Return to Play in Collision Sport After Hemorrhages of a Cerebral Cavernoma.

ABSTRACT: Discovering a cerebral vascular malformation in an athlete should lead to evaluating hemorrhagic risk, notably in contact sports. Cavernous angioma is one of the most frequent pathologies in this context. It can be identified by a hemorrhage, the onset of an epileptic seizure, or, increasingly so, incidentally, while performing a medical examination for another reason. Whether sports practice is a risk factor for hemorrhage is unclear in available literature. When treatment is needed, surgery remains the gold standard. Currently, little data are available on the possibility of resuming contact sports after craniotomy. We report the case of a rugby player who underwent surgery for intracerebral cavernoma. We provide details on how the player was finally cleared to resume rugby practice and on the therapeutic management of this lesion.

The Impact of Surgery on the Survival of Patients with Recurrent Glioblastoma.

OBJECTIVE: The purpose of this study was to investigate the possible benefit of repeat surgery on overall survival for patients with recurrent glioblastoma multiforme (GBM). METHODS: We performed a retrospective analysis of data from patients who presented with recurrent GBM over a 5-year period (n = 157), comparing baseline characteristics and survival for patients who had at least 1 new tumor resection followed by chemotherapy (reoperation group, n = 59) and those who received medical treatment only (no-reoperation group, n = 98) for recurrence. RESULTS: The baseline characteristics of the two groups differed in terms of WHO performance status (better in the reoperation group), mean age (60 years in the reoperation group vs. 65 years in the no-reoperation group), mean interval to recurrence (3 months later in the reoperation group than in the no-reoperation group) and more gross total resections in the reoperation group. Nevertheless, the patients in the reoperation group had a higher rate [32.8%] of sensorimotor deficits than those of the no-reoperation group [14.2]. There was no significant difference in sex; tumor localization, side, or extent; MGMT status; MIB-1 labeling index; or Karnofsky Performance Status [KPS] score. After adjustment for age, the WHO performance status, interval of recurrence, and extent of resection at the first operation, multivariate analysis showed that median survival was significantly better in the reoperation group than in the no-reoperation group (22.9 vs. 14.61 months, P < 0.05). After a total of 69 repeat operations in 59 patients (10 had 2 repeat surgeries), we noted 13 temporary and 20 permanent adverse postoperative events, yielding a permanent complication rate of 28.99% (20/69). There was also a statistically significant (P = 0.029, Student's t-test) decrease in the mean KPS score after reoperation (mean preoperative KPS score of 89.34 vs. mean postoperative score of 84.91). CONCLUSION: Our retrospective study suggests that repeat surgery may be beneficial for patients with GBM recurrence who have good functional status (WHO performance status 0 and 1), although the potential benefits must be weighed against the risk of permanent complications, which occurred in almost 30% of the patients who underwent repeat resection in this series.

Clinical long-term consequences of thoraco-lumbar spine fracture and osteosynthesis.

OBJECT: Although traumatic spine fractures can be treated by osteosynthesis, their long-term clinical, social, and familial consequences are less known. The aim of this study was to assess these global consequences to a very long-term (at least more than 12 years after the fracture). METHODS: Two groups, one composed of 30 patients operated for a thoracolumbar fracture by posterior fixation and one with 30 controls (who never had a spinal fracture) matched for age, sex, job and time of follow-up were studied. Patients and control subjects had to answer to 3 questionnaires: one about clinical, familial, and socio-professional changes, and 2 back pain (Dallas and Eifel) scales. RESULTS: The mean patient follow-up was 14.5 years (from 12 to 18 years, sd 2.3) - control subjects, 15 years. The majority (56%) of the fractures occurred at T12/L1 level. At last follow-up, the chronic low back pain concerned 20 (66,7%) patients versus 11 (36.7%) control subjects (p=0.03); more patients (13 patients - 43.3%) consumed analgesics than control (5 persons - 16.6%) subjects (p=0.04). A large majority (13 patients, 57%) had sick leaves that exceeded 6 months. The loss of wage due to traumatism or chronic low back pain was also significant (p=0.002) between patients and matched controls over the period. At follow-up, the mean Eifel score for the whole patients' cohort was significaty superior compared to control group (4.7 [sd 3.75] vs. 2.6 [sd 4.2], p=0.008). Dallas score was superior in the patient's group for the daily, work-leisure activities and sociability aspect (p<0.05). CONCLUSION: Chronic back pain, long sick leaves, changes in professional and familial life, the very long-term postoperative outcome of patients could be more difficult than expected in a majority of patients operated for thoracolumbar fracture. In order to facilitate the back to work and reduce these long-term consequences, we propose that guidelines about job resume in traumatic spinal fractures should be established along with early occupational medicine consultations. LEVEL OF EVIDENCE: III; retrospective case control study.

