[Traumatic uterine rupture: a rare complication of motor vehicle accidents during pregnancy. A case report]. / Rupture utérine traumatique: une complication rare des accidents de la voie publique au cours de la grossesse. A propos d'un cas.

The rupture of gravid uterus is a rare complication concerning less than one percent of the pregnant women involved in a motor vehicle accident. The authors report the case of a 39-year woman, gravida 4, referred for an uterine rupture with intrauterine fetal death at 24 weeks gestation, following a car crash. The surgical laparotomic exploration in emergency showed a wide fundal uterine tear with placental abruption. The placenta and the fetus were found in the abdominal cavity. A conservative surgical treatment could be realized. Principles of management, which must be quick and co-ordinated, are reminded.

Radiation-induced intracranial fibrochondrosarcoma.

A 50-year-old patient developed a left temporal fibrochondrosarcoma 27 years after radiation therapy for a suspected pituitary adenoma. The long latency between the irradiation and the development of the sarcoma and the histological nature of the tumour are unusual features for a malignant radiation-induced intracranial tumour. The histogenesis of fibrochondrosarcoma of the brain is discussed.

Hearing preservation after acoustic neurinoma operation.

Between 1981 and 1984, 44 patients underwent acoustic neurinoma removal by a posterior cranial fossa approach with an attempt to preserve hearing. Seven tumors were small (less than 20 mm), 28 were medium (20 to 40 mm), and 9 were large (greater than 40 mm). Preoperatively, 4 patients had normal hearing, 15 had serviceable hearing, 10 had poor hearing, and 15 had no hearing. Postoperative hearing was preserved in 11 cases. Of the 19 patients with normal or serviceable hearing, 8 (42%) had serviceable hearing preserved postoperatively. Hearing preservation was achieved in 43% of the patients with small tumors, 25% of those with medium tumors, and 11% of those with large tumors. This study confirms the value of the suboccipital approach, which can be used in an attempt to preserve hearing whenever the patient has serviceable hearing preoperatively and whenever the tumor size makes it feasible.

Lumbar posterior marginal node (LPMN) in adults. Report of fifteen cases.

This report concerns 15 adults (nine men and six women) who experienced lumbar and sciatic pain associated with an unusual defect of the edges of the vertebral bodies together with a small bony ridge protruding into the spinal canal. This lesion was well demonstrated by computed tomography and easily differentiated from the posterior longitudinal ligament or herniated disc calcifications, as well as from posterior degenerative ridge osteophytes. This lesion looked like the so-called lumbar posterior marginal node. First described in adolescents, this entity was considered as a traumatic fracture of the posterior ring apophysis. Recently, identical cases were noted in young adults in the absence of previous trauma, which were a particular type of marginal cartilaginous node. In the cases reported here, the computed tomographic scans suggested several mechanisms of formation of the vertebral lesion: a variant of marginal cartilaginous nodes; traumatic avulsion; avulsion related to disc herniation; and fusion of the avulsed bony fragment with the vertebral body.

Intraoperative facial nerve monitoring in posterior fossa acoustic neuroma surgery.

Intraoperative facial nerve monitoring has become an indispensable tool during cerebellopontine angle surgery. Ninety-seven patients underwent surgical removal of an acoustic neurinoma with the use of a pneumatic sensor monitoring between January 1, 1986, and December 31, 1990. In the early postoperative period, a normal or near-normal facial function (grades I and II) was achieved in 86% of the patients, a moderate dysfunction (grade III) was present in 7%, and a total or severe dysfunction (grades V or VI) was present in 6%. Normal function at 1 year was achieved in 90.5% of the patients, 4% were grade II, a moderate dysfunction (grade III) was present in 2%, and 3% showed a total or severe dysfunction (grade V and VI). The incidence of normal function decreased with tumor size, with an occurrence rate of 100%, 94%, and 91% in small, medium, and large tumors, respectively. In eight consecutive patients, all responses detected by the monitoring during the operation were collected and analyzed according to intraoperative events. Analysis of the results indicate that 95% of the 316 mechanically induced stimulations were of small or extremely small amplitude, and only 5% were of moderate amplitude. A medial-to-lateral strategy of dissection, preservation of the arachnoid veil over the facial nerve, a control by the monitoring of the amount of traction, and a more widespread use of sharp dissection were the major approaches to reduce surgical trauma during dissection.

