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

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

Surgical Management of Unstable U-Shaped Sacral Fractures and Tile C Pelvic Ring Disruptions: Institutional Experience in Light of a Narrative Literature Review.

Unstable U-shaped sacral fractures and vertical shear Tile C pelvic ring disruptions are characterized by rare lesions occurring in patients with severe trauma. Because the initial damage-control resuscitation primarily aims to stop life-threatening bleeding, emergency treatment often includes an anterior external pelvic fixator. Delayed surgery is mandatory to allow early mobilization, reduce mortality, and improve functional outcomes. Regarding U-shaped sacral fractures, although Roy-Camille type 1 U-shaped sacral fractures can be treated with iliosacral screws, types 2 (posteriorly displaced, equivalent to AO Spine C3) and 3 (anteriorly displaced, equivalent to AO Spine C3) fractures require spinopelvic triangular fixation. Besides, proper reduction of type 2 and some type 3 sacral fractures is mandatory to prevent wound complications. In patients with neurological deficits, the need for sacral laminectomy is left at the discretion of the surgeon, given the indirect decompression already obtained with fracture reduction. Tile C pelvic disruptions with posterior ring injury located lateral to the sacral foramen can be treated with either iliosacral screws or triangular spinopelvic fixation, combined with anterior pelvic fixation. Conversely, Tile C pelvic disruptions with posterior ring injury located at, or medial, to the sacral foramen (Denis zone II or III) induce vertical lumbosacral instability and thus require spinopelvic triangular fixation with anterior pelvic osteosynthesis. Although minimally invasive techniques have been developed, open surgeries are still required for inexperienced operators and in case of major displacement. The complication rate reaches approximately 33.33% of the cases, and complications include hardware malposition, wound infection or dehiscence, hardware prominence, and sometimes hardware failure.

ABO blood type and functional neurological outcome in patients with severe traumatic brain injury.

BACKGROUND: The ABO blood system has been involved in the pathogenesis of several diseases, including coagulopathy and bleeding complications. In trauma patients, blood type A has been associated with acute respiratory distress syndrome, and recently, blood type O has been associated with all-cause mortality. The purpose of this study was to assess the association between ABO blood types and long-term functional outcomes in critically ill patients with severe traumatic brain injury (TBI). METHODS: We conducted a single-center, retrospective, observational study including all patients admitted to the intensive care unit with severe TBI (defined as a Glasgow Coma Scale score of ≤8) between January 2007 and December 2018. Patient characteristics and outcomes were extracted from a prospective registry of all intubated patients admitted to the intensive care unit for TBI. ABO blood types were retrospectively retrieved from patient medical records. The association between ABO blood type (A, B, AB, and O) and unfavorable functional outcome (defined by a Glasgow Outcome Scale score between 1 and 3) 6 months after injury was assessed in univariate and multivariate analysis. RESULTS: A total of 333 patients meeting the inclusion criteria were included. There were 151 type O (46%), 131 type A (39%), 37 type B (11%), and 12 type AB patients (4%). No significant differences in baseline demographic, clinical, or biological characteristics were observed between blood types. The prevalence of unfavorable outcome was significantly different between the four groups. After adjustment for confounders, blood type O was significantly associated with unfavorable outcome at 6 months (odds ratio, 1.97; confidence interval [1.03-3.80]; p = 0.042). The prevalence of coagulopathy or progressive hemorrhagic injury was not statistically different between blood types ( p = 0.575 and p = 0.813, respectively). CONCLUSION: Blood type O appears to be associated with unfavorable long-term functional outcome in critically ill patients with severe TBI. Further studies are needed to detail the mechanism underlying this relationship. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Management of combat-sustained radial nerve injury during World War I: The case of Louis-Ferdinand Céline.

The radial nerve conveys sensory and motor information to and from the upper limb, and radial nerve injury can induce functional disability, as demonstrated by the case of the renowned French writer Louis-Ferdinand Céline (1894-1961), who sustained a gunshot injury to his right arm in October 1914. Radial nerve injuries treated during World War I inspired the publication of several medical handbooks and medical theses, such as that of the military surgeon Major Robert Bretton (1889-1956). The aim of this paper is, via Céline's injury, to explore the management of radial nerve injury during and since World War I. It is important to consider the historical perspective in order to improve radial nerve injury management so as to adapt to modern warfare.

