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.

Effects of sociodemographic and player characteristics on baseline cognitive performance in 1000 rugby players: A retrospective 8-year follow-up study.

OBJECTIVES: To analyze the effects of sociodemographic and player characteristics on the Sport Concussion Assessment Tool and neuropsychological scores over 8 years in a large sample of rugby players. DESIGN: An 8-year retrospective study of preseason clinical assessments of professional rugby players and players enrolled in training academies at professional clubs. METHODS: The Sport Concussion Assessment Tool-3 or -5, Trail Making Test and Digit Symbol Substitution Test were administered prior to the start of the competition season for each player. Statistical analyses included: (i) descriptive analyses of sociodemographic, player and neuropsychological characteristics; (ii) multivariate models to identify factors influencing cognitive scores at the first visit; and (iii) linear mixed models to assess the evolution of the scores over the years. RESULTS: One thousand players were included (mean age: 22.8, males: 92 %). Twenty-two percent of the athletes reported baseline symptoms. A higher level of education was associated with better cognitive scores at the first visit and over the years. Forwards had poorer processing speed performances compared to backs at the first visit and over repeated assessments. Finally, the number of examinations was associated with improved cognitive scores showing a practice effect on all the neuropsychological tests, except for the Standardized Assessment of Concussion 5th edition. CONCLUSIONS: Results from this retrospective study could help to improve the management of athletes and return-to-play decision-making in collision sports.

Update on the Efficacy of Cognitive Rehabilitation After Moderate to Severe Traumatic Brain Injury: A Scoping Review.

OBJECTIVES: To identify, categorize, and analyze the methodological issues of cognitive rehabilitation of patients with moderate to severe traumatic brain injury and its efficacy. DATA SOURCES: Pubmed and PsycINFO were searched for studies published between 2015 and 2021 using keywords for cognitive intervention and traumatic brain injury. STUDY SELECTION: Two independent reviewers selected articles concerning cognitive rehabilitation for adults with traumatic brain injury. Of 458 studies, 97 full-text articles were assessed and 46 met the inclusion criteria. DATA EXTRACTION: Data were analyzed by 1 reviewer according to criteria concerning the methodological quality of studies. DATA SYNTHESIS: Results showed a large scope of 7 cognitive domains targeted by interventions, delivered mostly in individual sessions (83%) with an integrative cognitive approach (48%). Neuroimaging tools as a measure of outcome remained scarce, featuring in only 20% of studies. Forty-three studies reported significant effects of cognitive rehabilitation, among which 7 fulfilled a high methodological level of evidence. CONCLUSIONS: Advances and shortcomings in cognitive rehabilitation have both been highlighted and led us to develop methodological key points for future studies. The choice of outcome measures, the selection of control interventions, and the use of combined rehabilitation should be investigated in further studies.

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.

What Is the Impact of Physical Effort on the Diagnosis of Concussion?

OBJECTIVE: Sport-related concussion commonly occurs in contact sports such as rugby. To date, diagnosis is based on the realization of clinical tests conducted pitch-side. Yet, the potential effect of prior physical effort on the results of these tests remains poorly understood. The purpose of this study was to determine whether preceding physical effort can influence the outcome of concussion assessments. DESIGN: Prospective observational study. SETTING: University Medicine Center. PATIENTS: A cohort of 40 subjects (20 rugby players and 20 athletes from a range of sports). INTERVENTION: A concussion assessment was performed immediately after physical activity. After a period of 6 months and under the same experimental conditions, the same cohort performed the same tests in resting conditions. MAIN OUTCOME MEASURES: Results of concussion tests. RESULTS: In both cohorts, the comparison for postexercise and rest assessments demonstrated a most likely moderate-to-very large increase in the number of symptoms, severity of symptoms, and balance error scoring system score. In the rugby cohort, scores for concentration, delayed memory and standardized assessment of concussion (SAC), likely-to-most likely decreased following completion of physical activity compared with baseline values. The between-cohort comparison reported a most likely greater impact after exercise in the rugby players for delayed recall (0.73 ± 0.61) and SAC score (0.75 ± 0.41). CONCLUSIONS: Physical activity altered the results of concussion diagnostic tests in athletes from a range of sports and notably in rugby players. Therefore, physical efforts before the concussion incident should be accounted for during pitch-side assessments and particularly during rugby competition and training.

Cerebral Venous Thrombosis and Subdural Collection in a Comatose Patient: Do Not Forget Intracranial Hypotension. A Case Report.

BACKGROUND: The typical sign of intracranial hypotension (IH) is postural headache. However, IH can be associated with a large diversity of clinical or radiological signs leading to difficult diagnosis especially in case of coma. The association of cerebral venous thrombosis (CVT) and subdural hemorrhage is rare but should suggest the diagnosis of IH. METHODS: Case report. CASE DESCRIPTION: We report here a case of comatose patient due to spontaneous IH complicated by CVT and subdural hemorrhage. The correct diagnosis was delayed due to many confounding factors. IH was suspected after subdural hemorrhage recurrence and confirmed by magnetic resonance imaging (MRI). After 2 epidural patches with colloid, favorable outcome was observed. DISCUSSION: The most common presentation of IH is postural orthostatic headaches. In the present case report, the major clinical signs were worsening of consciousness and coma, which are a rare presentation. Diagnosis of IH is based on the association of clinical history, evocative symptomatology, and cerebral imaging. CVT occurs in 1-2% of IH cases and the association between IH, CVT, and subdural hemorrhage is rare. MRI is probably the key imaging examination. In the present case, epidural patch was performed after confounding factors for coma had been treated. Benefit of anticoagulation had to be balanced in this case with potential hemorrhagic complications, especially within the brain. CONCLUSION: Association of CVT and subdural hemorrhage should lead to suspect IH. Brain imaging can help and find specific signs of IH.

