[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.

[Cavernous angioma of the cervical spinal cord]. / Angiome caverneux de la moelle cervicale.

A 34-year old man gradually developed a paraparesis which spontaneously regressed within a few months. One year later, the patient suffered from acute torticollis immediately followed by flaccid tetraparesis with pyramidal signs, dissociated sensory deficit and acute retention of urine. Magnetic resonance imaging (MRI) showed, in the cervical cord, a vascular malformation that was not opacified at angiography. The lesion, a cavernous angioma, was surgically removed, leading to recovery. So far, thirty five cases of spinal cord angioma have been published, most of them since the advent of MRI which makes it possible to determine the exact incidence of this lesion, as well as its signs, symptoms and course.

Upbeat and downbeat nystagmus occurring successively in a patient with posterior medullary haemorrhage.

In a patient with posterior medullary haemorrhage, first upbeat and later downbeat nystagmus occurred in the primary position. The lesion was limited to the posterior and medial part of the medulla. Clinical and electro-oculographic examination first showed upbeat nystagmus in the primary position and upgaze, with downbeat nystagmus in downgaze. Two and a half months later, there was downbeat nystagmus in the primary position and downgaze and upbeat nystagmus in upgaze.

Management of focal intracranial infections: is medical treatment better than surgery?

Three groups of patients with single hemispheric brain abscesses or subdural empyemas, from 1 to 5 cm large, with similar initial prognosis, have been treated either by medical treatment alone (20), aspiration (21), or excision (15). Differences in survival were not found, but medical treatment alone was better for long term sequelae. Surgical procedures (either aspiration or excision) were better for both isolation of the organism and the hospital stay before discharge. In spite of good results, it is unwise to conclude too strongly in favour of no surgical treatment as this study was not randomised.

[Natural history and current surgical prognosis of intracranial arterial aneurysms]. / Histoire naturelle et pronostic chirurgical actuel des anévrysmes artériels intracrâniens.

The abrupt flow of blood in the meninges or in the brain after fissure or rupture of an arterial aneurysm still remains a medico-surgical emergency which includes the mobilisation of important technical and financial means which justifies itself by the reduction of the occurrence of a more severe accident and to give the patient its best chances. The cure of a cerebral aneurysm and its intracranial consequences must not be dissociated from its clinical context. Surgical indication must take into account the cause of the vascular lesion, the background on which it has evoked, its natural outcome which is characterised by rebleeding and vasospasm. Surgical cure of intracranial aneurysm is one of the great achievement of modern surgery. A better understanding of the malformation, the improvement of neuro-anesthesia and intensive care, and the use of pre-operatoire adjuvants have considerably improved the surgical results over the years. At the moment, alternative treatment start to emerge such as selective vascular catheterism with ejectable balloon which become more feasible and seductive.

[Clinical course after surgery of aneurysms of the anterior communicating artery]. / Evolution, après chirurgie des anévrysmes de l'artère communicante antérieure.

The evolution and correlations between initial state and outcome (one year) are analysed in 81 patients with anterior cerebral artery aneurysm. The age and initial evaluations are seldomly correlated with late evaluations, Jennett and Holbook scales, frontal syndrome, amnesia. The evaluations at one month are very significantly correlated to the late evaluations.

[Cellular kinetics of cerebral glioma: study of the proliferative activity using monoclonal antibody Ki 67. Apropos of 60 cases]. / La cinétique cellulaire des gliomes cérébraux: étude de l'activité proliférative par l'anticorps monoclonal Ki 67. A propos de soixante cas.