Duret Brainstem Hemorrhage Secondary to Large Supratentorial Meningioma.

A 75-year-old female patient was admitted following head trauma responsible for an acute-onset neurological worsening with a Glasgow Coma Scalescore of 6. Computed tomography scan revealed a large bifrontal meningioma with extralesional bleeding causing cranio-caudal transtentorial brain herniation. Despite emergency surgical excision of the tumor using craniotomy, the patient remained comatose. The brain magnetic resonance imaging revealed a Duret brainstem hemorrhage of the upper and middle pons, associated with supratentorial decompression-related brain injuries. One month later, the patient was withdrawn from life support. To our knowledge, tumor-induced Duret brainstem hemorrhage has never been reported.

Neurosurgical management of penetrating brain injury during World War I: A historical cohort.

During World War I, 25% of penetrating injuries were in the cephalic region. Major Henri Brodier described his surgical techniques in a book in which he reported every consecutive penetrating brain injury (PBI) that he operated on from August 1914 to July 1916. The aim was to collate his data and discuss significant differences in management between soldiers who survived and those who died. We conducted a retrospective survey that included every consecutive PBI patient operated on by Henri Brodier from August 1914 to April 1916 and recorded in his book. We reported medical and surgical management. Seventy-seven patients underwent trepanation by Henri Brodier for PBI. Regarding injury mechanism, 66 procedures (86%) were for shrapnel injury. Regarding location, 21 (30%) involved the whole convexity. Intracranial venous sinus wound was diagnosed intraoperatively in 11 patients (14%). Postoperatively, 7 patients (9%) had seizures, 5 (6%) had cerebral herniation, 3 (4%) had cerebral abscess, and 5 (6%) had meningitis. No patients with abscess or meningitis survived. No significant intergroup differences were found for injury mechanism or wound location, including the venous sinus. Extensive initial surgery with debridement must be prioritized. Infectious complications must not be neglected. We should not forget the lessons of the past when managing casualties in present-day and future conflicts.

Hydrocephalus despite extra ventricular drainage in adults: a new description of multiloculated hydrocephalus.

Multiloculated hydrocephalus constitutes a challenging pathology due to intracerebral haemorrhage or ventriculitis leading to iterative shunt revision frequently described in paediatric neurosurgery, but poorly reported in adults. Nevertheless, this potential complication of intraventricular haemorrhage, already drained in emergency, should be considered with special interest, as ideal management of cerebrospinal drainage remains debated in such situation. We thus report herein the case of intraventricular haemorrhage in an adult complicated of multiloculated hydrocephalus, as an illustrative plea for endoscopic surgery.

Head Face and Neck Surgeon Deployment in the New French Role 2: The Damage Control Resuscitation and Surgical Team.

INTRODUCTION: High-intensity conflict is back after decades of asymmetric warfare. With the increase in the incidence of head, face, and neck (HFN) injuries, the French Medical Military Service has decided to deploy HFN surgeons in the new French Role 2: the Damage Control, Resuscitation, and Surgical Team (DCRST). This study aims to provide an overview of HFN French surgeons from their initial training, including the surgical skills required, to their deployment on the DCRST. MATERIALS AND METHODS: The DCRST is a tactical mobile medico-surgical structure with several configurations depending on the battlefield, mission, and flux of casualties. It represents the new French paradigm for the management of combat casualties, including HFN injuries. RESULTS: The HFN's military surgeon training starts during residency with rotation in the different subspecialties. The HFN surgeon follows a training course called "The French Course for Deployment Surgery" that provides sufficient background to manage polytrauma, including HFN facilities on modern warfare. We have reviewed the main surgical procedures required for an HFN military surgeon. CONCLUSION: The systematic deployment of HFN surgeons in Role 2 is a specificity of the French army as well as the HFN surgeon's training.Currently, the feedback from an asymmetric conflict is encouraging. However, it will have to innovate to adapt to modern warfare.

Application of a Near-infrared Spectroscope by an Extreme Forward Medical Team for the Triage of Casualties With Traumatic Brain Injury.