Diagnostic accuracy of a revised computed tomography angiography score for brain death confirmation, combining supra-tentorial arteries and infra-tentorial veins.

PURPOSE: The 4-point score is the corner stone of brain death (BD) confirmation using computed tomography angiography (CTA). We hypothesized that considering the superior petrosal veins (SPVs) may improve CTA diagnosis performance in BD setting. We aimed at comparing the diagnosis performance of three revised CTA scores including SPVs and the 4-point score in the confirmation of BD. METHODS: In this retrospective study, 69 consecutive adult-patients admitted in a French University Hospital meeting clinical brain death criteria and receiving at least one CTA were included. CTA images were reviewed by two blinded neuroradiologists. A first analysis compared the 4-point score, considered as the reference and three non-opacification scores: a "Toulouse score" including SPVs and middle cerebral arteries, a "venous score" including SPVs and internal cerebral veins and a "7-score" including all these vessels and the basilar artery. Psychometric tools, observer agreement and misclassification rates were assessed. A second analysis considered clinical examination as the reference. RESULTS: Brain death was confirmed by the 4-score in 59 cases (89.4 %). When compared to the 4-score, the Toulouse score displayed a 100 % positive predictive value, a substantial observer agreement (0.77 [0.53; 1]) and the least misclassification rate (3.03 %). Results were similar in the craniectomy subgroup. The Toulouse score was the only revised test that combined a sensitivity close to that of the 4-score (86.4 % [75.7; 93.6] and 89.4 % [79.4; 95.6], p-value < 0.001, respectively) and a substantial observer agreement. CONCLUSIONS: A score including SPVs and middle cerebral arteries is a valid method for BD confirmation using CTA even in patients receiving craniectomy.

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.

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.

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.

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.

Depression and sports-related concussion: A systematic review.

CONTEXT: Head injuries are risk factors for chronic depressive disorders, but this association remains poorly explored with regards to concussion. OBJECTIVES: The objective of this review was to evaluate the incidence of depressive symptoms and depression after sports-related concussion. We also endeavored to identify the response elements regarding the pathophysiology of these symptoms. METHODS: A systematic search of PubMed and Embase was conducted focusing on papers published until 1st December, 2016, according to PRISMA criteria The following MESH terms were used: (concussion or traumatic brain injury) and sport and (depression or depressive disorder). RESULTS: A depressive disorder can appear immediately after a concussion: depressive symptoms seem to be associated with the symptoms of the concussion itself. A depressive disorder can also appear later, and is often linked to the frequency and number of concussions. Furthermore, the existence of a mood disorder prior to a concussion can contribute to the onset of a depressive disorder after a concussion. LIMITS: There is an overall limit concerning the definition of a depressive disorder. In addition, when these studies had controls, they were often compared to high-level athletes; yet, practicing sport regularly is a protective factor against mood pathologies. CONCLUSIONS: Depressive symptoms after a concussion seem to be associated with postconcussion symptoms. Repeat concussions can contribute to later-onset major depressive disorders. However, playing sports can protect against major depressive disorders: thus, it is essential to evaluate concussions as accurately as possible.

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.

What are the possibilities of spontaneous resorption of a thoracic disc herniation occupying more than 20% of the spinal canal in the asymptomatic subject? Comparative study.

Thoracic disc herniation is a rare pathology for which surgical treatment is difficult. The discovery of asymptomatic or only slightly symptomatic lesions can be problematic, especially in cases of marked canal stenosis. The possibility of spontaneous resorption has been documented by a few case reports but there is no study on this subject. Our objective was to compare the clinical and radiological data for two groups of patients with significant thoracic herniation (occupying more than 20% of the spinal canal): one showing spontaneous resorption (group 1) and the other persistence of the lesion during follow up (group 2). The physiological processes of thoracic herniation are also discussed. We present a retrospective study of our database of patients with thoracic hernia. Only subjects who initially showed signs of slight or absent myelopathy (Frankel D or E) were included. Group 1 and 2 are composed of 12 and 17 patients respectively. The clinical and radiological data are compared. The two groups were not different for the following parameters: age, sex ratio, disc calcification, size, trajectory, side, hernia level. Other parameters were evaluated and were not associated with a higher rate of resorption: disc calcification, intramedullary hypersignal in T2 sequence, calcification of the posterior common vertebral ligament, calcification of another disc and Scheuerman's disease. Asymptomatic thoracic disc herniation is a condition that can disappear spontaneously, even in the case of a large lesion. To date, there are no clinical or radiological data that can predict such an evolution.

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.