The monoclonal antibody Ki 67 is able to detect a nuclear antigen expressed by proliferating cells during the cellular cycle (phase G1, G2, S and M). It is used as a marker of the proliferative activity of 60 cerebral gliomas including 41 biopsied under stereotaxic conditions. The immunocytochemical study performed with the peroxidase antiperoxidase technique on crushed and smeared fresh tumors, permit to define a nuclear marking index for each tumor. The index Ki 67 is correlated with the degree of tumor malignancy. The maximum values are found in astrocytomas IV (20%) and malignant ependymomas (18%), with a mean index at 11% in the 25 high-grade gliomas and 1.7% in low-grade gliomas. The minimum values are observed in pilocytic astrocytomas and low-grade oligodendrogliomas. Marked variations of the index Ki 67 are found in homogeneous tumor classes regrouping tumors of identical nature and grade: grade IV astrocytomas (5 to 20%), grade III astrocytomas (8 to 18%). These marking differences reflect the heterogeneous nature of the proliferative activity of morphologically similar gliomas. The nuclear marking index with antibody Ki 67 complements the findings of the standard histological examination of cerebral gliomas. This is an additional diagnostic mean to evaluate the proliferative potential and the prognosis of these tumors.

[Spinal cord ependymoma: contribution of MRI using gadolinium]. / Ependymome pan-médullaire: apport de l'IRM avec gadolinium.

In a case of panmedullary ependymoma, a rare tumour, MRI was performed before and after gadolinium injection. The latter clearly demonstrated the borders of the tumour. Throughout the procedure, neurophysiological exploration was carried out with recording of motor and somatosensory evoked potentials.

[Rhythmical myoclonus and tremor at rest disclosing mesencephalic metastasis]. / Myoclonies rythmiques et tremblement de repos révélant une métastase mésencéphalique.

We report a case in which rhythmical myoclonus and tremor at rest revealed a thalamo-subthalamic metastasis from a bronchial carcinoma. Tremor of the upper limbs and face (4 Hz) disappeared with sustained posture and action. A cogwheel phenomenon, hypotonia and disorders of automatic and voluntary movements were also present. Surface electromyographic recordings showed a rhythmical, synchronous activity of the biceps brachialis and triceps muscles at rest. Pathology disclosed lesions of the red nucleus and neighbouring area and severe compression of the substantia nigra which were likely to be the cause of the signs and symptoms.

[Correlation of thalamic aphasia and cerebral blood flow]. / Corrélations de l'asphasie thalamique avec le débit sanguin cérébral.

Relations between linguistic deficits and cerebral blood flow (CBF) were studied in 20 cases of thalamic aphasia due to hemorrhage. Language analysis was based on BDAE, verbal intelligence quotient and verbal subtest of the memory quotient (Wechsler). CBF analysis (and of asymmetry index: AI) was done with 133 Xenon by SPECT technique in tomographic slices and in 15 areas of interest, i.e. cortical and deep areas. Relationships were analyzed by multiple correlations procedure and stepwise regression. Significant correlations were observed between linguistic results and AI of cortical but also deep areas (lenticular). Dynamic anomalies (fluency) were correlated with the IA and/or CBF of the frontal cortex. Verbal comprehension, naming and paraphasia were related to the AI of deep structures (insula and lenticular nucleus) and the AI of posterior cortex (temporo-occipital). Several correlations were found significant between results on verbal IQ of the WAIS and IA of the insula and lenticular nucleus.

[Approach to the clivus via maxillary bipartition. Report of a case of chordoma]. / Abord du clivus par une bipartition maxillaire. A propos d'un cas de chordome.

Large tumors of the clivus require a combination of several approaches. We review the technique previously described; they cross numerous anatomical structures and include a transcranial approach. We propose to combine transoral and transrhino-septal approaches by means of maxillary bipartition which allows good exposure and an easy removal in a case of chordoma of the clivus.

[Surgical treatment of lumbar foraminal disk herniation. Value and indications for an interlaminar and extra-articular combined approach]. / Le traitement chirurgical des hernies discales foraminales lombaires. Intérêts et indications de la voie combinée interlamaire et extra-articulaire.

From 62 foraminal herniations seen over 2 years, the authors present a series of 22 lumbar foraminal disc herniations operated on by a combined interlaminar and extra-articular approach. After describing the technique the results are analysed. The objective of the combined approach is to provide satisfactory foraminal liberation without damage to the articular structures. They also define the indications. These are based on precise analysis of the topography of the hernia, provided by CAT scan examination. Three major topographical types may thus be defined.

[Automatized percutaneous nucleotomy in lumbar disc pathology]. / La nucléotomie percutanée automatisée en pathologie discale lombaire.

