[Evaluation of the clinical and radiological results of cervical longitudinal median somatotomy without graft]. / Evaluation des résultats cliniques et morphologiques de la somatotomie cervicale médiane longitudinale sans greffe.

OBJECTIVES: To evaluate the clinical and radiological results of cervical longitudinal median somatotomy without graft, used for the treatment of cervical myelopathy and radiculopathy, and compare it to techniques with graft and to laminectomies. MATERIAL AND METHOD: Thirty-four patients (25 males and nine females), with a mean age over 60 years, were included in a study comparing pre- and postoperative clinical status on the Japanese Orthopaedic Association (JOA) functional scale and radiological status with evaluation of the cervical curve on plain films and dynamic tests in flexion and extension. RESULTS: No significant difference was found with the clinical and anatomical results published in the literature concerning median somatotomies performed with graft and/or osteosynthesis and laminectomies and their variants. CONCLUSIONS: The cervical longitudinal median somatotomy without graft is an easy and reliable technique that can be proposed as first-line treatment for cervical spondylotic myelopathy related to anterior compression. It decreases the cost and the duration of the surgical procedure, it protects the patient from the complications and sequelae related to graft harvesting and the use of implants. It should be limited to patients without preoperative kyphosis who are over 50 years old.

Phase II study of a radiotherapy/etoposide combination for patients with newly malignant gliomas.

PURPOSE: Etoposide, a semisynthetic derivative of podophyllotoxine, is a topoisomerase II inhibitor. This drug is currently used in several types of human cancer. The aim of this study was to evaluate the efficacity and tolerance of a near-concurrent association of radiotherapy and etoposide for newly malignant gliomas. METHODS: From May 1995 to December 1996, 30 malignant glioma patients were included in this phase II study; 16 patients underwent surgical tumor resection, and a stereotactic biopsy was performed in 14 patients. Standard cranial irradiation and six courses of etoposide (100 mg/m2, x days 1-3) were administered. The first course of etoposide was administered on days 1-3 of radiotherapy and was resumed in the week following the end of radiotherapy. Treatment was consolidated by further courses of etoposide every 4 weeks. RESULTS: Only 26 patients could be evaluated for the purpose of our study. The median age was 60.1 years, and the median Karnofsky performance score (KPS) was 80.2. The rate of objective response for evaluable patients was 34.6%, and four complete responses (CR) and five partial responses (PR) were noted. The median survival (MST) was 12 months, and the average overall survival was 12.5 months. Hematological toxicity was mild, and grade 3 or 4 neutropenia (white blood cell count < 1500/ml) was noted in three patients, without any sepsis or bleeding. CONCLUSIONS: The results obtained in this study are comparable to the best reported results on the combination of radiotherapy and nitrosoureas. The near-concurrent combination of radiotherapy and etoposide seems to be effective and well tolerated in the treatment of newly malignant gliomas.

Cervical root compression by a loop of the vertebral artery: case report.

A case of an abnormal loop of the extracranial vertebral artery enlarging the intervertebral foramen at C5-C6 and the transverse foramen at C5 is reported. This occurrence is rare and was associated with cervicobrachial neuralgia caused by neurovascular compression of the C6 root. The patient was cured by microvascular decompression.

[Post-traumatic syringomyelobulbia and inferior vertical nystagmus]. / Syringomyélobulbie post-traumatique et nystagmus vertical inférieur.

A case of post-traumatic cervico-thoracic syringomyelia was complicated, 3 years after the injury, by a bulbar extension manifested by a downbeat vertical nystagmus which became a source of disabling oscillopsia. The syringobulbia was visualized at MRI. The usefulness of syringostomy in such a case is discussed.

[Spontaneous spinal epidural hematoma: 2 cases]. / Hématome épidural rachidien spontané: 2 cas.