Intraventricular administration of morphine in patients with neoplastic intractable pain.

Since February 1981, eight patients with neoplastic intractable pain have been treated by intracerebroventricular administration of small doses of morphine. Morphine was injected into the cerebrospinal fluid through a ventricular reservoir either by direct puncture or by self-administration. Clinical results were very good, and there were no deleterious effects.

[Technic of the peroperative use of Doppler in neurosurgery]. / Technique d'utilisation du Doppler peropératoire en neurochirurgie.

Intraoperative Doppler exploration during neurosurgery was used during treatment of intracranial aneurysms, arteriovenous malformations (AVM) and cerebral revascularization by extra-intra cranial anastomosis (EICA). It was also employed to study behavior of cortical arteries under different conditions. During treatment of aneurysms, Doppler can show, prior to clipping, whether blood flow through. The flow is regular--spasm of supply artery provokes acceleration of blood rate. After clipping it is possible to evaluate whether artery is still permeable without stenosis or torsion. In AVM, Doppler detects direction of blood. Flow and, in case of intraoperative embolization, confirms good exclusion of angiomatous nidus. Flow rate in cortical arteries was determined to verify reality of operative trauma under automatic retractors used in standard surgery. In EICA, Doppler provides precise data on exact localization of cutaneous incision centered on superficial temporal artery (STA) (longitudinal incision) and identifies its parietal branch. The artery in the cortical vessels with the lowest flow rate can be selected. After EICA it is possible to identify whether the donor artery is under spasm from the proximal clamp and whether or not the anastomosis is patent. When functioning is correct it can be defined whether there exists a preferential direction or a regular laminar distribution in T. In tumoral pathology, Doppler serves to identify arteries enclosed in lesion and therefore whether conservation is essential.

[Intracranial hypertension and ependymoma of the end of the spinal cord]. / Hypertension intracrânienne et épendymome de la terminaison de la moelle épinière.

A 42 year-old woman was admitted with a subacute intracranial hypertension which improved under medical treatment. Angiographic data and CT scan showed enlarged ventricles. CSF showed 1.95 g/l of proteins. Five months later, a relapsing acute intracranial hypertension led to a ventricular derivation. CT scans, angiographies and ventriculography showed progressively enlarged ventricles but failed to disclose any intracranial tumor. A thoraco-lumbar tumor of the spinal cord was incidentally discovered and removed. Histopathology concluded to an ependymoma. No sign of recurrence has occurred after an eighteen month follow up. The pathogenesis of intracranial hypertension occurring in spinal cord tumors is discussed.

[Intraventricular morphine analgesia. Apropos of 4 cases, 1 with self-administration]. / Analgésie morphinique par voie ventriculaire. A propos de quatre cas dont un avec auto-administration.

Intractable pain in four patients enduring disseminated cancer was treated by intraventricular morphine. For all these patients, previous efficiency of opiates therapy had been assessed by a positive trial of epidural injections of morphine. The latter method had to be stopped and a switch to intraventricular morphine was motivated in three cases by a local non-tolerance to the subarachnoid catheter. In one case, an intraventricular system was inserted at the first onset. In all cases, the intraventricular system consisted of a Holter type device, using a reservoir subcutaneously implanted in the frontal scalp and connected at right-angle with a catheter inserted in the lateral ventricle. Trial times were respectively of eight days, one month, two months and seven months, with a self administration system in one case. In comparison with the epidural and lumbar intrathecal administration of morphine, the authors insist upon the quality of analgesia obtained, the absence of respiratory depression, the comfort and minimal daily quantities of morphine injected (inferior to one mg daily in three cases). Enlightened by these four cases, the authors also discuss of relative importance of the spinal and brain mechanisms involved in morphine analgesia.

[Fracture-separation of the articular process of the lower cervical spine. Its relation to fracture-dislocation in hyperextension]. / La fracture-séparation du massif articulaire du rachis cervical inférieur. Ses rapports avec la fracture-dislocation en hyperextension.

The authors have seen 13 cases of fracture-separation of the articular processes in the lower cervical spine with horizontal facets. This type of lesion was caused by trauma in hyperextension, compression and rotation. The mechanism appears to be similar to that of dislocations in hyperextension. Four types are defined according to the displacement and the association of disc and ligamentous lesions. Most of the cases were unstable and had to be fixed surgically. Eleven cases were treated in this way, twice by a posterior approach, 6 times by an anterior approach and 3 times by a combined anterior and posterior approach.