The authors report on percutaneous automated lumbar discectomy for lumbar diks herniations. They discuss its advantages and inconvenients in front of non automated technics.

[Should a cancer of the bronchi be surgically treated after excision of a cerebral metastasis?]. / Faut-il opérer un cancer bronchique après exérèse d'une métastase cérébrale révélatrice?

Between 1964 and 1987 35 patients were operated on for cerebral metastases due to an underlying bronchial carcinoma. In 26 cases (group 1) there was excision of the primary tumour also and in 9 cases combined medical treatment was given with radiotherapy and chemotherapy. The neurological state was improved by the neurosurgical operation in 88% of patients in group 1 and in 66% of patients in group 2. This improvement was maintained in 30% of the patients as long as they survived. 2 patients died following thoracic surgery (7.69%). The median survival was 11 months in group 1 and 9 months in group 2. Three patients in group 1 were living two years after craniotomy whilst. 1 patient in group 2 is still alive four years after the neurosurgical procedure. The heterogeneity of the two groups does not permit a comparative statistical analysis but overall there does not seem to be any difference in duration or quality of life between the two groups. Complementary cerebral radiotherapy did not affect the prognosis.

[Anterior decompression and spinal stabilization in the treatment of dorsolumbar metastatic compression]. / Décompression antérieure et stabilisation rachidienne dans le traitement des compressions métastatiques dorso-lombaires.

The authors report their experience of the postero-lateral approach for the treatment of thoraco-lumbar spinal metastasis with anterior decompression and osteosynthesis. They stress the progress in the surgical technique which is designed to have a direct effect on osseous posterior wall compression with a more effective osteosynthesis to allow an immediate mobilization.

[Recurrent meningitis, hydrocephalus and tegmen tympani dehiscence]. / Méningite récidivante, hydrocéphalie et déhiscence du tegmen tympani.

Cerebrospinal fluid (CSF) otorrhea is the usual presenting symptom of spontaneous tegmen tympani defects. A case associated with recurrent meningitis and CSF rhinorrhea without otorrhea is described. The coexistence of an hydrocephalus had led initially to ventriculoperitoneal shunting, which did not prevent meningitis recurrence. Previously reported in cases of anterior fossa and sella defects, an aqueduct stenosis was here associated with the tegmen tympani defect.

[Secondary and late development of hematoma of the brain stem]. / Evolution secondaire et tardive des hématomes du tronc cérébral.

The functional and social outcome in 15 patients with brainstem hematomas surviving on the 15th day is reported. At the end of the first year post stroke, the main neurological deficits were sensory, postural and paresis of the 6th and 7th cranial nerves. This resulted from the preferential location of the lesions in the lateral and posterior pons. On a functional point of view, 8 patients were independent in daily living. Seven of them were regularly engaged in more elaborated activities, at home and outside: 1 had recovered his previous professional activities. Those functions evolved more slowly during the 2nd year and later on. A significant correlation was found between the initial neurological status and the functional outcome at 1 year, and also between the volume of the hematoma on C.T. scan and this outcome. In this series, the age of the patients was not correlated to the other variables.

[Bilateral anterolateral approach in primary tumors of the cervical vertebrae]. / L'abord par voie antérolatérale bilatérale des tumeurs primitives du rachis cervical.

The author reports on his experience with the bilateral anterolateral approach to the cervical spine for primary tumors of the cervical spine. It has a threefold objective: Neurological: aiming at the decompression of the spinal cord and the roots as much as possible without making any radicular or vascular sacrifice. Anatomic: the bilateral control of the foraminal segment and the vertebral arteries ensures absolute safety for the approach to the lateral parts of the vertebral body, the pedicles, and if necessary, the articular surfaces and the isthmi. Static: the anterior reconstruction graft and osteosynthesis with a plate or an acrylic prothesis ensure stability. Compared with the classic anterior approach, the bilateral anterolateral approach offers the following advantage: it allows more extensive surgery on tumors. However, the posterior segment of the spine appears to be difficult to control by this approach. An anterior support is necessary because of the removal of the stabilizing elements of the vertebra. Computed tomography provides great help in determining the exact indications for this surgical procedure.