One-Step Customized PEEK Cranioplasty After 3D Printed Resection Template Assisted Surgery for a Frontal Intraosseous Meningioma: A Case Report.

AIM: To present one-step customized cranioplasty for intraosseous meningiomas. CASE DESCRIPTION: The authors report the case of a 54-year-old woman with a consequent frontal intraosseous meningioma invading the superior sagittal sinus. The patient only suffered from local pain and cosmetic damage. A complete resection was scheduled with a one-step reconstruction of the frontal bone by a polyetheretherketone (PEEK) specific implant. This implant was computer-assisted designed and manufactured and verified by the surgeon before the intervention. During surgery, the resection was guided by a computer designed resection template and by the classic neuronavigation system. Cranioplasty has been considered optimal intraoperatively by surgeons. The patient, a few weeks after surgery, underwent a subcutaneous fluid collection, rapidly resolutive with a circumferential pressure bandage. Six months after surgery, the patient considered the surgery a success with a very good cosmetic result and a total regression of her local pain. CONCLUSION: One-step computer-assisted cranioplasty is a safe and effective procedure for large skull defects. PEEK specific implant for cranioplasty offer advantages compared to other materials that will be discussed under the scope of the one-step reconstruction.

Incidence and predicting factors of perioperative complications during monitored anesthesia care for awake craniotomy.

STUDY OBJECTIVE: To assess incidence and predicting factors of awake craniotomy complications. DESIGN: Retrospective cohort study. SETTING: Operating room and Post Anesthesia Care unit. PATIENTS: 162 patients who underwent 188 awake craniotomy procedures for brain tumor, ASA I to III, with monitored anesthesia care. MEASUREMENTS: We classified procedures in 3 groups: major event group, minor event group, and no event group. Major events were defined as respiratory failure requiring face mask or invasive ventilation; hemodynamic instability treated by vasoactive drugs, or bradycardia treated by atropine, bleeding >500 ml, transfusion, gaseous embolism, cardiac arrest; seizure, cerebral edema, or any events leading to stopping of the cerebral mapping. Minor event was defined as any complication not classified as major. Multivariate logistic regression was used to determine predicting factors of major complication, adjusted for age and ASA score. MAIN RESULTS: 45 procedures (24%) were classified in major event group, 126 (67%) in minor event group, and 17 (9%) in no event group. Seizure was the main complication (n = 13). Asthma (odds ratio: 10.85 [1.34; 235.6]), Remifentanil infusion (odds ratio: 2.97 [1.08; 9.85]) and length of the operation after the brain mapping (odds ratio per supplementary minute: 1.01 [1.01; 1.03]) were associated with major events. CONCLUSIONS: Previous medical history of asthma, remifentanil infusion and a long duration of neurosurgery after cortical mapping appear to be risk factors for major complications during AC.

Multicenter study of 37 pediatric patients with SCIWORA or other spinal cord injury without associated bone lesion.

BACKGROUND: Pure traumatic spinal cord injury (without associated bone lesion) are encountered in pediatric accidentology, the most typical being spinal cord injury without radiological abnormality (SCIWORA). The present study reports a multicenter series of under-18-year-olds admitted for traumatic medullary lesion. The objectives were: (1) to describe the causes of pure spinal cord injuries in children in France and their clinical presentation; (2) to identify any prognostic factors; and (3) to describe their medical management in France. PATIENTS AND METHOD: A multicenter retrospective study was conducted in 3 pediatric spine pathology reference centers. Files of 37 patients with confirmed spinal cord injury between January 1988 and June 2017 were analyzed: SCIWORA (n=30), myelopathy associated with severe cranial trauma (n=2), and obstetric trauma (n=5). Accident causes, associated lesions, initial Frankel grade, level of clinical spinal cord injury, initial MRI findings, type of treatment and neurology results at last follow-up were collated. The main endpoint was neurologic recovery, defined by improvement of at least 1 Frankel grade. RESULTS: Causes comprised 17 road accidents, 11 sports accidents, 5 obstetric lesions and 4 falls. Mean follow-up was 502 days. The rate of at least partial neurologic recovery was 20/30 in SCIWORA, 0/5 in obstetric trauma, and 0/4 in case of associated intracranial lesion. In SCIWORA, factors associated with recovery comprised age, accident type, and absence of initial MRI lesion. DISCUSSION: We report a large series of pediatric spinal cord injury without associated bone lesion. This is a potentially serious pathology, in which prognosis is mainly related to age and trauma mechanism. LEVEL OF EVIDENCE: IV, case series.

