Chronic low back pain during COVID-19 lockdown: is there a paradox effect?

PURPOSE: The coronavirus 2019 (COVID-19) pandemic led to a compulsory lockdown of 3 months with strict restrictions. The impact of the COVID-19 pandemic has shown broad repercussions on patients with chronic pain; especially for conditions that present a significant emotional participation such as chronic low back pain (cLBP). METHODS: We performed a prospective study on 50 patients. Pre- and 1-month post-lockdown questionnaires such as: the Impact of Event Scale (IES), the Oswestry Disability Index (ODI), the Roland-Morris questionnaire (RMQ) and the visual analogue scale (VAS) for back and leg pain intensity were collected. RESULTS: The mean time of the evolution of cLBP was 33.04 months (range 5-120 months). Eighteen (36%) patients improved their cLBP (i-cLBP), whereas for 14 (28%) it was worse (w-cLBP). Cox multivariate proportional hazard model identified that MODIC 1 disc disease [OR 19.93, IC95% (2.81-102.13), p = 0.015] and at-home workouts [OR 18.854, IC95% (1.151-204.9), p = 0.040] were good prognosis factors of the improvement of cLBP while subclinical/mild Covid-19 anxiety (IES score < 26) was a poor prognosis factor in improving cLBP [OR 0.21, IC95% (0.001-0.384), p = 0.009]. Furthermore, pre-lockdown benzodiazepine medication [OR 2.554, IC95% (1.20-9.9), p = 0.002] was a prognosis factor of worse cLBP. In contrast, patients with severe Covid-19 anxiety (IES score > 26) significantly improved their cLBP [OR 0.58, IC95% (0.025-0.834), p = 0.01]. CONCLUSION: Lockdown affected the somatic component of cLBP by decreasing activities and physical measures, whereas the SARS-CoV-2 pandemic spectrum paradoxically improved the psychic and emotional component of cLBP.

Acute hydrocephalus and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Delayed cerebral infarction (DCIn) following aneurysmal subarachnoid hemorrhage (aSAH) is a major cause of morbi-mortality; yet, the causes for DCIn remain incompletely understood. OBJECTIVE: We tested the hypothesis that acute hydrocephalus could be related to the occurrence of DCIn, independently of the occurrence and severity of vasospasm. METHODS: Radiological and clinical data of patients treated at a single large volume academic center for aSAH between 2017 and 2019 were retrospectively analyzed. DCIn was defined as imaging stigma of cerebral infarction visible on 6-week imaging follow-up after aSAH. Hydrocephalus was defined on baseline imaging as a relative bicaudate index above 1. Cerebral vasospasm was defined by reduction of artery diameter in comparison with initial diameter. We used uni- and multivariable models to test the associations between these variables, hydrocephalus and DCIn. RESULTS: Of 164 included patients, vasospasm occurred in 58 patients (35.4%), and DCIn in 47 (28.7%). Acute hydrocephalus was present in 85 patients (51.8%) on baseline CT. No relation was found between acute hydrocephalus and delayed cerebral infarction in our multivariate analysis (adjusted OR: 1.20 95% CI [0.43-3.37]; p = 0.732). Only vasospasm occurrence was independently associated with DCIn (adjusted OR: 10.97 95% CI [4.60-26.01]). CONCLUSION: Our study did not show an association between acute hydrocephalus and DCIn after aSAH, after adjustment for the presence and severity of cerebral vasospasm.

The trigeminal system: The meningovascular complex- A review.

Supratentorial sensory perception, including pain, is subserved by the trigeminal nerve, in particular, by the branches of its ophthalmic division, which provide an extensive innervation of the dura mater and of the major brain blood vessels. In addition, contrary to previous assumptions, studies on awake patients during surgery have demonstrated that the mechanical stimulation of the pia mater and small cerebral vessels can also produce pain. The trigeminovascular system, located at the interface between the nervous and vascular systems, is therefore perfectly positioned to detect sensory inputs and influence blood flow regulation. Despite the fact that it remains only partially understood, the trigeminovascular system is most probably involved in several pathologies, including very frequent ones such as migraine, or other severe conditions, such as subarachnoid haemorrhage. The incomplete knowledge about the exact roles of the trigeminal system in headache, blood flow regulation, blood barrier permeability and trigemino-cardiac reflex warrants for an increased investigation of the anatomy and physiology of the trigeminal system. This translational review aims at presenting comprehensive information about the dural and brain afferents of the trigeminovascular system, in order to improve the understanding of trigeminal cranial sensory perception and to spark a new field of exploration for headache and other brain diseases.

