Surgical treatment of vertebral metastasis.

Fifty-seven patients with spinal metastases underwent 60 operations. 36 patients were operated on by anterior approach with decompressive coporectomy and stabilization by metal and methylmetacrylate and 24 patients by laminectomy and/or stabilization by osteosynthesis. Postoperative improvement of the pain syndrome was observed after 56 operations. Neurologic signs were present in 23 patients with paraplegia (5 patients) or paraparesis (18 patients); 15 of the latter patients improved and recovered walking capacity. Two types of metastasis were distinguished: corporal metastasis, in which vertebral wedging and posterior protrusion led to neural deficit, with a good prognosis if treated by anterior surgery, and pericordal metastasis in which the cord compression is due to metastatic proliferation into the spinal canal. Results after decompressive surgery, either by posterior or anterior approaches are more doubtful. Surgery is beneficial and should be preferred to radiation when there is medullary compression by corporal metastasis and also in the presence of intense pain or potential instability of the spine.

[Aging of the pancreas. Its implication in malnutrition states in elderly persons]. / Vieillissement du pancréas. Son implication dans les états de dénutrition chez les personnes âgées.

The influence of ageing on exocrine pancreatic function was investigated in rats and in men. Young rats (3-months old, 150-200 g) and old rats (24-month old, 400-500 g) were killed after fasting overnight. Small pancreatic fragments were removed and kept for stereological analysis both in light and electron microscopy; in addition, levels of tritium-labelled leucine uptake and protein synthesis were measured by quantitative histoautoradiography on isolated acini in vitro. The human study was conducted retrospectively in 27 adults (mean age 36 +/- 1.5 years) and in 28 elderly subjects (mean age 72 +/- 0.6 years) with no clinical or radiological evidence of pancreatitis. Duodenal aspirates were taken over a 90 min period under secretin (0.5 U/kg.h) and cerulein (75 U/kg.h) infusion for comparisons of bicarbonate, lipase, chymotrypsin and amylase concentrations and outputs in the two groups. Elderly people were found to have significant and parallel decreases in bicarbonate, lipase and amylase output as compared to younger subjects (-40 per cent, P less than 0.001). The pancreatic deficiency was confirmed in rats by a significant decrease in zymogen volume density and zymogen diameter and a defect of protein synthesis with significant slowing down (-70 per cent, P less than 0.001) of newly synthesized protein transfer to the Golgian zone of acinar cells. Signs of exocrine parenchyma dystrophy (pancreatitis?) were also observed.

[Vertebral osteoid osteoma. Diagnostic problems apropos of 3 cases]. / L'ostéome ostéoïde vertébral. Problèmes diagnostiques à propos de trois cas.

One osteoblastoma and two osteoid osteomata were seen in cervical, dorsal and lumbar spines. In the three cases, the diagnosis was made by scintigraphy. In one case, a tomodensitometric (C.A.T.) scan was negative. In two cases the patients had been previously referred to Psychiatrists and in one case there was a painful scoliosis. A review of the literature was made. The value of scintigraphy is considerable and tomodensitometry allows a better localisation of the lesion. Complete excision has led to a complete cure in all cases. In one case, resection of the isthmus led to hypertrophy of the opposite isthmus.

[Treatment of secondary cancer of the spine]. / Le traitement du cancer secondaire du rachis.

Sixty spinal metastases have been treated surgically. In 22 cases a posterior approach was made with decompression laminectomy and internal fixation. In 38 others an anterior approach was made to resect the vertebral body and replace it by cement. In the thoracic and lumbar spines, internal fixation after a posterior approach led to secondary displacement in five cases out of nine. In contrast, spines approached anteriorly remain stable. The results were analysed after a follow-up period ranging from six months to four years. In most of the cases there was a dramatic improvement in spinal and radicular pain. Twenty-three cases had neurological impairment and in 15 of them this was improved, sometimes with complete recovery. The authors consider that surgery is indicated in metastasis of the vertebral body with collapse of the vertebra and bony compression of the spinal canal. In these cases radiotherapy is relatively ineffective. In contrast the results obtained after surgery in cases with epidural involvement are not better than those obtained by radiotherapy. Surgery should therefore be used only in radioresistant tumours.