Catastrophic Return to Play in Rugby After Double Cervical Arthrodesis.

For high-level athletes, most experts consider that 1-level arthrodesis in cervical spine surgery does not prevent return to play. Nevertheless, return remains controversial in cases of 2-level fusions. We report the case of a 27-year-old professional rugby player. He had had a double cervical fusion C5C6 and C6C7 for cervical hernia and was allowed to continue rugby activities afterward. Four years after this surgery, his neck was forced in hyperflexion during a match and complete tetraplegia occurred. A computed tomography scan showed a C3C4 unilateral facet dislocation. The patient was rapidly operated on. At follow-up, 2 years after the accident, the patient remained tetraplegic with no neurologic improvement. If no definitive conclusion can be established on this first observation, many precautions must be taken before a return-to-play decision, especially in contact sports.

Management of Giant Thoracic Disc Herniation by Thoracoscopic Approach: Experience of 53 Cases.

BACKGROUND: Giant thoracic disc herniation (gTDH) is a rare condition. It is defined by a herniation that occupies at least 40% of the thoracic spinal canal and is usually calcified. Several surgical techniques have been described to date but this surgery remains a technically difficult procedure. OBJECTIVE: To report the long-term outcome of 53 patients with myelopathy due to gTDH who were operated on by a thoracoscopic approach. The technical details of the preoperative assessment and the surgical procedure are presented. METHOD: We present a retrospective study of a database of 53 patients operated for symptomatic gTDH by a thoracoscopic approach. The following clinical parameters were assessed initially and used during follow-up: Frankel grade and JOA score adapted to the thoracic spine (mJOA), pain in the lower limbs and limitation of the walking perimeter to less than 500 meters. The quality of spinal cord decompression was assessed postoperatively by magnet resonance imaging (MRI). RESULTS: The mean follow-up was 78.1 mo (SD 49.4). At the last follow-up visit, clinical examination showed a mean improvement of 0.91 Frankel grade (P < 0.001) and 2.56 mJOA score respectively (P < 0.001). Lower limb pain and walking perimeter were also improved. Postoperative MRI revealed that the resection was complete in 35 cases, subtotal in 13 cases, and incomplete in 5 cases. CONCLUSION: gTDH is a condition that often evolves favorably after surgery. The thoracoscopic approach is a feasible alternative technique.

Improvement in Sagittal Balance After Decompression Surgery without Fusion in Patients with Degenerative Lumbar Stenosis: Clinical and Radiographic Results at 1 Year.

OBJECTIVE: To evaluate modifications in static spinal status after posterior decompression surgery without fusion in patients with symptomatic central canal stenosis. METHODS: From November 2014 to May 2016, 72 patients who underwent isolated decompression for lumbar spinal stenosis were enrolled prospectively in this single-center study. All of the patients had lateral full-body x-ray scans with the EOS system (EOS Imaging, Paris, France) before surgery and after 12 months of follow-up. Patients were classified into 3 groups according to their preoperative sagittal vertical axis (<50 mm, ≥50 mm, and <100 mm, ≥100 mm). RESULTS: SVA decreased significantly (SVA preoperative: 72.3 ± 43.1; SVA postoperative: 48.3 ± 46.8. P < 0.001). Lumbar lordosis increased significantly from 41.9 ± 13.4 in the preoperative period to 46.5 ± 14.8 at the last follow-up (P < 0.001). In the imbalance groups, the mean postoperative SVA decreased significantly compared with preoperative SVA (P = 0.004). Surgery led to a significant increase in lumbar lordosis in the 3 groups (P < 0.05). Nonetheless, a certain degree of residual imbalance persisted in the major imbalance group. In all of the groups, decompression surgery led to a significant improvement in clinical scores (P < 0.05). CONCLUSIONS: Our study showed an improvement in sagittal balance and lumbar lordosis after decompression surgery without fusion, even in patients with a preoperative SVA >100 mm. However, a certain degree of sagittal imbalance may persist after surgery in patients with major initial imbalance (SVA >100 mm). Nonetheless, after surgery, these patients experienced a clinical benefit comparable with that in the other groups.

Is There a Place for the Posterior Approach in Cases of Acute Myelopathy on Thoracic Disc Hernia?