Hotspots of small strokes in glioma surgery: an overlooked risk?

BACKGROUND: Small deep infarcts constitute a well-known risk of motor and speech deficit in insulo-opercular glioma surgery. However, the risk of cognitive deterioration in relation to stroke occurrence in so-called silent areas is poorly known. In this paper, we propose to build a distribution map of small deep infarcts in glioma surgery, and to analyze patients' cognitive outcome in relation to stroke occurrence. METHODS: We retrospectively studied a consecutive series of patients operated on for a diffuse glioma between June 2011and June 2017. Patients with lower-grade glioma were cognitively assessed, both before and 4 months after surgery. Areas of decreased apparent diffusion coefficient (ADC) on the immediate postoperative MRI were segmented. All images were registered in the MNI reference by ANTS algorithm, allowing to build a distribution map of the strokes. Stroke occurrence was correlated with the postoperative changes in semantic fluency score in the lower-grade glioma cohort. RESULTS: One hundred fifteen patients were included. Areas of reduced ADC were observed in 27 out of 54 (50%) patients with a lower-grade glioma, and 25 out of 61 (41%) patients with a glioblastoma. Median volume was 1.6 cc. The distribution map revealed five clusters of deep strokes, corresponding respectively to callosal, prefrontal, insulo-opercular, parietal, and temporal tumor locations. No motor nor speech long-term deficits were caused by these strokes. Cognitive evaluations at 4 months showed that the presence of small infarcts correlated with a slight decrease of semantic fluency scores. CONCLUSION: Deep small infarcts are commonly found after glioma surgery, but their actual impact in terms of patients' quality of life remains to be demonstrated. Further studies are needed to better evaluate the cognitive consequences-if any-for each of the described hotspots and to identify risk factors other than the surgery-induced damage of microvessels.

Arcuate foramen: "Anatomical variation shape or adaptation legacy?"

PURPOSE: The groove of the vertebral artery on the posterior arch of the atlas (sulcus arteriae vertebralis) may become a complete or partial osseous foramen: the arcuate foramen. The presence of a complete or partial arcuate foramen is a rare anatomical variant described in a minority of patients and it seems to be associated with vertigo, vertebro-basilar insufficiency, posterior circulation strokes, and musculoskeletal pain. As the number and morphology of cervical vertebrae is highly preserved, we questioned about its significance from an evolutionary point of view. We thus investigated through an extensive literature review if the arcuate foramen is a pure anatomical variation shape or if it might represent an adaptation legacy. METHODS: We observed five atlas of an extinct species, the Late Pleistocene Mammoths (M. primigenius), and we compared them with five atlas of a closely related existent species, the African elephant (L. africana). RESULTS: All the mammoths' atlas had an arcuate foramen through which the vertebral artery passed before turning anteriorly and becoming intradural. This foramen was not present in elephants' atlas, where only a groove was observed, such as in the majority of patients. CONCLUSION: We would like to raise the hypothesis that this peculiar morphology of mammoths' atlas might have contributed, in association with other factors, to their precocious extinction and that the arcuate foramen might represent a disadvantage in the evolutionary process, with a low prevalence in humans being the result of a natural selection.

Recurrent primary cutaneous mucinous carcinoma with neuroendocrine differentiation: case report and review of the literature.

We report the case of a 60-year-old woman presenting with primary cutaneous mucinous carcinoma (PCMC) with neuroendocrine differentiation, revealed by neuroendocrine tumor lymph node metastasis 7 years before identification of the skin tumor. Only five cases of PCMC with neuroendocrine differentiation have been reported to date. The frequency of this neuroendocrine component may be underestimated, as it can require immunohistochemistry for identification, rather than being obvious on initial histopathologic examination. In the case presented here, the prominent neuroendocrine component displayed the morphological features of a well-differentiated neuroendocrine tumor with expression of common neuroendocrine markers, strong expression of estrogen and progesterone receptors and low Ki67 proliferation index (5%). This case shows that not all primary cutaneous neuroendocrine carcinomas are Merkel cell carcinomas (MCCs). In addition to rare primary cutaneous carcinoid tumors, the diagnosis of PCMC with neuroendocrine differentiation must be considered, particularly when confronted by a mucinous tumor or lymph node metastases of neuroendocrine carcinoma of unknown origin. On the basis of this case, identification of a neuroendocrine component in a PCMC might be an adverse prognostic indicator of recurrence or of lymph node metastasis and should support wider excision margins of the tumor.