The authors report on two cases of spontaneous spinal epidural hematomas with atypical subacute clinical presentation and good recovery after surgical treatment. Etiologies, physiopathology, early diagnosis and treatment are considered through a brief review of the literature.

[Solitary fibrous tumor of the meninges]. / Tumeur fibreuse solitaire des méninges.

We report a case of solitary fibrous tumor (SFT) of the meninges. SFTs have been initially described in the pleura. SFTs show similar histological findings as in other locations. SFTs show a diffuse positive staining for vimentin and CD34. Meningeal SFTs have usually a favourable outcome. These tumors have to be essentially distinguished from hemangiopericytomas and fibrous meningiomas. Immunostaining for CD34 is of value for this purpose. CD34 expression is often patchy and weaker in hemangiopericytomas whereas it is rarely observed in fibrous meningiomas. It is of great interest to isolate SFTs from hemangiopericytomas because of their favourable outcome.

[Peroperative spinal cord ultrasonography in neurosurgery]. / L'échographie médullaire per-opératoire en neurochirurgie.

Intraoperative spinal sonography is a new method of investigation. We are reporting 14 observations. The results of these explorations permit to describe the normal spinal sonography and a spinal ultrasonic semeiology. We underline the advantage of this technic in the neurospinal surgery particularly to locate the tumors and to facilitate the removal.

[Acute pituitary necrosis after multiple pituitary stimulation test]. / Nécrose hypophysaire aiguë après test de multistimulation hypophysaire.

Iatrogenic necrosis of the pituitary gland is well-known but rarely caused by stimulation tests used to investigate pituitary adenomas; 26 cases have been reported in the literature. We report 2 new cases where the chronology of the events suggests the sudden necrosis resulted from stimulation tests. Several mechanisms have been proposed. It is not possible to define increased risk as a function of the adenoma histology. In most cases, voluminous tumors are revealed by visual dysfunction. These accidents should not overshadow the role of function tests in neurosurgical situations. Outcome is usually favorable after acute necrosis.

[Ultrasonically guided biopsy of cerebral tumors]. / Biopsies échoguidées des tumeurs cérébrales.

The authors have not an installation for stereotaxic neurosurgery. In this condition they have used for 3 years real-time ultrasonography to guide the biopsy of deep-seated brain lesions. For adopting finally their method, a preliminary study of 31 patients has been performed. This method is not available for superficial lesions (two failures) which are in the blind area of the probe. In 29 cases the lesion has been clearly identified and biopsed. Histologic diagnosis has been correct in 26 cases (90 percent), incorrect in 3 cases (lesion too necrotic in 2 cases, non specific gliosis in 1 case). The simplicity of this method, its innocuity and its low cost (versus sterotaxy) and its others applications prove its high interest for neurosurgery.

[Clinical recurrence of Cushing syndrome without evidence of tumor recurrence: radical hypophysectomy?]. / Les récurrences cliniques de la maladie de Cushing sans récidive tumorale documentée: hypophysectomie radique.

Outcome following radiation therapy for hormonally-active Cushing adenoma is reported. Conventional radiation using 20 to 30 grays improved mass and hormone level in 30 to 80% of the patient. Gamma-knife radiosurgery was at least as effective. These results are discussed in this review.

[Lumbar discal hernia after 65 years of age]. / Considérations sur les hernies discales lombaires au-delà de 65 ans.

The authors make a retrospective study of a series of 200 patients who had been surgically treated, within a period of 26 months, for a lumbar discal pathology. Twenty of these (20%) were over 65 years old. A similar study was carried out in a rheumatological unit over a period of three years, and has included 266 patients, 21 of whom (7,8%) were older than 65. The comparison of both these series permits us to make some considerations concerning the frequency of this pathology after the age of 65, its clinical presentation and its treatment, which, as for the younger adult, must be surgical when the correct treatment fails and when a complication appears.

