NOAC and intracerebral bleeding--presentation of four cases and review of the literature.

AF might be a life threatening disease. Patients have been under oral antithrombotic treatment in order to avoid thrombotic events. Although this treatment proved to be effective in the last decades there was always the inconvenience of a regular blood control. In the last months NOACs have been flooding the market promising to be as effective as their older concurrents in certain circumstances and highlighting the fact that the control of INR has become obsolete. However, as there is no specific antidote up to date, NOACs might present a life threatening event in case of an intracerebral haemorrhage. The brain surgeons might find themselves in a difficult situation when they have to decide whether to operate on a patient with a compromised haemostasis or not. We present four patients who were treated with NOACs for AF. Three of them were admitted with intracerebral haemorrhage in our neurosurgical unit from January to October 2013. The fourth patient bled one week after stopping his treatment with NOAC. Furthermore we take a closer look to the existing literature and try to portray the issue from a neurosurgical point of view.

[Surgical management of cervical radiculopathy in Forestier's disease. Case report and review]. / Radiculopathie cervicale au cours de la maladie de forestier: traitement chirurgical. A propos d'un cas et revue de la littérature.

Forestier's disease now called DISH (diffuse idiopathic skeletal hyperostosis) is a non inflammatory enthesopathy ossifying the anterolateral spine and sparing the disc and joint space in elderly men, mostly at thoracic levels. Radiology performed for minor trauma or to explore a stiff neck provides the diagnosis. The main differential diagnosis is ankylosing spondylitis presenting an inflammatory profile as well as previously existing alterations of the sacroiliac joint. Retinoic acid treatment or ossification of the posterior longitudinal ligament should also be discussed. Dysphagia is the most frequent symptom, but neurological signs are rarely observed. We report a case observed at the cervical level. Anterior decompression and cage-fusion was indicated. Ongoing hyperostosis was also documented. Surgery in DISH is mainly indicated for dysphagia and rarely after cervical trauma. Of note are associated lesions such as OPLL (ossification of the posterior longitudinal ligament) or synovial cysts responsible for the exceptional and severe myelopathy presentation. The neurosurgical community should become better aware of Forestier's disease.

Cervical cage fusion with 5 different implants: 250 cases.

BACKGROUND: Anterior decompression with interbody fusion is the surgical procedure of choice in cervical spondylosis. Graft harvesting complications occurring from classical fusion procedures favoured ongoing development of cage technology. To evaluate efficiency of cage fusion for surgical treatment of discogenic cervical disorders, this six-year retrospective study analyses 250 consecutive cases treated by interbody cage fusion with 5 different implants. METHODS: Indications for fusion concerned degenerative discopathies, disc herniations and selected cases of failed surgery presenting with radiculopathy (228 cases) or myelopathy (22 cases). Screwed threaded titanium cages (149 cases), impacted squared or anatomically shaped Peek cages (59 cases), and impacted titanium cages (42 cases) were used together with local graft or bone substitute. Additional plating was indicated in 16 unstable cases. FINDINGS: Excellent outcome for neck pain (96%) and radiculopathy (97%) was noted, but a less favourable one for myelopathy (60%). All cases were stabilised at 1 year. Complications leading to reoperation included cage migration and subsidence, adjacent level degeneration and stenotic myelopathy. INTERPRETATION: Cage technology simplified anterior cervical interbody fusion and proved efficient. The fact there was no graft harvesting saved operating time and hospital stay. STATEMENT: It is not the intention of the author to indicate material preference in this article.

Asymptomatic vertebral artery injury after acute cervical spine trauma.

