[Surgical treatment of spondylolisthesis in Gabon]. / Traitement chirurgical du spondylolisthésis au Gabon.

PURPOSE: Spondylolisthesis is a spinal disease revealed by lombalgia and/or lombosciatalgia, which may persist under medical treatment and physiotherapy. Indications for surgery are impairing symptoms and emergency conditions. We report outcome in 21 patients (14 women, 7 men, aged from 30 to 60 years old) who underwent surgery for isthmic (n = 10) and degenerative (n = 11) spondylolisthesis. Radiographic staging was: I in seven patients, II in ten, and III in four. METHOD: Many techniques were used: simple laminectomy (n = 4), Gill's operation (n = 4), Lapras' technique (n = 4), and Roy-Camille instrumentation (n = 9). RESULTS: Immediate and long-term postoperative follow-up of sixteen patients confirm good results: excellent outcome in eleven patients, good in four, and fair in one. CONCLUSION: Considering social and economic factors, we prefer Lapras' technique which provides very satisfactory results.

[Early anterolateral surgery for tuberculosis of the lower cervical spine with neurological complications in adult. Our experience in Gabon]. / Chirurgie antéro-latérale précoce du rachis cervical inférieur dans la spondylodiscite tuberculeuse avec troubles neurologiques chez l'adulte. Notre expérience au Gabon.

OBJECTIVE: To report our therapeutic experience with tuberculosis of the lower cervical spine with neurological complications in 9 adults in Gabon. PATIENTS AND METHODS: A retrospective study of these 9 adults treated for progressive Pott's tetraplegia or paraplegia from 1982 to 1998 was conducted. The medical treatment consisted of the early administration in the first 3 patients of rifampin, isoniazid and ethambutol for 18 months; and, in the remaining 6 patients, of rifampin, isoniazid, ethambutol and pyrazinamide for 6 months. This medical treatment was systematically started 3 weeks before surgery in 7 patients, once the disease had been diagnosed radiologically. Two patients with an acute onset of paraplegia underwent surgery on an emergency basis. The standard anterior approach was used: debridement was done in 3 cases, to establish the diagnosis; 6 patients underwent radical surgery for severe neurological deficit and spinal instability. Average follow-up time was 40.6 months. RESULTS: Three patients were found to be functionally and neurologically normal at follow-up examinations. Eight of the nine patients recovered sufficiently to walk unaided. One patient was able to get about on crutches. After 3-4 months, a satisfactory consolidation was already observed, with reduction of kyphosis in 4 cases. All patients were considered medically cured by the Antituberculous Center. CONCLUSION: Early radical surgery, as primary procedure, in conjunction with a six-month chemotherapeutic regimen (four drugs) seems to be adequate for the management of tuberculosis of the lower cervical spine with neurological complications and spinal instability, in our setting.

[Bacterial meningitis in the adult. Study of 85 cases observed in the infectious disease unit of the Fondation Jeanne Ebori (F.J.E.), Libreville, Gabon]. / Les méningites bactériennes de l'adulte. Etude de 85 cas observés dans l'unité des maladies infectieuses de la Fondation Jeanne Ebori (F. J. E.), Libreville, Gabon.

We conducted a retrospective review to specify the frequency, identify the aetiological factors of bacterial meningitis in adults (BMA) and to evaluate the therapeutic protocol used. This study was conducted on 85 (BMA) cases of hospitalised patients between January 1991 and December 1995 (5 years) on our service. The BMA represented 3% of all admissions for infectious diseases at the Foundation Jeanne Ebori in Libreville. It occurred in an endemosporadic fashion. All patients were Black Africans with an average age of 33 years (range: 16-60 years). Males predominated by a ratio of 2.4. Tha patients were seen late in the evolution of the disease, as shown by the folloxing clinical signs: neuropsychic problems (100%), 25 patients (29%) were in a profound coma, 5 (6%) had a hemiplegia, 2 (2%) an hypoacousie and 1 (1%) seizure. Aetiological factors were found in 17 cases (20%) to be in the ORL sphere (sinusitis: n = 8, ear infection: n = 4), pneumopathies (n = 4) and one case of breach dure-mere. The predominant germ was pneumocoque, isolated in 55 cases (65%), 15 cases had a LCR clear (18%). Bacteria gram negative (6%) were identified in the immunocompromised HIV. Third generation cephems had an efficiency higher than beta lactamines: 83% against 73%. The mortality was 18%; 3% of the remaining patients had neurological deafness. The seriousness of the results of this survey calls for the urgent implementation of a surveillance programme.