Evidence of a middle longitudinal fasciculus in the human brain from fiber dissection.

A rostrocaudal pathway connecting the temporal and parietal lobes was described in monkeys using autoradiography and was named the middle longitudinal fasciculus (MdLF). Recently, the use of diffusion tensor tractography has allowed it to be depicted in human volunteers. In the present study, a technique of fiber dissection was used in 18 cadaveric human brains to investigate the presence of this fasciculus and to detail its anatomical relationships. On the basis of our findings, fiber dissection provides evidence for a long horizontal bundle medial to the arcuate fasciculus and extending to the superior temporal gyrus. Its fibers occupy the lateral-most layer of the upper portion of the stratum sagittale and partially cover the inferior fronto-occipital fasciculus, which is situated deeper and slightly inferiorly. Whereas MdLF fibers continue on a relatively superficial level to reach the superior temporal gyrus, the inferior fronto-occipital fasciculus penetrates the deep temporal white matter and crosses the insular lobe. Although diffusion tensor imaging suggests that the MdLF terminates in the angular gyrus, this was not confirmed by the present study. These long association fibers continue onward posteriorly into upper portions of the occipital lobe. Further studies are needed to understand the role of the MdLF in brain function.

The inter-optic course of a unique precommunicating anterior cerebral artery with aberrant origin of an ophthalmic artery: an anatomic case report.

BACKGROUND AND IMPORTANCE: Some variations of the cerebral arterial circle of Willis, such as an inter-optic course of the anterior cerebral artery are exceedingly rare. Imaging of very rare anatomical features may be of interest. CLINICAL PRESENTATION: In a 67-year-old male individual, the unique precommunicating part of the left anterior cerebral artery was found to course between both optic nerves. There was an agenesis of the right precommunicating cerebral artery. This variation was associated with an aberrant origin of the ophthalmic artery, arising from the anterior cerebral artery. The anatomic features, the possible high prevalence of associated aneurysms of the anterior communicating artery complex as well as implications for surgical planning or endovascular treatments are outlined and embryologic considerations are discussed. CONCLUSION: To the best of our knowledge, this is a very rare illustrated case of an inter-optic course of a unique precommunicating anterior cerebral artery with aberrant origin of an ophthalmic artery.

Spinal lesions in multiple myeloma: Primary bone tumors with distinct prognostic factors.

PURPOSE: Although prognostic factors of spinal multiple myeloma (MM) seem to differ from those of other spine metastases (SpM), the data in the literature remains scarce. METHODS: A prospective population of 361 patients treated for spine MM lesions between January 2014 and 2017. RESULTS: OS for our series was 59.6 months (SD 6.0 months; CI 95%: 47.7-71.3). Cox multivariate proportional-hazards analysis showed that bone marrow transplant [HR: 0.390, 95% CI 0.264-0.577; p < 0.0001] and light-chain isotype [HR: 0.748, 95% CI 0.318-1.759; p = 0.005] were independent predictors of longer survival. In contrast, age >80 years [HR: 2.7, 95% CI 1.6-4.3; p < 0.0001], ISS III [HR: 2.510, 95% CI 2.01-3.124; p = 0.001], IgA isotype [HR: 1.475, 95% CI 1.031-2.11; p = 0.034] and IgD/M isotype [HR: 2.753, 95% CI 1.230-6.130; p = 0.013] were independent poor prognostic factors. However, ECOG (p = 0.486), spine surgery (p = 0.391), spine radiotherapy (p = 0.260), epidural involvement (p = 0.259), the number of vertebra lesions (p = 0.222), and synchronous/metachronous timeline (p = 0.412) were not significantly associated with improved OS. CONCLUSIONS: Spinal involvement in the context of MM does not influence OS. The main prognostic factors to consider before spinal surgery are the characteristics of the primary MM disease (ISS score, IgG isotype and systemic treatment).