Two recent cases of vertebral artery injury from cervical fracture-dislocation prompted us to review the literature of these wrongly thought uncommon lesions. Extracranial vertebral artery injury during cervical trauma needs to be suspected not only in the case of vertebrobasilar ischemia, but also in asymptomatic patients presenting serious flexion-distraction deformities. Fracture of a transverse foramen or facet joint dislocation should alert the clinician. Magnetic resonance evaluates blood flow and vessel injury, usually unilateral, localized to the traumatized unstable vertebral segment. A four-stage classification is useful to understand and treat vertebral artery injury, also a standardized therapeutic protocol is not documented. Anterior cervical fusion seems indicated to decompress the injured vessel, and to avoid further damage to both vertebral arteries. Unstable spine conditions may also promote clot mobilization at the traumatized vessel leading to vertebrobasilar embolization. The benefit of antithrombotic therapy in reducing neurological morbidity and improving outcome is not yet established and needs long-term follow-up.

[Lumbar interbody fusion with threaded titanium cages. Results on 222 cases]. / La fusion intersomatique lombaire à l'aide de cages vissées en titane. Résultats à propos de 222 cas.

Retrospective analysis of 222 cases of degenerative disc disease treated by threaded cage fusion. The objective was to determine the safety and efficiency of lumbar interbody fusions using screwed titanium cages and autogenous bone. Two hundred twenty-two patients had lumbar fusion at 243 levels between L2 and S1, at one or two disc spaces. Main indication was discogenic back pain with radicular leg radiation in degenerative discopathy complicated by disc protusion, segmental canal stenosis with chronic instability or spondylolysthesis of the first degree. Previous failed surgery after discectomy, nonunion or biologically cured discitis were other indications in selected cases. Results were classified as good to excellent in 80%, 15% improved but remained disabled, 5% had minimal or no improvement. Fusion rate was 91% at one year and 96% at 2 years. Peroperative dural tears occurred in 10 patients and transient neurological deficits in 9. A superficial infection occurred in one patient. Reoperation in the first three months included a cage revision in one patient and a foraminotomy in another. Two osteoporotic women needed an additional posterior fixation for kyphotic deformity. In conclusion, lumbar interbody fusion with threaded titanium cages appears to be efficacious with an acceptable rate of complications. Experience up to 7 years confirms that impression. Long term observation is needed before recommending this new method.

Rationale for interbody fusion with threaded titanium cages at cervical and lumbar levels. Results on 357 cases.

STUDY DESIGN: Retrospective analysis of 357 cases of degenerative disc disease treated by interbody fusion with threaded titanium cages. OBJECTIVE: To determine the safety and efficiency of cervical and lumbar interbody fusions using threaded titanium cages and autogenous bone. SUMMARY OF BACKGROUND DATA: Stabilizing the anterior column by interbody fusion, though reported over 50 years ago, is less commonly done than posterior fusions. The recent development of rigid cages housing autogenous bone simplifies the technique of interbody fusion. This report shows our combined results using this technique. MATERIALS AND METHODS: One hundred thirty-five patients had cervical fusions at 175 levels between C3 and C7. Two hundred twenty-two patients had lumbar fusion at 243 levels between L2 and S1. All surgeries involved one or two disc spaces except for one three level cervical fusion. We implanted all disc spaces with threaded cages containing autogenous bone. RESULTS: In the cervical area, 95% of the radiculopathic patients had a good to excellent result, but only 50% of the myelopathic patients did so. At lumbar level, 80% of the patients were classified as good to excellent, 15% improved but remained disabled, 5% had minimal or no improvement. The cervical fusion rate was 90% at 6 months and 100% at one year. Lumbar fusion rate was 91% at one year and 96% at 2 years. No late breakage or cage displacement occurred. CONCLUSIONS: Cervical and lumbar interbody fusions with threaded titanium cages appear to be efficacious with few complications. Long term follow-up (4 years cervical, 7 years lumbar) confirms that impression.

Anterior interbody fusion with the BAK-cage in cervical spondylosis.