BACKGROUND: Acute myelopathy in cases of thoracic disc herniation (TDH) is an exceptional condition for which the treatment is not codified. Here we present the results of a standardized procedure in 10 patients who underwent surgery for acute myelopathy on TDH between December 2009 and December 2016. METHODS: Our approach began with a cautious laminectomy without resection of the hernia on the day of admission. On subsequent days, a complementary thoracoscopic procedure was performed according to the patient's neurologic recovery and the nature of the hernia (calcified or fibrous). Outcome was assessed by the Frankel score at the last consultation. RESULTS: All patients had acute myelopathy, with Frankel score of C or worse and a TDH detected on magnetic resonance imaging occupying an average of 62.5 ± 18.4% of the canal. This lesion was calcified in 6 cases and soft in 4 cases. The laminectomy allowed stabilization in 1 case and a neurologic improvement in 9 cases. Complementary surgery via a thoracoscopic approach was performed in the 6 cases of calcified hernia. After an average follow-up of 44.55 ± 26.44 months, 6 patients showed complete neurologic recovery and 4 had moderate sequelae (Frankel D). CONCLUSIONS: Laminectomy appears to allow stabilization of the neurologic situation in rare cases of acute myelopathy on TDH. The need for complementary resection of the hernia by an anterior approach should always be discussed secondarily.

Reconstruction of Cranial Vault Defect with Polyetheretherketone Implants.

OBJECT: Reconstruction of a cranial vault defect is a frequent challenge in neurosurgery. Polyetheretherketone (PEEK) is used in many types of prostheses and has been employed for 10 years in our institution (University Hospital of Toulouse, France). The objectives of this study are to describe the benefits and drawbacks of reconstructing the cranial vault defect with a PEEK prosthesis. METHODS: Clinical data of the 37 patients who received a reconstruction with a custom-made PEEK prosthesis from 2007-2015 were retrospectively analysed. Operative technique, postoperative complications, and patient's satisfaction with the aesthetic result-on a scale ranging from 1 (very dissatisfied) to 5 (very satisfied)-were studied. RESULTS: Average follow-up was 4.3 years (from 2 months-9 years). The placement of the prosthesis was performed 195 days on average (from 0-1051 days, standard deviation 258 days) after the initial bone flap removal. One infection (2.7%), which required the removal of the prosthesis, was described. Six patients (16%) were reoperated by the maxillofacial surgery team to treat a lack of temporal projection related to muscle atrophy, using a fat cell autograft taken from the abdominal region. Overall, 30 patients (81%) answered the question about their aesthetic satisfaction, with good results on the satisfaction scale (average 4.5; from 3-5). CONCLUSION: The use of a PEEK prosthesis in cranial vault defect reconstruction is a reliable technique with a high patient satisfaction rate and few complications. Corrections of the temporal muscle atrophy by fat grafting may be performed in addition, without increasing the rate of complications.

Clinical and radiological cervical spine evaluation in retired professional rugby players.

OBJECT Acute cervical spine injuries have been extensively studied in high-level contact sports. However, the relation between the appearance of degenerative cervical spine disease and the exposure to repeated trauma in such sports as rugby is still unclear. Using clinical and MRI evaluation, we aimed to determine if former professional rugby players had more serious degenerative cervical spine symptoms than the general population. METHODS Two groups, one composed of 101 former rugby players (all men, mean age 40.3 years, range 35-47 years, SD 2.3 years) and the other of 85 male volunteers serving as a control group (mean age 41.6 years, range 35-49 years, SD 4.5 years) were studied. The former rugby players were evaluated on average 5.8 years after retirement (range 1-16 years, SD 3.5 years). The groups were matched in terms of sex, age, job, current sports training, and smoking habits. Each participant received a complete neurological evaluation. Clinical symptoms were evaluated using the Japanese Orthopaedic Association (JOA) questionnaire, and chronic neck pain was specifically evaluated using a visual analog scale (VAS) and the Neck Disability Index (NDI). Overall, 25 MRI studies were performed in each group. MRI studies, including dynamic sequences, focused on degenerative lesions (Matsumoto score and canal diameter) and on muscular and medullary morphological analysis. RESULTS Significantly more former rugby players than controls complained of chronic neck pain (51 [50.50%] of 101 vs 27 [31.76%] of 85, p = 0.01). Rugby players also had significant reductions of neck mobility. Nevertheless, in those complaining of pain, there was no statistically significant difference between groups with respect to VAS and NDI scores (p = 0.57). On MRI, former rugby players had a narrower vertebral canal (on average 0.88 ± 0.167 cm vs 0.99 ± 0.130 cm, p = 0.007) and more foraminal stenosis (p = 0.01). No significant difference in the Matsumoto score was found between the 2 groups with respect to other degenerative lesions. Former rugby players had more often undergone surgery for a degenerative condition than had members of the control group (10 cases vs 0 in the control group, p = 0.0021). CONCLUSIONS A few years after retirement, former professional rugby players seem to have more frequent cervical spine pain and MRI degenerative lesions, such as foraminal stenosis and narrowing of the spinal canal, compared with controls who had not been professional rugby players. A longer evaluation is necessary to determine if these findings persist over time.