Cauda Equina Syndrome: Poor Recovery Prognosis Despite Early Treatment.

STUDY DESIGN: A prospective patient's database operated on a cauda equina syndrome (CES). OBJECTIVE: The aim of our study was to identify prognosis factors for favorable functional recovery after CES. SUMMARY OF BACKGROUND DATA: CES is a neurologic impairment of variable symptoms associating urinary, bowel, and sexual dysfunctions with or without motor or sensitive deficits caused by nerve root compression of the cauda equina. The definition of CES remains debated, as well as the prognosis factors for favorable functional recovery and the benefit of early surgery. METHODS: One hundred forty patients were included between January 2010 and 2019. Univariate and multivariate cox proportional hazard regression models were conducted. RESULTS: The patients were young with a median age of 46.8 years (range 18-86 yrs). At presentation, 60% were affected by a motor deficit, 42.8% a sensitive deficit, 70% urinary dysfunctions, and 44% bowel dysfunctions. The mean follow-up was 15.5 months. Bilateral motor deficit (P = 0.017) and an initial deficit severity of 0 to 2 (P = 0.001) represented prognosis factors of poor motor recovery. Initial anal incontinence (P = 0.007) was associated with poor bowel recovery. Only 32.8% of the patients went back to work. Initial motor deficit (P = 0.015), motor sequelae (P = 0.001), sphincter dysfunctions sequelae (P = 0.02), and long LOS (P = 0.02) were poor return-to-work prognosis factors. Time to surgery within an early timing < 24 or 48 hours or later did not represent a prognosis factor of recovery in CES. Incomplete versus complete CES did not show better recovery. CONCLUSION: CES remains a profound disabling syndrome with poor functional prognosis: in the long run, few patients go back to work. The main prognosis factors established in our series regarded the initial severity of deficits whether motor or sphincteral. Early or later surgical cauda equina decompression did not show to represent a prognosis factor for functional recovery.Level of Evidence: 4.

Hydrogen Peroxide Skull Base Specimen Preparation: Singular View of Hidden Topographic Anatomy.

AIM: To present the technical principles of the hydrogen peroxide head preparation method, and to demonstrate the high quality of anatomical studies performed using these specimens, particularly for arachnoid exploration. MATERIAL AND METHODS: Five cadaveric heads were set with a 10% formalin solution and then injected with coloured latex. Thereafter, the heads were bleached with hydrogen peroxide solution 20%. Anatomical dissection of all specimens was performed. The skull base was drilled, dura mater gradually resected and outer arachnoid membranes examined and opened. The topographical anatomy was studied. RESULTS: All soft tissues, the brain, cranial nerves, the vasculature, the dura mater and even the arachnoid, were macroscopically intact, which enabled high-quality skull base specimens. In addition, the bone was softened, facilitating the drilling process. The topographical anatomy of anterior clinoid process was selected as an example and depicted in photos. CONCLUSION: High-quality anatomical specimens were obtained using the hydrogen peroxide head preparation. The topographic anatomy was studied from a unique downside-up angle, as well as by following the passage of the key neurovascular structures during its course. We propose the use of this method in neurosurgical training, especially to practice extradural approaches. Moreover this method seems promising as a complementary method for arachnoid studies.

Is the musculocutaneous nerve really in the coracobrachialis muscle when performing an axillary block? An ultrasound study.