[Severe hypothermia in a tropical setting]. / Hypothermie grave en milieu tropical.

Hot, humid conditions in tropical regions generally rule out any risk of hypothermia due to cold exposure. In this report, we describe a case of severe hypothermia involving a core temperature of 26 degrees C in a 61-year-old man living in Gabon. Parkinson's disease and chronic alcoholism may have been predisposing factors. The patient was treated by active and passive rewarming (intestinal irrigation with warm water). Sudden circulatory collapse occurred during treatment but the final outcome was successful. This case demonstrates that hypothermia can occur in tropical areas. Emergency diagnosis may be difficult in Black Africa where adequate temperature monitoring equipment is rarely available. Standard mercury thermometers do not allow measurement of temperatures lower than 34 degrees C. African physicians should be aware of the possibility of potentially life-threatening hypothermia and be prepared to initiate proper treatment and surveillance in intensive care.

[How to manage intracranial empyemas in the absence of computerized tomography?]. / Quelle attitude adopter devant les empyèmes intracrâniens en l'absence de tomodensitométrie?

BACKGROUND: Intracranial, and especially subdural, empyemas are a medical emergency usually requiring surgical intervention. We suggest herein a protocol for their management in areas where CT is not yet available. MATERIALS AND METHODS: 16 patients with supratentorial empyemas (6 epidural abscesses, 6 subdural empyemas and 4 with both) diagnosed by surgical intervention in our department between 1986 and 1995 were studied. The etiological features were frontal sinusitis (7 cases), mastoid infection (1), trauma (5), previous operations (2) and unknown (1). Three patients were in a normal state of consciousness, 8 were drowsy and 5 were in a coma. Antibiotic treatment was empirical in 6 patients and specific in 10 patients. Surgical treatment was by multiple burr holes in 9 patients, small craniotomies in 3 patients, major craniotomies in 3 patients and by exploration of a previous craniotomy in 1 patient. A catheter was used for drainage in 12 patients. RESULTS: Average follow-up was 2.7 years. Two patients died, 3 had seizures and 11 were able to lead a normal life. CONCLUSION: We recommend a regime of 2 or 3 antibiotics as an initial treatment. A number of factors including ecological environment, availability of drugs and financial circumstances of each patient should be considered when determining the treatment to be used. Surgical techniques vary according to the surgeon's experience. In our medical centre, drainage via burr-holes is the initial method of treatment for supratentorial empyemas.

[Suppurative intracranial infections in Africa]. / Les suppurations collectées intra-crâniennes en milieu africain.

The purpose of this study was to review recent African literature on suppurative intracranial infection and its implications for neurosurgery. In order of decreasing frequency the main lesions are brain abscess, subdural empyema, and epidural abscess. Despite progress in diagnostic imaging and availability of antibiotic therapy, these lesions still cause disturbingly high morbidity and mortality especially in sub-Saharan Africa where diagnosis is often delayed. The male-to-female ratio was 3.6:1 and 70 to 80% of patients were under the age of 20 years. Spread from the paranasal sinus or ear was the most common mechanism of infection. Hematogenous processes accounted for 22% of cases and the origin was undetermined in 11% to 26% of cases. Staphylococcus aureus and enteric gram-negative bacilli were the most common bacteria identified but cultures were reported as sterile in 30% to 50% of cases. While ultrasonography can be useful in newborns with an open fontanelle, arteriography is often the only feasible procedure for diagnosis in Black Africa. The diagnostic modality of choice is computed tomography which allows precise mapping prior to neurosurgery. Introduction of computed tomography in some African cities has led to a decrease in mortality ranging from 4.7% to 43%. The most effective treatment is a combination of appropriate antimicrobial therapy and surgical decompression of expanding lesions. The main procedures are aspiration through burr holes and craniotomy. Use of this combined strategy requires close cooperation between the neurosurgeon, infectious disease specialist, and microbiologist. Therapeutic indications are discussed within the context of Black Africa.

Medical-surgical treatment of progressive tuberculous (Pott's) paraplegia in Gabon.

