Indications and scientific support for supratentorial unilateral decompressive craniectomy for different subgroups of patients: A scoping review.

CONTEXT: Even though supratentorial unilateral decompressive craniectomy (DC) has become the gold standard neurosurgical procedure aiming to provide long term relief of intractable intracranial hypertension, its indication has only been validated by high-quality evidence for traumatic brain injury and malignant middle cerebral artery infarction. This scoping review aims to summarize the available evidence regarding DC for these two recognized indications, but also for less validated indications that we may encounter in our daily clinical practice. MATERIALS AND METHODS: A scoping review was conducted on Medline / Pubmed database from inception to present time looking for articles focused on 7 possible indications for DC indications. Studies' level of evidence was assessed using Oxford University level of evidence scale. Studies' quality was assessed using Newcastle-Ottawa scale for systematic reviews of cohort studies and Cochrane Risk of Bias Tool for randomized controlled trials. RESULTS: Two randomized trials (level 1b) reported the possible efficacy of unilateral DC and the mitigated efficiency of bifrontal DC in the trauma setting. Five systematic reviews meta-analyses (level 2a) supported DC for severely injured young patients with acute subdural hematoma probably responsible for intraoperative brain swelling, while one randomized controlled trial (level 1b) showed comparable efficacy of DC and craniotomy for ASH with intraoperative neutral brain swelling. Three randomized controlled trials (level 1b) and two meta-analyses (level 1a and 3a) supported DC efficacy for malignant ischemic stroke. One systematic review (level 3a) supported DC efficacy for malignant meningoencephalitis. One systematic review meta-analysis (level 3a) supported DC efficacy for malignant cerebral venous thrombosis. The mitigated results of one randomized trial (level 1b) did not allow to conclude for DC efficacy for intracerebral hemorrhage. One systematic review (level 3a) reported the possible efficacy of primary DC and the mitigated efficacy of secondary DC for aneurysmal subarachnoid hemorrhage. Too weak evidence (level 4) precluded from drawing any conclusion for DC efficacy for intracranial tumors. CONCLUSION: To date, there is some scientific background to support clinicians in the decision making for DC for selected cases of severe traumatic brain injury, acute subdural hematoma, malignant ischemic stroke, malignant meningoencephalitis, malignant cerebral venous thrombosis, and highly selected cases of aneurysmal subarachnoid hemorrhage.

Open reduction and C1C3 posterior Harms-Goel fixation for unstable Hangman's fracture: technical note.

Hangman's fracture occurs in the elderly following low kinetic energy fall from their height, or in the young during traffic accident. Classically described as bipedicular C2 fracture, Hangman's fracture results from oblique hyperextension-flexion vector forces which can lead to anterior dislocation of C1C2 complex over C3 vertebral body in case of associated damage to C2C3 disc and ligaments. Even though most cases of Hangman's fracture are not displaced (grade 1) and can be managed with orthopaedic treatment using cervical brace, highly displaced cases of Hangman's fractures (some grade 2, all grade 3) require surgical stabilization. Given the limited capabilities of reduction and the odds for mechanical failure of anterior C2C3 discectomy and fusion, we provide a reproducible method using a specific rod persuader on C1 screws aiming to realign and stabilize displaced cases of Hangman fracture using the C1C3 "Harms-Goel" procedure.

How I do it: en-bloc thoracic vertebrectomy.

BACKGROUND: Some young patients with preserved functional status suffering from aggressive isolated neoplastic disease of the thoracic spine may be eligible from curative en-bloc vertebrectomy surgical treatment. METHOD: Long-segment posterior pedicle screw fixation is performed. Complete excision of the posterior arch and of ribs posterior aspect is performed. Finger blunt dissection is performed between vertebral body, pleura, and aorta allowing to place a soft abdominal valve and then Gigli saws surrounding the anterior aspect of the spine, in order to saw the upper and the lower discs. Unilateral temporary rod is placed. The vertebral body is dislodged from posterior ligament and then removed by circling laterally around spinal cord. An expandable vertebral implant is placed. CONCLUSION: Posterior en-bloc thoracic vertebrectomy is a highly technical yet achievable procedure which carries a curative intent for isolated neoplastic spine lesions.