[Possibilities of preserving hearing in the surgery of acoustic neurinoma]. / Les possibilités de conservation de l'audition dans la chirurgie des neurinomes de l'acoustique.

Between 1981 and 1984, 44 patients underwent acoustic neurinoma removal by a posterior cranial fossa approach in an attempt to preserve hearing. 7 tumors were small (less than 20 mm), 28 were medium (20 to 40 mm) and 9 large (greater than 40 mm). Of these 44 patients, 4 had normal hearing preoperatively, 15 had serviceable hearing, 10 non-serviceable hearing and 15 anacousis. Postoperative hearing was preserved in 11 cases. Of the 19 patients with normal or serviceable hearing, 8 (42%) had serviceable hearing preserved postoperatively. Hearing preservation was achieved in 43% of small tumors, 25% of medium tumors and 11% of large tumors. This study stress the importance of the suboccipital approach which can be used in an attempt of hearing preservation whenever the patients have serviceable hearing preoperatively and whenever the tumor size makes it feasible.

[Strategy of the surgical treatment of primary tumors of the spine]. / Stratégie du traitement chirurgical des tumeurs primitives du rachis.

The surgical treatment of the primary spinal tumors is started after the analysis of the following data: --location of the tumor, --pathological identification after the biopsy examination, --staging of the lesion according to Enneking. In case of benign tumors it is possible to realize: a total resection by morcellement until healthy margins in case of chondroma or osteochondroma, intralesional excision until healthy borders in case of osteoid osteoma, total excision by partial anterior or posterior vertebrectomy (with previously embolization) according to the location (body or neural arch resection) in case of giant cells tumour or aneurysmal bone cyst. In case of malignant tumors, the total resection is an absolute goal when the feasability occurs (total vertebrectomy), in case of chordoma, chondrosarcoma and malignant giant cells tumours; the stabilization surgery is indicated without attempt of total tumor removal because others means are availables and/or accurates (radio and/or chemotherapy) in cases of Ewing's sarcoma, plasmocytoma and lymphoma.

[Surgery of the craniocervical junction in primary tumors of the spine]. / Chirurgie de la jonction crânio-cercicale dans les tumeurs primitives du rachis.

Tumors of the cranio-cervical junction can be surgically approached either anteriorly or posteriorly. The main anterior (transoral, transcervical or lateral) and posterior routes are described. Posterior approach is used for localization on the posterior arch and for anthrodesis. Anterior approach is proposed for extra-dural lesions of the anterior part of C1 and the foramen magnum.

[Tumor surgery of the thoracolumbar vertebrae (mobile spine)]. / La chirurgie tumorale à l'étage thoraco-lombaire (rachis mobile).

Three main techniques can be discussed for surgery of spinal tumor at the thoraco-lumbar level: posterior stabilization, partial vertebrectomy (lamina or body) and total vertebrectomy. Surgical principles to realize these 3 techniques are described according to the tumoral level: upper thoracic (C7-T3), midthoracic (T4-T10), thoraco-lumbar (T11-L2), upper lumbar (L2-L4) and lower lumber (L5-S1).

[Primary tumors of the spine. A multicenter cooperative study]. / Les tumeurs primitives du rachis. Etude coopérative multicentrique.

This chapter incorporates 206 observations from the different neurosurgery units which replied to the questionnaires on primary tumours of the vertebral column. A homogeneous data bank, analysed and processed using the Excel database, was established by retranscribing each observation into 32 sections. The majority of the sample population (fig. 1) was male and included 42 observations of subjects under the age of 18 years, thereby constituting one of the largest series in this age range. The global histological distribution demonstrates a predominance of malignant tumors in the adult (65%) with no sexual bias. In children, malignant (19 cases) and benign (23 cases) tumours are more homogeneously distributed (fig. 3 and 4). The different histological types encountered are listed in table I in order of frequency. In order to make it easier to read the following tables, the numerical code given to each histological type is indicated in table II. Chordomas (code 14), which most authors classified among the malignant tumours, are situated in a transitional zone between benign tumours (from 1 to 13) and malignant tumours (from 15 to 37) on the various graphs. Histological distribution in adults (fig. 5) demonstrates the existence of two peaks in the malignant tumor zone: the highest peak correspond to the chordomas, the other to solitary myelomas. In children (fig. 6), distribution is different: the benign osteoblastoma and the aneurysmal bone cyst are the most common benign tumors, and the most common malignant tumor observed is Ewing's sarcoma. The different tumor sites along the spinal axis are reported in figures 7, 8, 9, 10 and 11.(ABSTRACT TRUNCATED AT 250 WORDS)

[Experimental paraplegia]. / Paraplégie expérimentale.