BAK-C is a new autostabilizing interbody cage which is implanted during an anterior cervical procedure to provide stability to the motion segment and allow fusion to occur. Special instrumentation is provided with a bone collecting reamer. The system utilizes surgical site bone graft as the osteo-inductive material within the implant. Biomechanical testing indicates improved stability and animal studies show good fusion. The basic principle is distraction-compression using the tension forces of the annulus fibrosus. Operative material concerns a two years experience with 80 patients (101 levels), 72 with cervical radiculopathy, 8 with myelopathy. Clinical evaluation is assessed on a ten point analogue pain scale for neck and arm/shoulder pain, with neurological examination. Radiological evaluation includes dynamic X-rays, myelo-CT and MRI. Patients are re-evaluated at 1, 6, 12 months postoperatively. Results for neck and radicular pain is excellent, but neurological recovery for radiculopathy and myelopathy is quite different. Radiological results are also good with (except one case) no instability, no cage migration, no kyphosis, no pseudarthrosis. Bone fusion is assessed at 6 and 12 months. Complications are few with proper technique, mainly correct distraction, symmetrical endplate drilling and lateral X-ray control. Only one patient needed an early re-operation with additional miniplate fixation. Immediate stability with good clinical response and no graft morbidity are the advantages of this implant compared to conventional cervical interbody grafting techniques.

Interleukin-4 affects phenotype and proliferative response of peripheral blood lymphocytes from glioblastoma patients after specific or nonspecific in vitro stimulation.

Immunosuppressive events are often observed in glioblastoma-bearing patients. We tested the response of circulating lymphocytes from glioblastoma patients to low concentrations of interleukin (IL)-4 and IL-2 after lectin activation or specific in vitro stimulation by autologous tumor cells. In the presence of IL-2, IL-4 up-regulates the proliferation rate of phytohemagglutinin (PHA)-P-stimulated glioblastoma patients' peripheral blood lymphocytes (PBL)s. Allogeneically- and syngeneically-stimulated PBLs of these patients present an increased proliferation rate in the presence of IL-4. This specifically stimulated lymphocyte population presents a very low proportion of CD8+ cells. This proportion is slightly increased in the presence of IL-4. Our results indicate that the glioblastoma cell-imposed inhibition on T-cells can be partly overcome by low concentrations of IL-4 during in vitro stimulation. Our experiments also demonstrate that glioblastoma-bearing patients' PBLs constitute a good model in which to study the effects of IL-4.

[Proximal temporo-sylvian anastomosis with an arterial cuff glued with fibrin. Technical, anatomical and arteriographic considerations]. / L'anastomose temporo-sylvienne proximale avec coiffe artérielle collée à la fibrine. Considérations techniques, anatomiques et artériographiques.

The authors present a new method of temporo-sylvian anastomosis used 8 times since 1982. This anastomosis called proximal is done on the insular segment (M2) of the sylvian artery and gives better revascularizations than the classic method (M4 or distal). The arterial cuff and the fibrin glue simplify, accelerate and improve the usual microsuture. A good knowledge about the microsurgical anatomy of the middle cerebral artery and its variants is important. The proximal sylvian artery and its perforators (50% occlusion in our cases) may be explored by this approach.

[Congenital anomalies at the emergence of lumbosacral roots]. / Les anomalies congénitales de l'émergence des racines lombosacrées.

Thirteen of 45 cases of congenital anomalies of the lumbosacral nerve roots at their site of emergency (ARE) were treated surgically. The most frequently involved roots were L5 and S1, and the commonest anomaly observed was fusion of adjacent roots. The malformations were either bilateral, symmetric or asymmetric, their preoperative diagnosis being by radiculography with metrizamide. Diagnostic criteria and limitations relating to the different varieties of ARE are discussed, confirmation of the presence of the anomaly depending on two peroperative findings. Conventional operative techniques involve wide surgical exploration, but pediculectomy supplies a new approach to the problem, and the advantages of a microsurgical technique are discussed. Improved results can be expected in the future following preoperative recognition of the presence of ARE and advances in operative techniques.