Accuracy and Safety of Freehand Placement of Upper Thoracic Pedicle Screws Supported Solely by Anteroposterior, i.e., Frontal, X-Ray Fluoroscopy (C-Arm): Technical Note Including 23 Patients.

BACKGROUND: Biomechanical resistance and surgical morbidity of spinal posterior pedicle screw fixation depend on the intraosseous position of the implants. Upper thoracic pedicle screws are particularly demanding given their convergence and thin character. We present our experience as military surgeons of freehand placement of upper thoracic pedicle screws supported solely by anteroposterior, i.e., frontal x-ray fluoroscopy. METHODS: A single-center retrospective analysis was performed at Sainte-Anne Military Teaching Hospital between 2017 and 2024 of patients in whom upper thoracic pedicle screw (T1-T5) were placed with anteroposterior fluoroscopy guidance only. RESULTS: Analysis included 23 patients (mean age 59; male/female ratio 3.6; 16 traumatic lesions and 7 neoplastic lesions) in whom 15 cervicothoracic junction fixation and 8 upper thoracic spine surgeries were performed. Of 124 screws inserted (T1-T5), 85% (106/124) were graded 0 (Gertzbein-Robbins scale), whereas 14.5% (18/124) displayed some degree of misplacement (grades 1-3). All T1 screws (22/22) were accurately placed compared with 83% (20/24) of T2 screws, 88% (30/34) of T3 screws, 85% (17/20) of T4 screws, and 71% (17/24) of T5 screws, with no clinical complications. There were 3 surgical revisions (1 asymptomatic misplaced screw, 2 mechanical failures in trauma). Finally, 92.7% (51/55) of the screws inserted during working hours were accurately placed compared with 79.7% (55/69) inserted during after-hours surgeries (P = 0.039). CONCLUSIONS: Clinically, placement of upper thoracic pedicle screws supported solely by anteroposterior fluoroscopy appears to be safe. The surgical technique is simple enough to be used in settings with limited resources, such as a mobile field surgical team.

Combined Deficit of the Four Lower Cranial Nerves also Known as the Syndrome of Collet-Sicard: A Systematic Review and Meta-analysis.

Combined deficit of the four lower cranial nerves (CN IX, X, XI, and XII) was originally described by French physicians Collet (1915) and Sicard (1917) during World War I. To date though, this rare neurological clinical picture lacks systematic evidence regarding its epidemiology, clinical presentation, treatment strategies, and outcome. We conducted a systematic review and meta-analysis concerning Collet-Sicard syndrome (CSS) on Medline database in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The research yielded 84 articles among which 73 individual case reports were eventually retained. Mean age was 53.7 (± 16) years old and the male-to-female ratio was 1.8/1. CSS was firstly caused by tumors (38.4%), following by vascular etiologies (28.8%), trauma (16.4%), and infection (6.8%), among others. Temporary enteral nutrition was required for 17 patients (23.3%). The four CN presented significant chances of complete or partial recovery: 52.1% for CN IX ( p < 0.001), 46.6% for CN X and CN XII ( p < 0.001), and 39.7% for CN XI ( p = 0.002). Tumoral causes presented significantly lower chances of favorable CN recovery (7.1%) compared to infection (60%), vascular (52.4%), and trauma (41.7%) ( p < 0.001). Older age (> 53 years old) was not associated with a dismal CN prognostic ( p = 0.763). Most patients (71.2%) presented a favorable outcome (Glasgow Outcome Scale score ≥ 4). All the patients who died (6.8%) suffered from skull base tumors. CSS is a rare condition requiring prompt clinical and radiologic diagnostic and multidisciplinary management. Vascular or infectious-related CSS seem to present a rather good prognostic, closely followed by trauma, whereas tumoral-related CSS seem to suffer from a more dismal prognostic.

Triangular spinopelvic fixation for U-shaped sacral fractures and tile C pelvic disruptions: counter-nutation (anteflexion and rotation) load-bearing instability requires complementary anterior pelvic ring fixation.