[Intramedullary bronchogenic cyst. Apropos of 1 case. Discussion of the endo-ectodermal adhesion syndrome]. / Kyste bronchogénique intramédullaire. A propos d'un cas. Discussion du syndrome d'adhésion ento-ectodermique.

The authors report the case of a 40-year-old man who has presented for many years an intermittent progressive spastic paraplegia. Plain films of the spine show very important dysraphic abnormalities of the inferior dorsal column and the myelography shows a complete block suggesting an intramedullary space-occupying lesion at four levels above the vertebral abnormalities. The operation permits a total removal of an intramedullary "bronchogenic cyst". In the post-operative course, the neurologic deficit improves, six months later a spastic paraparesia remains. The review of the literature shows that this is an exceptional observation. Intramedullary bronchogenic cysts must be regarded as similar to intramedullary enterogenic cysts. They are not teratomas but dysembryoplasiae due to failure of the ento-ectoblastic separation between the second and the third weeks of life. These cysts form a part of the "ento-ectodermal adhesion syndrome" of Prob et al. The preoperative diagnosis is possible on the association of intermittent progressive syndrome of medullary compression and dysraphic spondylotic changes. The total surgical removal of the cyst, by micro-surgical techniques, is able to preserve the neurologic evolution with an excellent result if the operation is performed before definitive neurologic deficits occur.

[Intra operative embolization of unresectable cerebral arterio-venous malformations. Occlusion attempt by means of a delayed polymerization mixture. Report of two cases (author's transl)]. / Embolisation per-opératoire des malformations artério-veineuses cérébrales inextirpables: tentative d'oblitération par un mélange à polymérisation retardée. A propos de deux cas.

Two cases of unresectable intra-cranial arterio-venous malformation (AVM) are reported, treated by direct intra-operative embolization. A 50% mixture of Butyl-2-Cyano-Acrylate and Mono-Iodo-Stearate of Ethyle (Duroliopaque) was used after catheterization of some of the feeding cortical arteries. No intra-operative angiography was performed. The first patient, admitted after subarachnoid hemorrhage and presenting with a mild transient right hemiparesia and aphasia, showed evidence of a left temporal AVM with a left middle cerebral artery supply and contribution from the left cerebral posterior artery. The AVM was embolized with 3 cc of the mixture. A mild aphasia occurred after surgery and completely recovered after two weeks. Roughly half of the AVM was occluded on the postoperative angiograms. The second patient suffering from a long history of seizures had a huge right frontal AVM, with a right middle cerebral artery and right anterior cerebral artery supply, and contribution from a right lenticulostriate artery, the left anterior cerebral artery and the right posterior cerebral artery. The AVM was embolized with 7 cc of the mixture. A complete palsy of the left upper limb occurred after surgery, with complete recovery after two weeks. On the post-operative angiograms, more than three fourth of the AVM was occluded.

[Treatment of chronic hydrocephalus in adults by lumboperitoneal shunt. Results and indications apropos of 82 cases]. / Traitement de l'hydrocéphalie chronique de l'adulte par dérivation lombo-péritonéale. Résultats et indications à propos de 82 observations.

Patients with chronic hydrocephalus are most often aged people and in bad general condition. It seems that treatment may be more simplest possible and the less iatrogenic. Furthermore, the diagnosis of chronic hydrocephalus is not often certain, and can be generally assert after the good result of the CSF shunting. Since 1985, when hydrocephalus appears communicant, a lumboperitoneal shunt was systematically implanted in the aim to decrease the number of complications due to ventricular shunts. The operation can be performed on neuroloptanalgesia and/or local anesthesia. Post-operative orthostatic intracranial hypotension can be prevented by using valves with opening pressure varying with the position or valves with a flow depending of the opening pressure. Our clinical series includes 82 patients (51 males and 31 females), aged from 27 to 88 years (average 55 years). In 47 cases, hydrocephalus was idiopathic and in 35 cases hydrocephalus was secondary to an identified aetiology: subarachnoid or intracranial hemorrhage (20 cases), post-traumatic (11 cases), post meningitic (1 case) and post anoxic (1 case). In this last case, physiopathological mechanism was unclear. The middle delay between the first symptom and the operation was greater than 6 months for the majority of observations, but in few cases, precoce shunting was performed (between 1 to 3 months) in post S.A.H. and post traumatic hydrocephalus when C.T. Scan shows increasing ventricular size. Clinical results are evaluated after 2 months and at long term, and complications analysed. The lumbo-peritoneal shunt gives same results on the clinical symptoms, and less iatrogenic complications than ventricular shunts.(ABSTRACT TRUNCATED AT 250 WORDS)