[Contribution of pirprofen to the medical treatment of radicular neuralgia]. / Apport du pirprofène dans le traitement médical des névralgies radiculaires.

A multicentric therapeutic double blind study, conducted according to the incomplete block method and including 108 observations from 5 hospital centers, was conducted among patients suffering from acute radicular, sciatic, cervico-brachial or crural neuralgia. The purpose was to compare the analgesic effect of 4 treatments given in single dose: pirprofen 200, pirprofen 400, ketoprofen 150 and placebo. Overall analysis showed a significant decrease in pain during the 4 hours following administration of the products and in all groups. However, pirprofen 400 and ketoprofen 150 mg caused a decrease in painful phenomena, more intense than that induced by pirprofen 200 and placebo. The great heterogeneity among the different treatment centers led the investigators to carry out a second analysis limited to the 4 most homogeneous centers. This analysis, of 84 observations, shows clearly the analgesic efficacy of both doses of pirprofen and ketoprofen compared to placebo. It also emphasizes the rapidity of action of pirprofen compared to the other products. The overall tolerance of the tested products was good. In the treatment of acute radicular neuralgia, pirprofen 400 mg is active in comparison to the placebo and more quickly effective than ketoprofen 150 mg.

[Natural cytotoxic function and ankylosing spondylitis]. / Fonction cytotoxique naturelle et spondylarthrite ankylosante.

Natural Killer (NK) cell function was evaluated in 28 ankylosing spondylitis (AS) patients (21 B27 positive), at one hand by the use of a Leu7 (HNK-1) monoclonal antibody, at the other hand by spontaneous cytotoxicity against a K562 cell line (preincubated with a fluorogenic substrate) evaluated by a flow cytometric assay. There is no difference in NK cell activity neither between AS patients and controls nor between B27 positive and negative AS. The study brings no evidence for a NK function control by the B27 gene. There is no correlation between NK activity and each of the other parameters investigated (ESR, B2m, IgA, Leu7, T4/T8). At the opposite, NK activity is significantly decreased (p = 0,006) in AS patients under NSAIDs treatment compared with non treated patients. NSAIDs rather enhance NK activity, the decrease observed in the present study could be due to evolution of the disease itself, and may be a pathogenetic factor contributing to remaining of bacterial antigens according to the current hypothesis of the disease's aetiology.

[Intravertebral gaseous lucency. Apropos of 7 new cases]. / L'image de clarté gazeuse intra-vertébrale. A propos de 7 nouvelles observations.

The authors report a personal series of 7 new cases with an appearance of intra-vertebral gaseous lucency, which was described by Maldague et al. [16] in 1978. They found the majority of the features of the disease as described in the 44 cases reported in the literature: advanced age, female predominance, predilection for the thoraco-lumbar junction, constancy of diffuse bony demineralization and the possibility of metabolic disturbances. Case no 2 suggests the hypothesis of a pathology induced by bismuth salts and cases no 3 and 4 raise the question of the benign nature of this appearance. Finally, the authors show that this image is not so much rare as mis-diagnosed. 4 of the 7 cases were found during a retrospective study of 140 case-files.

[Hypophosphatasia in adults. Apropos of 2 cases]. / L'hypophosphatasie à l'âge adulte. A propos de 2 observations.

Two very dissimilar cases of hypophosphatemia in the adult patient are described by the authors. The first case was symptomatic since childhood, with typical clinical and radiologic findings (fissures, diaphyseal bone spurs, bony deformities), whereas the second case was minimally symptomatic (loss of teeth and back pain). Articular chondrocalcinosis was observed in both cases, as was a decrease in alkaline phosphatase and the increased urinary excretion of phosphoethanolamine. Histological examination demonstrated an increase in osteoid. Review of the literature revealed 40 cases of this inborn error of metabolism seen in adulthood, enabling a detailed description of the characteristics of this polymorphic condition.