BACKGROUND: In reference textbooks describing axillary block, the ulnar, radial, and median nerves are located in a common sheath surrounding the axillary artery. In contrast, the musculocutaneous nerve is described as lying outside this sheath in the coracobrachialis muscle. In a recent case report of ultrasound-guided axillary block, the musculocutaneous nerve was joined to the median nerve outside this muscle. Our study evaluated the prevalence of atypical musculocutaneous nerve localizations during axillary block. METHODS: All patients undergoing ultrasound-guided axillary block were included from December 2006 to December 2008. Before needle insertion, musculocutaneous, median, ulnar, and radial nerves were localized using ultrasound. Nerve stimulation confirmed atypical nerve localization. After injection of local anesthetics, musculocutaneous and median nerve anatomical relationships were observed. RESULTS: The musculocutaneous nerve was outside the coracobrachialis muscle in 83 of the 387 analyzed blocks (22%). It was near the axillary artery in 22 cases (6%). The musculocutaneous and median nerves appeared as a common neural structure in 61 cases (16%). After local anesthetic injection, a common trunk persisted in 16 of 61 cases (26%), musculocutaneous and median nerves separated in 37 cases (61%), and 2 roots of the median nerve appeared (with or without a separated musculocutaneous nerve) in 6 cases (10%). Two cases (3%) remained undefined. Ulnar nerve location of the 83 patients with atypical musculocutaneous nerve position differed from the ones with a classical musculocutaneous nerve localization. CONCLUSIONS: During axillary block, the musculocutaneous nerve is outside the coracobrachialis muscle in 1 of 5 patients. This atypical location should be considered during performance of axillary blockade to avoid repeated IM puncture.

Anterior transpetrosal and subtemporal transtentorial approaches for pontine cavernomas.

OBJECTIVE: Pontine cavernomas are benign vascular lesions whose surgical treatment is challenging due to their localization. We report our experience in the surgical management of these lesions exclusively using a lateral, subtemporal transtentorial approach in high pontine lesions and an anterior petrosal approach in low pontine lesions. METHODS: We performed a retrospective study on a series of patients who were operated on for a pontine cavernoma in our neurosurgery department between 1987 and 2007. In the study, we detail the patients' clinical and preoperative radiological data and compare the two surgical techniques we used. Finally, we analyze the postoperative follow-up, the morbidity encountered according to the surgical approach used, and the long-term outcomes. RESULTS: We enrolled nine patients into the study. Six patients were operated on using an anterior petrosal approach. None of the patients died. Five patients were able to resume their former professional activity after surgery and were clearly improved following surgery. One patient was worse after surgery (hemiplegia and deafness). We used a subtemporal transtentorial approach in three of the patients. None of the patients died. Two of the patients were able to resume their prior professional activities without any sequels, and the third patient's condition worsened following surgery (temporal hematoma). CONCLUSION: The lateral surgical approach for pontine cavernomas constitutes a reasonable surgical alternative to the transventricular, suboccipital, retromastoid, or transclival approaches. Patient morbidity in both approaches is acceptable, and the long-term outcome is satisfactory with respect to sequels and the resumption of prior professional activity.

Peritumoral Edema/Tumor Volume Ratio: A Strong Survival Predictor for Posterior Fossa Metastases.

BACKGROUND: Twenty percent of all brain metastases (BM) occur in the posterior fossa (PF). Radiotherapy sometimes associated with surgical resection remains the therapeutic option, while Karnovsky performance status and graded prognostic assessment (GPA) are the best preoperative survival prognostic factors. OBJECTIVE: To explore the prognostic role of peritumoral brain edema in the PF, which has never been explored though its role in supratentorial BM has been debated. METHODS: A total of 120 patients diagnosed with PF metastasis who underwent surgical resection were included retrospectively in this analysis. Clinical data were retrieved from electronic patient medical files. The tumor volumes and their associated edema were calculated via manual delineation; subsequently the edema/tumor volume ratio was determined. RESULTS: In multivariate analysis with Cox multivariate proportional hazard model, the edema to tumor volumes ratio (hazard ratio [HR]: 1.727, 95% confidence interval [CI] 1.427-2.083; P < .0001) was identified as a new strong independent prognosis factor on overall survival (OS) whereas edema volume alone was not (P = .469). Moreover, BM complete resection (HR: 0.447, 95% CI 0.277-0.719; P < .001), low (0-1) World Health Organization status at diagnosis (HR: 2.109, 95% CI 1.481-3.015; P < .0001), high GPA class at diagnosis (HR: 1.77, 95% CI 0.9-2.9; P < .04), and postoperative brain irradiation (HR: 2.019, 95% CI 1.213-3.361; P < .007] were all confirmed as independent predictive factors for survival. CONCLUSION: The edema/tumor ratio appears to greatly influence OS in patients suffering from PF metastases unlike the extent of edema alone. This easily determined as well as strong prognostic factor could be used as an interesting tool in clinical practice to help the management of these patients.

