervation of the perineum, pain originating in other nerve trunks can occur and must be remembered. Nerves originating high in the thoracolumbar area (ilioinguinal nerve, iliohypogastric nerve, genitor femoral nerve) can be the seat of traumatic lesions occurring during surgical approaches through the abdominal wall or can undergo compressions when crossing the fascia of the large abdominal muscles. Misleading perineal irradiations do not resemble pudendal neuralgia and should suggest pain in these trunks whose cutaneous territories are not solely perineal and whose clinical expression as pain is does not occur in the seated position. Similarly, painful minor intervertebral dysfunction of the thoracolumbar junction is not simply in the mind and should be considered, searched for, and treated. Related more to pudendal neuralgia, pain in the inferior cluneal nerve, triggered by the seated position, should be considered when the pain reaches the lateral anal region, the scrotum, or the labia majora but not involving the glans penis or the clitoris. Specific treatments (physical therapy, infiltrations, surgery) have proven effective.