Electrostimulation mapping of spatial neglect.

BACKGROUND: Cortical and subcortical electrostimulation mapping during awake brain surgery for tumor removal is usually used to minimize deficits. OBJECTIVE: To use electrostimulation to study neuronal substrates involved in spatial awareness in humans. METHODS: Spatial neglect was studied using a line bisection task in combination with electrostimulation mapping of the right hemisphere in 50 cases. Stimulation sites were identified with Talairach coordinates. The behavioral effects induced by stimulation, especially eye movements and deviations from the median, were quantified and compared with preoperative data and a control group. RESULTS: Composite and highly individualized spatial neglect maps were generated. Both rightward and leftward deviations were induced, sometimes in the same patient but for different stimulation sites. Group analysis showed that specific and reproducible line deviations were induced by stimulation of discrete cortical areas located in the posterior part of the right superior and middle temporal gyri, inferior parietal lobe, and inferior postcentral and inferior frontal gyri (P < .05). Fiber tracking identified stimulated subcortical areas important to spare as sections of fronto-occipital and superior longitudinal II fascicles. According to preoperative and postoperative neglect battery tests, the specificity and sensitivity of intraoperative line bisection tests were 94% and 83%, respectively. CONCLUSION: In humans, discrete cortical areas that are variable in location between individuals but mainly located within the right posterior Sylvian fissure sustain visuospatial attention specifically toward the contralateral or ipsilateral space direction. Line bisection mapping was found to be a reliable method for minimizing spatial neglect caused by brain tumor surgery.

Awake craniotomy vs surgery under general anesthesia for resection of supratentorial lesions.

BACKGROUND: The use of an awake craniotomy in the treatment of supratentorial lesions is a challenge for both patients and staff in the operation theater. OBJECT: To assess the safety and effectiveness of an awake craniotomy with brain mapping in comparison with a craniotomy performed under general anesthesia. METHODS: We prospectively compared 2 groups of patients who underwent surgery for supratentorial lesions: those in whom an awake craniotomy with intraoperative brain mapping was used (AC group, n = 214) and those in whom surgery was performed under general anesthesia (GA group, n = 361, including 72 patients with lesions in eloquent areas). The AC group included lesions in close proximity to the eloquent cortex that were surgically treated on an elective basis. RESULTS: Globally, the 2 groups were comparable in terms of sex, age, American Society of Anesthesiologists score, pathology, size of lesions, quality of resection, duration of surgery, and neurological outcome, and different in tumor location and preoperative neurological deficits (higher in the AC group). However, specific data analysis of patients with lesions in eloquent areas revealed a significantly better neurological outcome and quality of resection (P < .001) in the AC group than the subgroup of GA patients with lesions in eloquent areas. Surgery was uneventful in AC patients and they were discharged home sooner. CONCLUSION: AC with brain mapping is safe and allows maximal removal of lesions close to functional areas with low neurological complication rates. It provides an excellent alternative to craniotomy under GA.

Spinal meningioma surgery in elderly patients with paraplegia or severe paraparesis: a multicenter study.

OBJECTIVE: In a multicenter study, 102 patients aged 70 years or older with paraplegia or severe paraparesis, and who underwent operation for spinal meningiomas, are presented to correlate surgery and outcome and to determine the most influential factors that affected this outcome. METHODS: Five French neurosurgical centers participated in this retrospective study between 1990 and 2007. Pre- and postoperative neurological status were assessed using a grading system. All patients underwent operation, and neurological evaluations were conducted 3 months and 1 year after surgery. The median follow-up period was 49.5 months (range, 12-169 months). Data were analyzed using a multiple logistic regression model. RESULTS: Twenty-six patients were paraplegic (Grade 4). Complete tumor removal was obtained in 93 patients. There was no surgical mortality, and morbidity was 9%. Three months after surgery, 7 of the patients were unchanged, 87 patients had improved, and 8 were not evaluated. One year after surgery, 7 of the 100 surviving patients were clinically unchanged and 93 had improved. Of those who had improved, 49 patients experienced complete recovery. CONCLUSION: Advanced age did not seem to contraindicate surgery, even in patients with severe preoperative neurological deficits and/or an American Society of Anesthesiologists class of III. Quality of life can be improved in most cases.