The present study deals with the results of the medical-surgical treatment of 22 patients with Pott's tetraplegia or paraplegia. Seventeen had progressive tetraplegia-paraplegia which failed to respond solely to medical treatment. On admission, four patients exhibited an acute onset tetraplegia-paraplegia, and one had a 'spinal tumour syndrome'. In addition to antituberculous therapy, seven patients had anterior spinal surgery, consisting of four corporectomies, two anterior debridments and grafting, and one debridment alone. Moreover, one patient had a posterior interbody fusion, four had laminotomies, and 10 had laminectomies. The causes of the spinal cord or cauda equina compression, as was determined at operation, were extradural abscess in eight patients, bony compressions in 11, arachnoiditis in two, and posterior neural arch tuberculosis in one patient. Neurological recovery began between 10 and 21 days postoperatively. The mean length of follow-up was 42.36 months (range 8-144 months). Fourteen patients were found to be functionally and neurologically normal at follow-up examinations (63%). Eighty-two percent recovered sufficiently to walk unaided. Two patients were left paralysed and unable to walk. Two patients were able to get about on crutches. The onset of objective improvement soon after surgical decompression suggests a causal effect. It was concluded that early neural decompression and spinal stabilisation provided the maximum potential for neurological recovery.

[Tumor-related epilepsy in adults in Gabon: diagnostic problems and therapeutic management]. / Epilepsie tumorale chez l'adulte au Gabon: problèmes diagnostiques et attitude thérapeutique.

The incidence of supratentorial brain tumors revealed by epileptic seizure is certainly underestimated in developing countries due to the lack of adequate diagnostic facilities. This report describes 10 cases of tumor-related epilepsy observed in Gabon over a 54-month period. Tumor-related seizures accounted for 5% of patients hospitalized for epilepsy in neurosurgical and neurologic units in Gabon during the study period. In two patients who refused surgery, diagnosis of the tumor was made solely on angiographic findings. Surgery was performed in 8 patients based on electroencephalographic and arteriographic findings. There were 4 astrocytomas, 3 meningiomas, and 1 glioblastoma. One patient died 8 days after the procedure due to convulsions. Another patient was lost from follow-up three months after the procedure. The remaining 6 patients are asymptomatic with follow-up periods ranging from 10 to 72 months (mean: 40.6 months). The value of early diagnosis and resection as well as post-operative use of antiepileptic drugs is emphasized.

[Medico-surgical treatment of Pott's disease. Our attitude in Gabon]. / Traitement medico-chirurgical du mal de pott de l'adulte. Notre attitude au Gabon.

Twenty-six of 95 adults treated for tuberculous spondylitis, between 1982 and 1993, underwent surgery. Twenty-one exhibited neurological deficits: radicular deficits: 4, and progressive spinal cord syndromes: 17 (incomplete, 13, complete, of acute onset: 4). Vertebral body compression fracture was the most prominent finding. Indications for surgery were neurologic: 11, mechanical: 1, etiologic: 1, and mixed: 13. Twelve patients had vertebrectomies, 3 laminotomies and 11 laminectomies. The average follow-up was 23 months. The neurological recovery was complete in 16 cases, partial in 4 cases and unchanged in one case. Bony consolidation occurred after 3-5 months. The medicosurgical treatment produced a very high cure rate, so rapidly, that it became the treatment of choice in our setting. Moreover, that allows to specify the diagnosis. Anterior decompression and fusion is recommended in the cervical and lumbar spine. In the thoracic segment, significant kyphosis is infrequent, so that surgical correction is rarely necessary. Laminotomy may occasionally be indicated for posterior decompression for abscess. Laminectomy is now preferred for uncommon cases of thoracolumbar posterior compression by tuberculous arachnoiditis or associated posterior vertebral tuberculosis. Indications for open biopsy are discussed.

[Is there a place for surgery in Pott's disease in adults? Our experience in Gabon]. / Reste-t-il une place pour la chirurgie dans le mal de Pott de l'adulte? Notre expérience au Gabon.

Tuberculous spondylitis treatment in developing nations remains controversial. We report our experience, working in a Center where appropriate medical and human structures are available. 22 of 78 adults treated at Jeanne-Ebori Hospital (Gabon), for tuberculous spondylitis, between August 1982 and June 1992, underwent surgery. The average age was 48 years (range, twenty-six to sixty-eight years). Eighteen patients had neurological complications: progressive spinal cord lesions: 15 cases (tetraplegia: 3, paraplegia: 11, tetraparesis: 1) and radicular syndromes (3 cases). The patients were seen in advanced stages of the disease with bone destruction, associated with collapse of vertebrae in ten cases. Indications for surgery were: neurologic in eleven cases, mechanical in one case, and mixed in ten cases (neurologic and mechanical: 5, etiologic and mechanical: 3, etiologic and neurologic: 2). Anterior approach were performed in 10 cases, posterior approach in 12 cases, generally, following an initial three weeks course of antituberculous therapy. The average length of time spent in hospital including rehabilitation had been 10.4 weeks. The average follow-up was 23.7 months (range: 8 months to 8 years). All patients obtained fusion, and stability was achieved after 3-5 months. The neurological recovery was complete in 9 cases, partial in 8 cases, unchanged in one case. All patients were considered medically cured. The analysis of material and socio economic difficulties obliges us to reduce the treatment length by favoring surgical intervention in relatively advanced lesions. Moreover, that allows to specify the diagnosis.