[Metastatic chordoma. General review apropos of 2 cases]. / Les chordomes métastasants. Revue générale à propos de deux observations.

The authors report on two cases of sacrococcygeal chordoma, with complications involving visceral organ metastases and distal bony metastases. Chordomas are malignant tumors which develop in adult subjects which originate from remnants of the embryonic notochord. Sacrococcygeal localization is found in 50% of the 1,300 cases reported in the medical literature, which represents 20% of sacrococcygeal tumors observed. The difficulty and the delay in diagnosing these tumors should decrease by routine CAT scan examination. Diagnostic certainty is based on histological examination, often suggestive of the diagnosis (physaliphore-like cells), possibly combined with ultrastructure and immunohistological study. The clinical course involves local recurrences, but there is a real risk of metastatic development, notably in the case of sacrococcygeal chordomas, with their incidence estimated at 17.5% of cases. Sometimes developing in later stages of their course, histological findings are similar to those of the initial lesion. Organs which are frequently the sites of metastases are the lung (48% of cases) and bone (26%), then the lymphatic organs, the liver, and subcutaneous tissue... Therapeutic management is unsatisfactory, with ideally, complete surgical excision of the initial tumor of its size permits and hence early diagnosis of this condition is a prerequisite for good results.

[Serum beta 2-microglobulin and ankylosing spondylitis]. / Bêta-2-microglobuline sérique et spondylarthrite ankylosante.

The serum beta-2-microglobulin (B2-m) was evaluated by radio-immunoassay in 28 patients with ankylosing spondylarthritis. The mean B2-m level is within normal limits. There is no overall correlation with other biological or immunological parameters (Sed Rate, IgA, CD3+, CD4+, CD8+, Leu 7, NK activity). There is no difference between treated and untreated patients, between patients with recent or old disease. On the contrary, the mean the mean B2-m level is significantly lower in patients B27 positive, as compared with B27 negative. The possible role of anti-B2-m antibodies interfering with the serum B2-m assay discussed.

[Bone necrosis during osteomalacias]. / Les nécroses osseuses au cours des ostéomalacies.

On the basis of 3 personal cases, the authors study the characteristics of osteonecroses during osteomalacias. They compare their findings to those in the literature. Clinically, the location at the femoral head is predominant, with absence of pain and functional tolerance often noted. On the radiological level, the demineralization of the skeleton is not constant, and there are few Looser-Milkman striae. In the lower limbs the necrosis is always located in the supporting areas, showing a restricted surface with little or no perinecrotic condensation and an absence of bone sequestrum. The cartilage remains intact for long periods. A pathogenic interpretation is proposed: the increasingly fragile state of the bones causes a subchondral fatigue fracture. The malacia bone thus adapts itself to the mechanical constraints thus imposed on it.

Receptors for cholecystokinin and gastrin peptides display specific binding properties and are structurally different in guinea-pig and dog pancreas.

In the light of the strong potency of gastrin-related peptides on pancreatic exocrine secretion in dog, we analyzed the binding properties of peptides related to cholecystokinin (CCK) and gastrin on dog pancreatic acini compared to guinea-pig acini. Moreover, we determined apparent molecular masses of photoaffinity labelled CCK/gastrin receptors in the two models. Using the CCK radioligand, receptor selectivity towards CCK/gastrin agonists and antagonists was found to be lower in dog acini than in guinea-pig acini. Performing the binding with CCK and gastrin radioligands in combination with N2,O2'-dibutyryl-guanosine 3',5'-monophosphate, revealed that in dog acini there exist two different sub-classes of CCK/gastrin receptors having high and low selectivity, the latter ones being able to bind gastrin with high affinity (Kd = 2.1 nM). SDS-PAGE analysis of covalently cross-linked receptors using several photosensitive CCK and gastrin probes of different peptide chain lengths demonstrated that in guinea-pig, CCK peptides bound to a 84-kDa component whereas in dog pancreas, CCK and gastrin peptides bound to three distinct molecular species (Mr approximately equal to 78,000, 45,000, 28,000). Performing cross-linking in the presence of 1 microM CCK indicated that a 45-kDa protein is the putative CCK/gastrin receptor in dog pancreas. Our results support the concept of heterogeneity of CCK/gastrin receptors.