[Giant traumatic aneurysms of the internal carotid developing in the sphenoid sinus. Apropos of 2 cases]. / Les anévrysmes traumatiques géants de la carotide interne développés dans le sinus sphénoïdal. A propos de 2 cas.

Two cases of traumatic aneurysms of the internal carotid artery developed into the sphenoidal sinus are reported by the authors. It is a very rare pathology (about fifteen cases are reported in the literature). Recurrent epistaxis are the most frequent symptom associated or not with a sphenoidal sinus syndrome. Our first observation corresponds to this description but the second suggests a tumour of the sphenoidal base. The diagnosis is performed by carotid angiography. The treatment consists of the exclusion of the aneurysm by ligating the cervical internal carotid artery or by trapping the aneurysmal segment. This treatment has produced a good result in nine cases of the literature and in our two cases. The direct approach of the aneurysm is very difficult, but the endovascular techniques can be performed in the future.

[Anterior osteosynthesis of the cervical spine by phusiline bioresorbable screws and plates. Initial results apropos of 5 cases]. / Ostéosynthèse antérieure du rachis cervical par vis et plaques biorésorbables en Phusilines. Résultats préliminaires à propos de cinq cas.

The authors have designed a biocompatible and bioresorbable plate (1) in Phusilines* for anterior cervical interbody stabilization. Phusilines* are polymer of alpha hydroxyacid (poly lactic acid), and their in vivo degradation (in lactic acid and via the Krebs circle, in water and carbon dioxide), is complete within 18 months. Screws are available in the same material. Phusilines* are radiotransparent and do not interfere with MRI. The size and shape of the plate have been determined with three dimensional computed tomography, their thickness and their molecular weight and chemical structure have been determined to obtain the best compromise in mechanical properties and time of resorption. Biomechanical studies have been performed in cadaver, and have showed a good quality of the osteosynthesis. Five patients with anterior cervical disco-ligamental instability were operated on according the french law of bioethic (Huriet Law). In these five cases the operation was performed via antero lateral approach, and it consisted in a interbody xenograft with Surgibone (2) and interbody osteosynthesis with a plate and four screws of 16 mm of length and 4 mm of diameter. Clinical and radiological examinations were realised during 18 months. In all cases, clinical results in rachialgia and neurological signs were excellent, in four case the tolerance was excellent, in a case inflammatory phenomens were observed the 8th and the 14th month successfully treated with non steroid anti-inflammatories. Anatomical results were excellent in two cases, good in two cases and incomplete in one case. Reasons of these incomplete results are discussed. These preliminary results are sufficient to continue these implantations.

[Spontaneous rhinorrhea disclosing intranasal meningoencephalocele and ependymoma of the 4th ventricle]. / Rhinorrhée spontanée révélatrice d'une méningoencéphalocèle intranasale et d'un épendymome du IVe ventricule.