[Primary lymphoma of frontoparietal localization in the cranial vault. Report of a case]. / Lymphome primitif de la voûte du crâne de localisation fronto-pariétale. Un cas.

The authors report an exceptional case of primary malignant non-Hodgkin's lymphoma of cranial vault, with intra(extradural)-extra-cranial extension. The duration of symptomatology before surgery was six months. The main clinical and radiological particularities were: large soft-tissue mass (17 x 12 cm); extensive osteolytic lesions of the left frontal and parietal bones, with intratumoral calcifications; contribution of meningeal and scalp vessels. Surgery was performed to relieve progressive intracranial compression. According to the international working formulation, it was classified as an intermediary malignant tumor. Unfortunately, the patient died of a traffic accident, six weeks after his discharge.

Tuberculosis of the lower cervical spine (C3-C7) in adults: diagnostic and surgical aspects.

From 1976 to 1992, 160 cases of tuberculosis of the spine were treated at Jeanne Ebori Medical Center (Gabon); among whom 10 were localized to the lower cervical spine (C3-C7). From those 10 cases, 5 concerned children and had a medical treatment, whereas the remaining 5 cases concerned adults and underwent surgery (anterior approach), following an initial three-weeks course of antituberculous therapy. Prominent features of the disease in the 5 adult cases included neck pain and stiffness, neurological deficits and osteolytic erosions with myelographic block. The mean length of follow-up was 32 months (range: 8 to 96 months). All five patients improved their cord function and had a satisfactory bony consolidation. Socio-economic difficulties explain the necessity of reducing the treatment length by favoring surgical intervention in relatively advanced lesions.

[Review of 19 cases of dislocation and fracture-dislocation of the cervical spine treated with anterior screw plates without intersomatic graft]. / Revue de 19 cas de luxations et fractures-luxations du rachis cervical inférieur traités par plaque vissée antérieure sans greffe intersomatique.

In comparison to posterior fixation by Roy-Camille plates which does not require bone grafting, 19 cases of anterior plate fixation, also without bone grafting, are presented (11 dislocations, 2 severe sprains, 4 fracture-dislocations and 2 "tear-drop" fractures of the lower cervical spine). A satisfactory osteoligamentary consolidation was obtained in every patient. The advantages of this technique are discussed.

Diagnostic et traitement des lesions traumatiques instables du rachis cervical inferieur sans complication neurologique au Gabon

23 lesions traumatiques instables du rachis cervical inferieur (C3-C7) sans signe de deficit neurologique ont ete traites sur une periode de 8 ans. Le traitement a ete conservateur (6 cas) ou chirurgical (5 cas); 2 patients sont decedes sous traction cranienne avant le traitement definitif. Une fois; des complications neurologiques transitoires sont survenues en post-operatoire immediat. Une re-intervention a ete necessaire dans un cas. Dans l'ensemble; on a observe une consolidation osteoligamentaire satisfaisante. La discussion porte sur l'importance du bilan radiologique et les indications operatoires

[Diagnostic problems with cerebral vascular accidents in Gabon]. / Problèmes de diagnostic des accidents vasculaires cérébraux au Gabon.

This retrospective study covers a period of eleven years (1977-1988). It concerns 365 patients who developed a cerebrovascular accident or stroke and originated from different provinces of Gabon. The authors report their experiences in order to emphasize the diagnostic problems and the need of computerized tomography.

[Echographic diagnosis of hepatic abscess (General Referral Hospital, Gbadolite, northern Zaire)]. / Diagnostic échographique de l'abcès hépatique (hôpital général de référence Gbadolite (Zaïre-Nord).

The two most important liquefying liver diseases are the pyogenic and the amoebic liver abscess. The clinical, pathomorphological and ultrasonographic evolution is of some regularity. So a classification in three stages is of practical usefulness. The ultrasonographic characteristics of those stages for the two forms of liver abscess are presented as well as their specific treatment.