BACKGROUND: During deployment of military medical teams similarly to prehospital practice, without immediate computed tomography scan access, identifying patients requiring neuro-specific care to manage pragmatic triage proves crucial. We assessed the contribution of this portable near-infrared spectroscope (NIRS) handheld device, Infrascanner Model 2000 (InfraScan Inc.; Philadelphia, PA), to screen patients suspected to require specific neurosurgical care. MATERIALS AND METHODS: This single-center retrospective analysis was based on the data from the medical records of the traumatic brain injured patients. We analyzed all the patients strictly over 18 years old presenting a clinical history of traumatic brain injury (TBI) with a Glasgow Coma Scale (GCS) < 15. RESULTS: Thirty-seven medical records of patients admitted for TBI met the inclusion criteria for our analysis. The median GCS was 9 [3-14]. Eight patients (21.6%) underwent neurosurgery and 25 (67.6%) required intensive care unit (ICU) admission, after initial assessment and resuscitation. The NIRS was the most sensible to detect intracranial hematoma (n = 21), intracranial hematoma leading to surgery (n = 8), and intracranial hematoma leading to admission in ICU (n = 25). Its negative predictive value was 100% regarding hematomas leading to surgery. False-positive results were encountered in 10 cases (27.0%). Excluding cases harboring confounding extracranial hematomas, parietal area was still the most represented (n = 3). CONCLUSION: The NIRS was relevant to detect hematoma leading to prompt surgery in our study. The lack of specificity in a nonselected cohort of patients underlines the need to associate simple clinical feature such as neurological deficit and NIRS results to perform rational triage.

Emergency Cranial Surgeries Without the Support of a Neurosurgeon: Experience of the French Military Surgeons.

INTRODUCTION: Unlike orthopedic or visceral surgeons, French military neurosurgeons are not permanently deployed on the conflict zone. Thus, craniocerebral war casualties are often managed by general surgeons in the mobile field surgical team. The objective of the study was to provide the feedback of French military surgeons who operated on craniocerebral injuries during their deployment in a role 2 surgical hospital without a neurosurgeon. MATERIALS AND METHODS: A cross-sectional survey was conducted by phone in March 2020, involving every military surgeon currently working in the French Military Training Hospitals, with an experience of cranial surgery without the support of a neurosurgeon during deployment. We strived to obtain contextual, clinical, radiological, and surgical data. RESULTS: A total of 33 cranial procedures involving 64 surgeons were reported from 1993 to 2018. A preoperative CT scan was not available in 18 patients (55%). Half of the procedures consisted in debridement of craniocerebral wounds (52%, n = 17), followed by decompressive craniectomies (30%, n = 10), craniotomy with hematoma evacuation (15%, n = 5), and finally one (3%) surgery with exploratory burr holes were performed. The 30-day survival rate was 52% (n = 17) and 50% (n = 10/20) among the patients who sustained severe traumatic brain injury. CONCLUSIONS: This survey demonstrates the feasibility and the plus-value of a neurosurgical damage control procedure performed on the field by a surgeon nonspecialized in cranial surgery. The stereotyped neurosurgical techniques used by the in-theater surgeon were learned during a specific predeployment training course. However, the use of a live telemedicine neurosurgical support seems indispensable and could benefit the general surgeon in strained resources setting.

Historical Vignette Portraying the Difference Between the "Sinking Skin Flap Syndrome" and the "Syndrome of the Trephined" in Decompressive Craniectomy.

Decompressive craniectomy has been adopted as a possible therapeutic option for extreme cases of traumatic brain injury and malignant ischemic stroke. The history of decompressive craniectomy, though, involves civilian and military discoveries that have been progressively confused and even forgotten. The syndrome of the trephined was introduced in 1939 as a feeling of tenderness, discomfort, and insecurity located at the site of craniectomy. Forty years later, in 1977, the sinking skin flap syndrome was defined as new-onset neurologic deficits or even coma associated with marked skin depression at the site of craniectomy, indicating urgent need for cranioplasty. These 2 syndromes illustrate the paradigm shift of the indications for cranioplasty, which have evolved from cosmetic reasons in the 1940s to cerebral metabolism improvement in the early 21st century.

Severe Trauma Patients Requiring Undelayable Combined Cranial and Extra-Cranial Surgery: A Proof-of-Concept Monocentric Study.