In this review of spinal cord injury research, the authors have selected contributions including their own research in electrophysiological changes after impact, which in their opinion best represent modern experimental concepts regarding the physiopathological mechanism of spinal cord injuries. The discrepancy between immediate electrophysiological changes and progressive hemorrhagic necrosis of the spinal cord could offer a rational treatment at the acute stage of spinal cord injury.

[Aneurysmal bone cyst of C5. Complete 2-stage excision]. / Kyste anévrysmal osseux de C5. Exérèse complète en deux temps.

A case of aneurysmal bone cyst of the fifth cervical vertebra was unusual in that it occurred in a 35 year old man treated initially by radiotherapy (3,800 rads), within 3 years, worsening of clinical and radiologic signs led to a complete two-stage exeresis because of extension of lesion to body and posterior arch of C5. This male patient was 35 years old at diagnosis and 38 at time of surgery (respectively 1.2 and 2.5% of cases in the Hay series and 1.9% in the Ruiter series), this lesion affecting mainly age groups under 20 years. Aneurysmal bone cyst (ABC) constitutes 1.4% of primary bone tumors (Dahlin), and spinal localizations 3% (Biesecker), 14% (Reiter) or 20% (Tillman) of total ABC. The cervical lesion represents 13% (Reiter) or 22% (Hay) of spinal localizations, C5 being affected twice in the 17 cases reported by Ameli, and fills, according to Hay, 3.3% of all spinal column lesions and 15% of cervical lesions. Initial treatment applied in another center was by radiotherapy alone at the dose of 3,800 rads (the recommended dose-level in the literature being 20 to 30 Grays). Neither clinical nor radiologic improvement was reported. The recurrence rate after all types of treatment for ABC was 12.6%, and after radiotherapy alone was 11% in the Hay series, MacCarty reporting only one recurrence among 9 patients treated with irradiation alone.(ABSTRACT TRUNCATED AT 250 WORDS)

[Microsurgery of common discal sciatica. Technics and results]. / Microchirurgie de la sciatique discale commune. Technique et résultat.

The authors report their own experience of microsurgery for surgical treatment of lumbar disc herniation. Series include 30 cases with a one year of mean follow up. Comparative studies are discussed according to others microsurgical series already published. Good care of peridural fat and gently retraction of the root seem to be main factors for good functional result.

[Traumatic elongation-traction lesions of the roots of the sciatic nerve, secondary to fractures of the pelvis]. / Lésions d'élongation-traction traumatique des racines du nerf sciatique, secondaires aux fractures de la ceinture pelvienne.

Three cases of complex pelvic fractures associated with lumbo sacral roots lesions are reported. The authors stress this possible association should be suspected through clinical and conventional radiological findings. The contrast sacco-radiculography brings up confirmation. However the so called pseudo-meningocele is by far of less topographical value than the same myelographic findings at cervical level (for brachial plexus avulsion injuries). Direct and concise evaluation is performed by surgical approach of roots during a homolateral hemi-laminectomy. This procedure allows to appreciate the anatomical lesions and to clarify the anatomo-radiological discrepancies. Moreover endodural closure and reduction of volume of meningoceles and removal of arachnoidal adhesions is to pain relief value and may prevent delayed complications of neighboring roots compression related to increase in volume of meningocele. According to the literature and our findings, in future, the aim should be microsurgical repair of such roots lesions as they ar not avulsed from the conus but merely more distally ruptured on the cauda equina. We could not so far achieve this procedure, because of difficulties to identify the distal part of root, often retracted far away from its spinae foramen.

[Conservative lumbar laminectomies. Technic and results]. / Laminectomies conservatrices lombaires. Technique et résultats.

The patient is lying on his left side. Paravertebral muscles of the right side are separated from the spinous processes and from the right laminae. Spinous processes are then cut at their base, and hold with a strong retractor Laminectomies are then feasible, as wide as necessary. Reconstruction is particularly strong. Our 3 years experiences of 200 cases, with clinical and radiologically very good late results, is underlined.