Effect of long-term intraluminal perfusion of pentagastrin on rat small-intestinal mucosa.

Mucosal changes occurring during long-term intraluminal perfusion of pentagastrin in the duodenum of conscious adult rats (100 micrograms/24 h/kg, 6 days) were studied. Significant increases of labelling and of mitotic indices were noted in the whole small intestine, with an enlargement of the crypt epithelial proliferative compartment. Differential kinetic variations were observed between upper and lower parts of the small intestine when labelling indices were measured in accordance with the cell position in the crypts. Kinetic variations were correlated to the increases of villous and microvillous area. Alkaline phosphatase and leucine-aminopeptidase-specific activities were significantly increased, suggesting modifications of synthesis and/or maturation of these enzymes. The ileal Paneth cell number was also significantly increased in the ileum. Pharmacologic doses of pentagastrin intraluminally perfused have a trophic effect at all levels of the small-intestinal mucosa.

[Unusual muscular manifestations in a case of Horton's disease]. / Manifestations musculaires inhabituelles au cours d'une maladie de Horton.

The authors report the case of a 66-year-old woman with temporal arteritis. The unusual muscular involvement consists in proximal muscle wasting, electromyographic changes and increased muscle enzyme levels. The improvement of these objective manifestations under steroid therapy allows to include them in the systemic spectrum of temporal anteritis. Attention is drawn to the infrequency of such objective manifestations published in the literature on temporal arteritis or polymyalgia rheumatica.

Bronchoalveolar lavage in ankylosing spondylitis.

Bronchoalveolar lavage and bronchial biopsies were performed in 15 patients with ankylosing spondylitis (AS) and 17 control subjects. There was no difference in total cell count, number of lymphocytes, CD4+/CD8+ ratio, or beta 2 microglobulin concentrations in bronchoalveolar lavage fluid between these two groups. Bronchoalveolar lavage IgA concentrations were not increased, but bronchial IgA deposits were more common in AS. This study failed to show any subclinical alveolitis in AS.

[The kidney in Still's disease in adults]. / Le rein de la maladie de Still de l'adulte.

Renal involvement during Still's disease in the adult is rarely mentioned in the literature. Proteinuria and hematuria are frequently reported during systemic involvement in the disease but, conversely, observations including an anatomical account of the kidney are rare: amyloidosis is mentioned the most often (5 compatible cases), while other cases are more disparate: non specific glomerulitis (4 cases), glomerulonephritis with mesangial deposition of IgA (2 cases), tubulo-interstitial nephritis; these different non specific aspects may correspond to an immune complex disease. The apparent rarity of renal investigations is a factor in marking out Still's disease in the adult from other systemic diseases.

Degenerative spondylolisthesis, synovial cyst of the zygapophyseal joints, and sciatic syndrome: report of two cases and review of the literature.

Two cases of sciatica secondary to nerve root compression by a "synovial cyst" of a zygapophyseal joint are described. In light of these 2 cases and on reviewing the literature, it appears that zygapophyseal joint osteoarthritis with degenerative (or articular) spondylolisthesis can be a predisposing factor to the formation of such synovial expansions and, consequently, the cause of nerve root compression. The coexistence of a lumbar degenerative spondylolisthesis with a radicular syndrome should therefore encourage early investigation by computed tomography scan, so that conservative treatment would not be unnecessarily prolonged.