INTRODUCTION: To date, there is no evidence concerning the emergency surgical management of severe trauma patients (STP) with severe traumatic brain injury (STBI) presenting a life-threatening intracranial hematoma and a concomitant extra-cranial noncompressible active bleeding. Current guidelines recommend stopping the extra-cranial bleeding first. Nevertheless, the long-term outcome of STP with STBI mainly depends from intracranial lesions. Thus, we propose a combined damage-control surgical strategy aiming to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. The main objective of the study is to evaluate the benefits of combined cranial and extra-cranial surgery of STP on the long-term outcome. MATERIALS AND METHODS: We retrospectively searched through the database of STBI of a level 1 trauma center facility (Sainte-Anne Military Teaching Hospital, Toulon, France) from 2007 until 2021 looking for patients who benefited from combined cranial and extra-cranial surgery in an acute setting. RESULTS: The research yielded 8 patients. The mean age was 35 years old (±14) and the male to female sex ratio was 1.7/1. The trauma mechanism was a fall in 50% of the cases and a traffic accident in 50% of the cases. The median Glasgow coma scale score was 8 (IQR 4) before intubation. The median Injury Severity Score was 41 (IQR 16). Seven patients (88%) presented hypovolemic shock upon admission. Six patients (75%) benefited from damage-control laparotomy among, whom 4 (67%) underwent hemostatic splenectomy. One patient benefited from drainage of tension pneumothorax, and one patient benefited from external fixator of multiple limb fractures. Seven patients (88%) benefited from decompressive craniectomy for acute subdural hematoma (5 patients) or major brain contusion (2 patients). One patient (12%) benefited from craniotomy for epidural hematoma. Three patients presented intraoperative profound hypovolemic shock. Six patients (75%) presented a favorable neurologic outcome with minor complications from extra-cranial surgeries and 2 patients died (25%). CONCLUSION: Performing combined life-saving cranial and extra-cranial surgery is feasible and safe as long as the trauma teams are trained according to the principles of damage control. It may be beneficial for the neurologic prognostic of STP with STBI requiring cranial and extra-cranial surgery.

Severe trauma patients requiring undelayable combined cranial and extracranial surgery: A scoping review of an emerging concept.

Objectives: Although patients suffering from severe traumatic brain injury (sTBI) and severe trauma patients (STP) have been extensively studied separately, there is scarce evidence concerning STP with concomitant sTBI. In particular, there are no guidelines regarding the emergency surgical management of patients presenting a concomitant life-threatening intracranial hematoma (ICH) and a life-threatening non-compressible extra-cranial hemorrhage (NCEH). Materials and Methods: A scoping review was conducted on Medline database from inception to September 2021. Results: The review yielded 138 articles among which 10 were retained in the quantitative analysis for a total of 2086 patients. Seven hundrer and eighty-seven patients presented concomitant sTBI and extra-cranial severe injuries. The mean age was 38.2 years-old and the male to female sex ratio was 2.8/1. Regarding the patients with concomitant cranial and extra-cranial injuries, the mean ISS was 32.1, and the mean AIS per organ were 4.0 for the head, 3.3 for the thorax, 2.9 for the abdomen and 2.7 for extremity. This review highlighted the following concepts: emergency peripheric osteosynthesis can be safely performed in patients with concomitant sTBI (grade C). Invasive intracranial pressure monitoring is mandatory during extra-cranial surgery in patients with sTBI (grade C). The outcome of STP with concomitant sTBI mainly depends on the seriousness of sTBI, independently from the presence of extra-cranial injuries (grade C). After exclusion of early-hospital mortality, the impact of extra-cranial injuries on mortality in patients with concomitant sTBI is uncertain (grade C). There are no recommendations regarding the combined surgical management of patients with concomitant ICH and NCEH (grade D). Conclusion: This review revealed the lack of evidence for the emergency surgical management of patients with concomitant ICH and NCEH. Hence, we introduce the concept of combined cranial and extra-cranial surgery. This damage-control surgical strategy aims to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. Further studies are required to validate this concept in clinical practice.

Brain metastases in endometrial cancer: A systematic review of the surgical prognostic factors.