[Unstable traumatic lesions of the lower cervical spine without neurologic deficiency. Our experience at the Fondation Jeanne Ebori in Libreville (Gabon)]. / Lésions traumatiques instables du rachis cervical inférieur sans signe de déficit neurologique. Notre expérience à la Fondation Jeanne Ebori de Libreville (Gabon).

23 cases of unstable traumatic lesions of the lower cervical spine, without neurologic complication, were treated over a period of eight years. These cases consisted of eight dislocations, five subluxations, nine fracture-dislocations and one "tear drop" or fracture of the vertebral body. Six cases were treated conservatively and fifteen operatively. Two patients died in skeletal traction while awaiting surgical intervention. The surgical approaches were anterior (6 cases), posterior (8 cases) and combined (1 case). There was one case of transitory neurologic deficit immediately after surgery. One case required re-intervention. Overall they obtained satisfactory osteoligamentary consolidation.

[Spinal and spinal cord injuries. Therapeutic approach in Gabon]. / Traumatismes vertébro-médullaires. Attitudes thérapeutiques au Gabon.

The authors present their experience with 81 cases (66.4%) of acute cervical spine injuries (C.S.I.) and 41 cases (33.6%) of acute thoracolumbar spine injuries (T.L.S.I.) treated by a multidisciplinary approach, at Jeanne Ebori Hospital (Libreville, Gabon) between the years 1981 and 1987. Traffic accidents were the leading cause of injury. The largest group consisted of patients in their third decade. The anatomic localizations were: upper cervical spine: 22 cases (27%); lower cervical spine: 56 (69%); upper thoracic spine: 11 (26.8%); lower thoracic spine or thoracolumbar area: 19 (46.3%); lumbar spine: 7 (17%). There were osteoligamental lesions in 3 cases (3.7%) of C.S.I. and 4 (9.7%) of T.L.S.I. Clinically, 44 patients (54.3%) with C.S.I. and 37 (90.2%) with T.L.S.I. had neurological deficits. Surgical indications depended upon the osseous as well as neurologic lesions. There were five important steps in the treatment of spinal injuries associated with neurological deficit: (1) immobilization, (2) medical stabilization, (3) spinal alignment (skeletal traction), (4) operative decompression if there was proven cord compression, and (5) spinal stabilization. Twenty patients (24.6%) with cervical injuries were treated conservatively (traction, collar, kinesitherapy); 53 (65.4%) underwent a surgical intervention (anterior approach - 21, posterior fusion - 30, combined approach - 2); and in 8 patients (9.8%) refraining from surgery seemed the best alternative. After lengthy multidisciplinary discussion, the authors elected not to operate on tetraplegic patients with respiratory problems that necessitated assisted ventilation, because of its fatal outcome. Of injuries to the thoracolumbar spine, 13 (31.7%) were treated conservatively (bedrest, orthopedic treatment). Twenty-eight patients (68.2%) with unstable thoracic and lumbar fractures associated with neurologic deficit required acute surgical intervention (stabilization with or without decompression of the neural elements). Laminectomy alone was performed in 5 cases, laminectomy with graft in 2, stabilization by Roy-Camille plates in 16 and by Harrington rods in 5. Most upper thoracic spine fractures were treated conservatively. Surgical intervention was increasingly possible with the availability of more material and qualified staff. There were 17 patients (21%) who died from C.S.I. (15 were tetraplegic), and 6 (14.6%) from T.L.S.I. In general, osteoligamental consolidation was satisfactory. Neurological recovery was observed only in patients with partial deficits. Most cases posed socioeconomic problems.

[Surgical treatment of lumbar spinal stenosis in Gabon]. / Traitement chirurgical des canaux lombaires étroits au Gabon.

The authors report their experiences based on 41 cases operated on for lumbar spinal stenosis between 1981 and 1988. The series included 28 men and 13 women aged between 23 and 63 years (mean age: 48 years). Neurogenic intermittent claudication was the presenting symptom in only 12% of the cases, as opposed to lumbago-sciatica in 78%. Clinical examination did not provide any specific elements. The key to diagnosis was lumbar myelography. Laminectomy was the most important aspect of treatment which, in certain cases, was associated with vertebral stabilization by arthrodesis (3 cases). There were ten minor operative complications. Further surgery was necessary in five cases (12%). Therapeutic results in patients followed from one to eight years (35 cases) were satisfactory. The discussion covers nosologic, clinicoradiologic and therapeutic aspects.