Through the orbit and beyond: Current state and future perspectives in endoscopic orbital surgery on behalf of the EANS frontiers committee in orbital tumors and the EANS skull base section.

Introduction: Orbital surgery has always been disputed among specialists, mainly neurosurgeons, otorhinolaryngologists, maxillofacial surgeons and ophthalmologists. The orbit is a borderland between intra- and extracranial compartments; Krönlein's lateral orbitotomy and the orbitozygomatic infratemporal approach are the historical milestones of modern orbital-cranial surgery. Research question: Since its first implementation, endoscopy has significantly impacted neurosurgery, changing perspectives and approaches to the skull base. Since its first application in 2009, transorbital endoscopic surgery opened the way for new surgical scenario, previously feasible only with extensive tissue dissection. Material and methods: A PRISMA based literature search was performed to select the most relevant papers on the topic. Results: Here, we provide a narrative review on the current state and future trends in endoscopic orbital surgery. Discussion and conclusion: This manuscript is a joint effort of the EANS frontiers committee in orbital tumors and the EANS skull base section.

Prognostic factors for progression-free survival of the filum terminale ependymomas in adults.

OBJECTIVE: To define the prognostic factors for progression and to determine the impact of the histological grading (according to the World Health Organization) on the progression-free survival (PFS) of filum terminale ependymomas. METHODS: A retrospective chart review of 38 patients with ependymoma of the filum terminale was performed, focusing on demographic data, preoperative symptoms, tumor size, quality of resection, presence of a tumor capsule, and histological grade. RESULTS: Gross total resection (GTR) was achieved in 30 patients (78.9%). Histopathological analysis found 21 (55.3%) myxopapillary grade I ependymoma (MPE), 16 (42.1%) ependymoma grade II (EGII), and 1 (2.6%) ependymoma grade III. There was no significant difference between the mean±SD volume of MPE (5840.5±5244.2mm3) and the one of EGII (7220.3±6305.9mm3, p=0.5). The mean±SD follow-up was 54.1±38.4 months. At last follow-up, 30 (78.9%) patients were free of progression. In multivariate analysis, subtotal resection (p=0.015) and infiltrative tumor (p=0.03) were significantly associated with progression. The PFS was significantly higher in patients with encapsulated tumor than in patients with infiltrative tumor (log-rank p=0.01) and in patients who had a GTR in comparison with those who had an incomplete resection (log-rank p=0.05). There was no difference in PFS between patient with MPE and EGII (p=0.1). CONCLUSION: The progression of ependymoma of the filum terminale highly depends on the quality of resection, and whether the tumor is encapsulated. Except for anaplastic grade, histopathological type does not influence progression.

CSF Lumbar Drainage: A Safe Surgical Option in Refractory Intracranial Hypertension Associated with Acute Posttraumatic External Hydrocephalus.

INTRODUCTION: External lumbar drainage (ELD) of cerebrospinal fluid (CSF) in posttraumatic refractory intracranial hypertension (ICHT) is controversial. We report our experience of ELD in ICHT associated with acute disturbance of CSF flow within subarachnoid spaces (SASs). MATERIALS AND METHODS: Four adult patients admitted to the neurointensive care unit for severe TBI who presented with secondary ICHT are retrospectively reported. When refractory to second-tier therapy, if external ventricular drainage were not possible or failed, and in the absence of an indication for craniotomy to treat a mass lesion or decompressive craniectomy, we assessed the evolution of CSF volume within cranial SAS and checked the presence of basal cisterns and the absence of tonsillar herniation to evaluate interest in and the safety of ELD. RESULTS: As second-tier therapy failed to lower intracranial pressure (ICP; mean ICP 37 ± 5 mmHg), and computed tomography (CT) showed abnormally enlarged cranial SAS following traumatic subarachnoid hemorrhage, patients received ELD. ICP decreased, with immediate and long-term effect (mean ICP 5 mmHg ± 2 mmHg). There were no complications to report. DISCUSSION: Acute traumatic external hydrocephalus may explain some of the specific situations of secondary increased ICP, with a "normal" CT scan, that is refractory to medical treatment. In these situations, lumbar drainage should be considered to be a safe, minimally invasive, and effective surgical option.

Intracranial Hypertension Is Painless!

INTRODUCTION: Headache is usually considered a key symptom of intracranial hypertension (ICHT). However, there are no published experimental data to support the concept that increased intracranial pressure (ICP) is painful in humans. MATERIALS AND METHODS: This prospective study was performed in 16 patients with suspected normal-pressure hydrocephalus, necessitating a lumbar infusion test with measurement of cerebrospinal fluid (CSF) hydrodynamics. During the test, ICP was increased from baseline to a plateau. Headache was scored on a visual analog scale (VAS) (0 = no pain, 10 = very severe pain) at baseline ICP and when ICP plateaued. RESULTS: At baseline, mean ICP was 11 ± 3.6 mmHg and VAS was 0. At plateau, mean ICP was 28 ± 9.5 mmHg and VAS was 0. There was a significant increase in ICP (p <0.001), but no increase in headache intensity (VAS). An acute (20-min) moderate increase in ICP was not accompanied by a headache. DISCUSSION: We demonstrate that an acute, isolated increase in CSF pressure does not produce a headache. To occur, a headache needs activation of the pain-sensitive structures (dura and venous sinuses) or central activation of the cerebral nociceptive structures. This peripheral or central activation does not occur with an isolated increase in CSF pressure.

[Young French neurosurgeons: Working conditions and outlook]. / Jeunes neurochirurgiens français: conditions de travail et perspectives.

INTRODUCTION: Due to the increase in the number of French neurosurgeon residents the neurosurgical workforce is changing. The main objective of this survey was to assess working conditions and perspectives for young French neurosurgeons. METHOD: An on-line survey was sent to young French neurosurgeons based on a mailing-list (219 mail addresses of Residents and Fellows obtained during previous meetings). The form contained questions about career, amount of work, salary, quality of life, teaching and university work. RESULTS: We received 78 replies from January to March 2014. A total of 56% from fellows saying they had undergone difficulties in obtaining a fellowship, although 78% were satisfied. Fellows considered a private career more often than residents. Overall, young neurosurgeons were worried about future employment. Some 33% admitted contemplating a different career from one they originally wanted. The average weekly working time of 76.8 hours was deemed to be excessive. Security rests after overnight shifts were lacking or incomplete in 91% of cases. The work atmosphere was good overall (3.7/5), and so was the quality of life (3.2/5). Theoretical teaching was unsatisfactory (2.43/5) as well as the time allowed for academic work (approximately 1.58 half-days per month). However, practical teaching was considered rewarding (3.63/5). CONCLUSION: This study provides some guidance for upcoming reforms, and should be considered again at a later date to evaluate progress.