CONTEXT: Although endometrial cancer is the fourth most common malignancy in women, dissemination to the brain is an exceptional event in the course of the disease. The aim of this review is to determine the important surgical prognostic factors for patients with endometrial cancer metastatic to the brain. MATERIALS AND METHODS: Report of two cases. Medline database was used to conduct a systematic literature review from inception to December 2020 looking for English-language articles focused on brain metastases from endometrial cancer. RESULTS: The research yielded 108 articles, among which 23 articles were retained for a total of 87 patients. Mean age was 60 years-old ±11 at the time of diagnosis of endometrial cancer, and most of the tumors were aggressive (grade 3) with an advanced-stage disease (FIGO III-IV). At the time of diagnosis of cerebral disease, a single brain metastasis (p < 0.0001) and no extra-cerebral metastatic site (p = 0.0011) were significant good prognostic factors for the median overall survival. Surgical excision of brain metastasis followed by radiotherapy provided the longest median overall survival compared to radiotherapy and/or chemotherapy, and surgery alone (respectively 32, 5.4 and 4.8 months, p < 0.0001). An age of 60-year-old or less was not associated with a better prognosis. CONCLUSION: This review confirms that surgical excision followed by radiotherapy is a reliable option in patients with a single brain metastasis from endometrial cancer and no extra-cerebral metastatic site. This work could help to adapt the Graded Prognostic Assessment for brain metastases in endometrial cancer.

Neurosurgery for intracranial meningioma in patients aged more than 80 years: benefits and rationale.

BACKGROUND: Elderly patients with symptomatic benign intracranial tumours such as meningioma pose particular problems in decision making. We report on the outcome, morbidity and mortality in patients aged over 80 years after undergoing cranial surgery for meningiomas. METHODS: In this retrospective study, 37 patients aged more than 80 years underwent surgery at our neurosurgery department. The Karnofsky Performance Scale (KPS) was used to assess functional status. The American Society of Anesthesiologists (ASA) classification system, the Geriatric Scoring System, the Clinical-Radiological Grading System and the Sex, Karnofsky, ASA, Location and Edema score were used to define clinical status and tumour characteristics. The Charlson Comorbidity Index and Clavien-Dindo classification scores reflected therapeutic morbidity. RESULTS: Preoperative KPS scores were generally higher than 60 (n = 32). Of the 37 patients, 24 (64.8%) were in ASA class I or II, and 27 (73.0%) had one or more comorbidities. The median length of follow-up was 80.0 months (range: 1-96 months). The 1-year mortality rate was 2.7% (n = 1). Tumour control was achieved in 33 patients. At discharge, KPS scores were improved in 21 patients (with an average gain of +18.1 ± 8.7), stable in 10 patients and poorer in 6 patients. KPS scores improved or were stable in patients with shorter lengths of hospital stay (15.5 ± 17.9 days vs 51.4 ± 25.4 days; p < 0.01), those with Clavien-Dindo scores lower than 2 (p < 0.01) and those with less favourable preoperative KPS scores (69.4 ± 10.9 vs 82.0 ± 11.0; p = 0.04). CONCLUSION: Historically, surgery for intracranial meningiomas in patients aged >80 years has been feasible; this series demonstrated decreasing rates of postoperative mortality. Functional benefit should be the main goal of surgery. Perioperative morbidity should be better assessed and predicted because it significantly influences functional outcomes.

Surgical Site Infections after glioblastoma surgery: results of a multicentric retrospective study.

BACKGROUND: The effects of surgical site infections (SSI) after glioblastoma surgery on patient outcomes are understudied. The aim of this retrospective multicenter study was to evaluate the impact of SSI on the survival of glioblastoma patients. METHODS: Data from SSI cases after glioblastoma surgeries between 2009 and 2016 were collected from 14 French neurosurgical centers. Collected data included patient demographics, previous medical history, risk factors, details of the surgical procedure, radiotherapy/chemotherapy, infection characteristics, and infection management. Similar data were collected from gender- and age-paired control individuals. RESULTS: We used the medical records of 77 SSI patients and 58 control individuals. 13 were excluded. Our analyses included data from 64 SSI cases and 58 non-infected glioblastoma patients. Infections occurred after surgery for primary tumors in 38 cases (group I) and after surgery for a recurrent tumor in 26 cases (group II). Median survival was 381, 633, and 547 days in patients of group I, group II, and the control group, respectively. Patients in group I had significantly shorter survival compared to the other two groups (p < 0.05). The one-year survival rate of patients who developed infections after surgery for primary tumors was 50%. Additionally, we found that SSIs led to postoperative treatment discontinuation in 30% of the patients. DISCUSSION: Our findings highlighted the severity of SSIs after glioblastoma surgery, as they significantly affect patient survival. The establishment of preventive measures, as well as guidelines for the management of SSIs, is of high clinical importance.