The authors report a case of a spontaneous rhinorrhea due to an intranasal meningoencephalocele associated with a benign, perhaps congenital, ependymoma of the floor of the fourth ventricle. The tumour was initially unknown, because clinical symptoms suggested a congenital aqueductal stenosis (macrocrania, no neurological signs, association with a congenital defect of the cranial base). This observation, which belongs to "hypertensive spontaneous rhinorrhea" suggests that the C.S.F. fistula is possible only when hydrocephalus coexists with a congenital abnormality of the cranial base. Therapeutic problems are discussed: the direct approach of the fistula alone is most often insufficient, the treatment of the hydrocephalus alone is possible, but may induce a tension pneumocephalus, the best attitude is the treatment in the same stage, of the fistula and the hydrocephalus. But, in case of chronic non communicant hydrocephalus, aqueductal tubing or ventriculocisternostomy can be insufficient and permanent internal C.F.S. derivation may be performed.

[Anterior sacral meningocele. Apropos of 11 cases]. / Méningocèle sacrée antérieure. A propos de onze cas.

The authors report 11 cases of anterior sacral meningocele, cystic mass connected with lumbar sac through a sacral bony defect: 2 children and 9 adults. Clinic presentations are analysed. Examination including, X ray, ultrasonography, scanner is discussed. The authors believe that these lesions must be treated surgically because a risk of rupture in the rectum with important meningitis exists. There is also a septic risk if an error of diagnosis ends at a puncture. The transacral approach is easy and it gives the best results.

[Cerebral aspergillosis. Apropos of 4 cases]. / Aspergillose cérébrale. A propos de quatre observations.

Four patients with aspergillosis of the central nervous system collected in less than two years are reported. Three patients had hematologic malignancies (acute myelogenous leukemia, Hodgkin's disease) and were treated with corticosteroids and chemotherapy. One patient received antimicrobial agents fort a post operative meningitis (after acoustic neuroma surgery). Analysis of these cases and review of literature available us to point out the increased frequency of invasive and cerebral aspergillosis particularly in immunocompromised hosts treated by cytotoxic drugs or broad spectrum antibiotic therapy. Diagnosis is very difficult because: --there are non specific radiologic features for aspergillus granuloma, abscess, aneurysm or meningitis, --blood and cerebrospinal fluid cultures are invariably negative, --serologic tests have limited value in immunosuppressed patients (poor capacity to elaborate antibodies). Diagnosis can be made only by surgical biopsy who isolate fungal elements. However diagnosis in greatest cases is only made at autopsy. Treatment consist by antifungal drugs administered intravenously and surgery when it is possible. Prognosis of cerebral aspergillosis is very poor and mortality rate very high about 70%.

[Non traumatic spinal epidural hematomas. Report of twenty cases. Review of the literature and outcome aspects]. / Hématomes épiduraux non traumatiques du rachis. Présentation de 20 cas. Revue de la littérature et étude des aspects évolutifs.

BACKGROUND AND PURPOSE: We report a personal series of 20 non traumatic spinal epidural hematomas and study outcome aspects with a review of data in the literature. METHOD: Clinical presentation of non-traumatic spinal epidural hematomas observed between January 1980 and December 1998 was acute in 17 cases (85%) and chronic in 3 (15%). Symptoms were spinal and/or radicular pain, sensorimotor and sphincter dysfunction. Radiological evaluation consisted in myelography (n=6), myelography-CT scan (n=5), CT scan (n=1) and MRI (n=9). Patients underwent surgery in 15 cases, between 8 hours and 2 months after the first symptoms. All our patients were clinically reevaluated between 2 and 4 months after either surgery or admission for cases of spontaneous resolution. RESULTS: Good results (complete neurological resolution or moderate sequelae) were observed in 14 patients (70%). A partial recovery with major persistent neurological impairment was observed in 1 patient (5%), an initial persistent neurological impairment in 1 (5%). Three patients (15%) died and 1 (5%) was lost to follow-up. Complete spontaneous resolution were observed in four patients. CONCLUSION: Postsurgical outcome is mainly related to the preoperative neurological impairment, the duration of spinal cord compression and the time interval between the onset of symptoms and maximal deficit. A prompt laminectomy is necessary except in the cases where a spontaneous resolution can be expected from the early neurological course.