Hydrogen Peroxide Head Preparation: Enabling Cuttings and Anatomic Studies of Skull Base Dura Mater and Arachnoid Without Use of Drilling.

INTRODUCTION: Anatomic pieces that are preserved using formaldehyde allow us to undertake high-quality skull base studies. However, extensive drilling is often necessary, which can lead to damages to the dura mater and thus arachnoid. Formaldehyde and hydrogen peroxide can soften the bone, which, in turn, can be easily cut with a scalpel or removed with a curette. After having discovered this technique by chance, our aim was to establish a study protocol of the skull base dura mater without the use of the drill. METHODS: Ten heads were set with a 10% formalin solution and then injected with colored latex. Five heads were then subsequently bleached with 20% hydrogen peroxide solution (HPS). The following were studied weekly: 1) macroscopic modification of the bone, dura mater, arachnoid and brain; 2) histology; 3) computed tomography scans; and 4) calcium concentration screenings were studied weekly. RESULTS: After several weeks (mean 6.1, range 5-8 weeks), all HPS specimens were flexible, similar to rubber in consistence. Geometrical bone cuts could be made while preserving all the surrounding anatomic structure (cranial nerves, dura mater, and vascular elements). Histologically, the dural and bone structure are preserved. The HPS cadavers appear to be radiologically demineralized. We note a significant calcium concentration augmentation in HPS solution after 1 month, 6 weeks, and 2 months compared with day 0. CONCLUSIONS: The softening of the bone, probably caused by decalcification from the use of corrosive chemicals present in hydrogen peroxide solution, can ease the cutting of the skull base geometrically, which is useful for anatomic and workshop studies.

Surgical Thrombectomy Combined with Bilateral Decompressive Craniectomy in a Life-Threatening Case of Coma from Cerebral Venous Sinus Thrombosis: Case Report and Literature Review.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke. Medical and neurointerventional strategies, such as in situ thrombolysis, are standard therapies. These techniques are insufficient when clinical deterioration arises from mass-associated effects and transtentorial herniation; in such cases, decompressive hemicraniectomy may be indicated. To the best of our knowledge, the association of open surgical thrombectomy with bilateral decompressive craniectomy has not been reported to date. CASE DESCRIPTION: A 45-year-old woman presented with extensive cerebral venous sinus thrombosis that was resistant to anticoagulation and endovascular therapies. Her clinical condition deteriorated until she became comatose, and bilateral hemicraniectomy combined with open surgical thrombectomy through the superior sagittal sinus was indicated. Computed tomography angiography confirmed postoperative maintenance of sinus permeability. The patient's clinical status improved dramatically, and she had a favorable outcome, including recovery of her functional independence to perform all activities of daily living (modified Rankin Scale score = 0). The follow-up period was 5 years. CONCLUSIONS: Open surgical thrombectomy combined with decompressive craniectomy is a lifesaving procedure that can lead to favorable outcome and should be considered for treatment of refractory malignant cerebral venous sinus thrombosis.

Therapeutic Failure in Trigeminal Neuralgia: from a Clarification of Trigeminal Nerve Somatotopy to a Targeted Partial Sensory Rhizotomy.

BACKGROUND: Trigeminal neuralgia (TN) is a severe unilateral facial pain involving 1 or more branches of the trigeminal nerve (CNV). Microvascular decompression is a standard curative treatment of pharmacoresistant classic TN. Alternative procedures used for secondary or idiopathic TN usually lead to a high rate of pain recurrence and sensitive deficits. Partial sensory rhizotomy (PSR) is one of these ablative procedures. However, the lack of anatomic knowledge about the somatotopy of CNV lead to variable results in pain relief and hypoesthesia. OBJECTIVE: To refine the somatotopy of CNV and bring new anatomic landmarks for PSR, studying a cohort of patients treated by a targeted PSR (TPSR). METHODS: Retrospective and consecutive cases of adult patients treated in our institution between March 2000 and June 2015 for pharmacoresistant TN without vascular compression were collected. Our surgical procedure was performed using a precision map of the somatotopy of CNV. We compared our results with other surgical and nonsurgical therapies. RESULTS: Twenty-two patients had undergone TPSR. Fourteen had an idiopathic TN without compression of the nerve root, 6 had a secondary TN caused by multiple sclerosis, and 2 had a trigeminal conflict by inoperable tumor. Complete pain relief was achieved in 86.4% of the patients. Postoperative hypoesthesia was partial and focalized (22.7%). TN recurrence rate at 5 years was 31.5% (standard deviation, 10.9%). CONCLUSIONS: We clarified the functional somatotopy of CNV in its juxtapontine portion. TPSR is an interesting alternative to other ablative procedures to treat pharmacoresistant TN without vascular compression.