Unstable trauma lesion of the spinopelvic junction, including U-shaped sacral fractures and Tile C pelvic ring disruptions, require surgical stabilization in order to realign the bone arches of the pelvis thus reducing the upcoming orthopaedic impairment during sitting, standing, and walking positions, decompress the nerves roots of the cauda equina in a view of reducing neurological impairment, and allow early weight bearing. Even though posterior open modified triangular spinopelvic fixation is particularly efficient for treating unstable trauma lesions of the spinopelvic junction, it may not be sufficient alone in order to prevent long-term counter-nutation, i.e. rotation and anteflexion deformity of the anterior pelvis under load bearing conditions. Such progressive deformation is caused by either the slight rotation of the iliac connectors within the head of iliac screws for spinopelvic constructs, or the slight rotation of sacral cancellous bone around transsacral screws in case of percutaneous procedure. Regardless of the posterior surgical technique that is used, complementary anterior pelvic fixation appears mandatory in order to prevent such deformation over time, which can lead to pelvic asymmetry and then gait imbalance.

Fluoroscopy guided teardrop technique for open trans-muscular iliac screw placement and open reduction maneuvers during modified triangular spinopelvic fixation for unstable U-shaped sacral and tile C pelvic traumas: technical note.

Unstable traumas of the spinopelvic junction, which include displaced U-shaped sacral fractures (Roy-Camille type 2 and type 3) and Tile C vertical shear pelvic ring disruptions, occur in severe traumas patients following high speed traffic accident or fall from a height. These unstable traumas of the spinopelvic junction jeopardize one's ability to stand and to walk by disrupting the biomechanical arches of the pelvis, and may also cause cauda equina syndrome. Historically, such patients were treated with bed rest and could suffer a life-long burden of orthopedic and neurological disability. Since Schildhauer pioneer work back in 2003, triangular spinopelvic fixation, whether it is performed in a percutaneous fashion or by open reduction and internal fixation, allows to realign bone fragments of the spinopelvic junction and to resume walking within three weeks. Nevertheless, such procedure remains highly technical and it not encountered very often, even for spine surgeons working in high-volume level 1 trauma centers. Hence, this visual technical note aims to provide a few tips to guide less experience surgeons to complete this procedure safely.

Simplified supine modified park bench / lateral decubitus position using a shoulder pad and a Mayfield head clamp for neurosurgical approach to lesions located in the occipital lobe or the posterior fossa: technical note.

Neurosurgical approach to lesions located in the occipital lobes or in the posterior fossa require very specific and time-consuming patient installations, such as the park bench position, the prone position, or the sitting position. Nevertheless, each of these position present major drawbacks regarding specific installation-related adverse events and potentially serious neurosurgical complications such as venous air embolism, iatrogenic intracranial hypertension, and supratentorial remote hematoma just to cite a few. In order to provide neurosurgeons with a simpler, physiologically-respective, easily tolerated, less time-consuming, and less provider or specific adverse events patient installation, Ochiai (1979) introduced the supine modified park-bench / lateral decubitus position. Given that this patient position has not gained wide visibility among the neurosurgical community despite its obvious numerous advantages over its classic counterparts, we provide our experience using this installation for neurosurgical approach to lesions located in the occipital lobes and in the posterior fossa.

Ultrasound-guided needle aspiration of immediate postoperative symptomatic spinal epidural hematoma after lumbar stenosis surgical decompression in the elderly: a proof-of-concept case.

BACKGROUND: Symptomatic spinal epidural hematoma (SSEH) is one of the most feared complications and source of litigation in spine surgery. Its occurrence rises up to 2% in minimally invasive spine surgery. In parts of the world where the population is aging, more fragile patients are expected to undergo degenerative spine surgery. Management of the SSEH includes emergent spine MRI, though some experts advocate for direct second-look surgery without imaging. Then, an urgent revision surgery under general anesthesia for hematoma evacuation is warranted. We report the case of a threatening SSEH in an 88-year-old patient after lumbar spine stenosis surgery. In order to spare a second general anesthesia for this fragile patient, we opted for a percutaneous ultra-sound guided drainage of the hematoma under local anesthesia as a first line treatment. The procedure was successful, we report an instant relief of his neurological deficit while performing the procedure. CONCLUSION: Ultra-sound guided percutaneous drainage of hyperacute SSEH successfully avoided a revision surgery. It spared a second general anesthesia in a fragile patient. This procedure could be an alternative first-line treatment of SSEH for fragile patients.