The interperiosteodural concept applied to the jugular foramen and its compartmentalization.

OBJECTIVE The dura mater is made of 2 layers: the endosteal layer (outer layer), which is firmly attached to the bone, and the meningeal layer (inner layer), which directly covers the brain and spinal cord. These 2 dural layers join together in most parts of the skull base and cranial convexity, and separate into the orbital and perisellar compartments or into the spinal epidural space to form the extradural neural axis compartment (EDNAC). The EDNAC contains fat and/or venous blood. The aim of this dissection study was to anatomically verify the concept of the EDNAC by focusing on the dural layers surrounding the jugular foramen area. METHODS The authors injected 10 cadaveric heads (20 jugular foramina) with colored latex and fixed them in formalin. The brainstem and cerebellum of 7 specimens were cautiously removed to allow a superior approach to the jugular foramen. Special attention was paid to the meningeal architecture of the jugular foramen, the petrosal inferior sinus and its venous confluence with the sigmoid sinus, and the glossopharyngeal, vagus, and accessory nerves. The 3 remaining heads were bleached with a 20% hydrogen peroxide solution. This procedure produced softening of the bone without modifying the fixed soft tissues, thus permitting coronal and axial dissections. RESULTS The EDNAC of the jugular foramen was limited by the endosteal and meningeal layers and contained venous blood. These 2 dural layers joined together at the level of the petrous and occipital bones and separated at the inferior petrosal sinus and the sigmoid sinus, and around the lower cranial nerves, to form the EDNAC. Study of the dural sheaths allowed the authors to describe an original compartmentalization of the jugular foramen in 3 parts: 2 neural compartments-glossopharyngeal and vagal-and the interperiosteodural compartment. CONCLUSIONS In this dissection study, the existence of the EDNAC concept in the jugular foramen was demonstrated, leading to the proposal of a novel 3-part compartmentalization, challenging the classical 2-part compartmentalization, of the jugular foramen.

Spheno-Orbital Meningiomas Surgery: Multicenter Management Study for Complex Extensive Tumors.

BACKGROUND: Spheno-orbital meningiomas (SOMs) are complex tumors involving the sphenoid wing, the orbit, and sometimes the cavernous sinus with bone hyperostosis and sheet-like dural involvement. Optimal removal, proptosis cure, and visual preservation remain a challenge. OBJECTIVE: To study the management of surgically treated SOMs. METHODS: The clinical records of 130 consecutive patients undergoing surgery for SOMs were retrospectively collected in a database during a 20-year period to analyze symptoms, surgical technique, clinical outcome, and follow-up. RESULTS: Among the 130 patients (mean age 51.2 ± 9.5 years), 91.5% were female. The most typical symptoms recorded were proptosis in 94.6%, visual impairment in 37.7%, and oculomotor paresis in 10.0%. Simpson grade I-II removal was achieved in 97 patients (74.6%). After 1 year, proptosis was improved in 60% of cases. A total of 44.9% of the patients with preoperative visual acuity impairment were improved. Periorbital excision was statistically linked to proptosis decreasing (P = 0.0001) and optic canal decompression was linked to visual stabilization (P = 0.03). Bone reconstruction prevented temporal muscle atrophy (P = 0.01) and unaesthetic results (P = 0.0001). Mean follow-up was 76.5 months (range 3-288 months), and the mean time for recurrence was 54.2 months. CONCLUSIONS: A single-stage optimal surgery with bone reconstruction appears to be the best first-line treatment, on a case-by-case analysis. Optic canal decompression and periorbital excision have to be performed in case of visual disturbance and proptosis. SOMs require a long-term follow-up because of a delayed high rate of recurrence.