Clinical and radiological evaluation of cervical disc arthroplasty with 5-year follow-up: a prospective study of 384 patients.

BACKGROUND: Cervical total disc replacement was developed to avoid known complications of cervical fusion. The purpose of this paper was to provide 5-year follow-up results of an ongoing prospective study after implantation of cervical disc prosthesis. METHODS: Three hundred and eighty-four patients were treated using Mobi-C cervical disc (Zimmer Biomet, Troyes, France) and included in a prospective multicentre study. Routine clinical and radiological examinations were reported preoperatively and postoperatively with up to 5-year follow-up. Complications and revision surgeries were also explored. RESULTS: Results at 5 years showed significant improvement in all clinical outcomes (NDI, VAS for arm and neck pain, SF-36 PCS and MCS). Motion at index level increased significantly from 6.0° preoperatively to 8.0°, and 72.1% of the implanted segments were still mobile (referring to threshold of ROM > 3°). Proximal and distal adjacent discs showed no significant change in average motion 5 years after surgery compared to baseline. Ossification resulting in complete fusion was observed in 16.4% of the implanted segments. Distal and proximal adjacent disc degeneration occurred in 42.2% and 39.1% of patients, respectively. Complications rate was 8.9%, and 1.5% of the patients had reoperation at the index level. Surgery rate of adjacent discs was 2.9%. An increased percentage of working patients and a decrease in medication consumption were observed. At 5 years, 93.3% patients were satisfied regarding the overall outcome. CONCLUSIONS: In this study, favourable 5-year follow-up clinical and radiological outcomes were observed with a low rate of adjacent level surgery. These slides can be retrieved under Electronic Supplementary Material.

Comparison between single- and multi-level patients: clinical and radiological outcomes 2 years after cervical disc replacement.

In cervical multi-level degenerative pathology, considering the morbidity of the extensive fusion techniques, some authors advocate for the multilevel disc replacement. This study compared the safety and efficacy of disc replacement with an unconstrained prosthesis in multi- versus single-level patients. A total of 231 patients with cervical degenerative disc disease (DDD) who were treated with cervical disc replacement and completed their 24 months follow-up were analyzed prospectively: 175 were treated at one level, 56 at 2 levels or more. Comparison between both groups was based on usual clinical and radiological outcomes [Neck Disability Index (NDI), Visual Analog Scale (VAS), Range of Motion, satisfaction]. Safety assessments, including complication and subsequent surgeries, were also documented and compared. Mean NDI and VAS scores for neck and arm pain were improved in both groups similarly. Improvement of mobility at treated segments was also similar. Nevertheless, in the multi-level group, analgesic use was significantly higher and occurrence of Heterotopic Ossification significantly lower than in the single-level group. Subject satisfaction was nearly equal, as 94.2% of single-level group patients would undergo the surgery again versus 94.5% in the multi-level group. The overall success rate did not differ significantly. Multi-level DDD is a challenging indication in the cervical spine. This study showed no major significant clinical difference between the two groups. We need further studies to know more about the impact of multi-level arthroplasty, especially on the adjacent segments, but these results demonstrate initial safety and effectiveness in this patient sample.

[Vertex aplasia cutis congenita with bone defect: Management synthesis and review of the literature]. / Aplasia cutis congenita du vertex avec atteinte osseuse : synthèse sur la prise en charge et revue de la littérature.

Aplasia cutis congenita (ACC) of the vertex is a rare and potentially severe malformation. We report the case of a newborn boy presenting ACC of the vertex with a skull defect. Surgical closure of the skin was performed 5 days following birth, which allowed skin healing. The skull spontaneously remodelled perfectly 6 months later. When associated with skull defect, this rare malformation characterized by the absence of skin carries the risk of severe complications such as rupture of the superior sagittal sinus or infections. Based on a review of the literature, we purpose an overview of the medical and surgical management of vertex ACC, which depends on the size of the skin defect and the presence of a skull defect.

[Anterior lumbar interbody fusion for treatment of failed back surgery syndrome: a retrospective study of 46 cases]. / Arthrodèses lombaires par voie antérieure dans le traitement des lombalgies et lomboradiculalgies récidivantes postchirurgicales : étude rétrospective de 46 cas.

BACKGROUND AND PURPOSE: Anterior lumbar interbody fusion (ALIF) has gained popularity for the treatment of degenerative disease of the lumbar spine. In this report, we present our experience with the ALIF procedure for treatment of failed back surgery syndrome following lumbar discectomy in a noncontrolled retrospective cohort. METHODS: From 1st January to 31 December 2005, we performed an ALIF in 46 patients presenting with low back pain with or without radiculopathy. All patients had a history of intractable pain resistant to conventional medical treatment and failed posterior lumbar surgery. Clinical and radiological outcomes were recorded. Neurological pain and functional outcomes were measured postoperatively (at 1, 3 and 12 months). Operative data, intraoperative complications, and the fusion rate were recorded. RESULTS: Forty-six patients with a preoperative diagnosis of failed back surgery syndrome underwent ALIF. The mean follow-up was 21 months. Back pain and leg pain completely disappeared in 60.9% of patients, decreased but required occasional medication in 28.3%, and 10.8% declared no benefit from ALIF surgery. CONCLUSION: On the basis of our results, we found ALIF to be a safe and effective procedure for the treatment of failed back surgery syndrome.

[Chronic sciatic pain caused by sciatic nerve schwannoma]. / Sciatalgie chronique révélant un schwannome du nerf sciatique.

Schwannomas are tumors with slowly progressive symptoms, more often painful than associated with neurologic deficits. Involvement of the sciatic nerve mimics chronic sciatic pain due to a herniated disk. If there is no lumbar pain and lumbar MRI is normal, the sciatic nerve must be clinically and radiologically examined all along its course. We report a patient with chronic sciatica in whom physical examination revealed a painful mass with a Tinel sign in her back thigh. MRI showed a multilobular mass along the sciatic nerve. Surgery of this plexiform schwannoma allowed a complete relief from pain.

Prognosis factors of survival time in patients with glioblastoma multiforme: a multivariate analysis of 340 patients.

BACKGROUND: The prognosis of glioblastoma multiforme remains poor despite recent therapeutic advances. Several clinical and therapeutic factors as well as tumour characteristics have been reported as significant to survival. A more efficient determination of the prognostic factors is required to optimize individual therapeutic management. The aim of our study was to evaluate by univariate then multivariate analysis the factors that influence prognosis and particularly survival. METHODS: Data of 340 patients with newly-diagnosed GBM were retrospectively analyzed. Univariate analysis of prognosis factors of survival time was performed. Factors that seemed determinant were evaluated by Kaplan-Meier survival curves. Finally, the significant factors found in univariate analysis were tested in multivariate analysis using the COX regression method. FINDINGS: Using multivariate analysis, the following factors were found to influence survival: radiotherapy was the predominant factor followed by radical surgery, tumour location, age and chemotherapy. Patients treated with temozolomide had a markedly better survival rate than patients treated with other chemotherapies (Log-rank test P < 0.005). The values of GBM type (de novo or secondary), as well as repeated surgery and partial surgery (vs. simple biopsy) were suggested by univariate analysis but not confirmed by the COX regression method. After radical surgery, progression-free survival was correlated to overall survival (r = 0.87, P < 10e-5). CONCLUSIONS; The influence of radiotherapy on survival was greater than the influence of age, an argument supporting the proposition of radiotherapy for patients until at least age 70. In the case of recurrence, the correlation between overall survival and progression-free survival is an important factor when considering the therapeutic options. Initial radical surgery and repeated procedures dramatically influence survival. The benefit of partial surgery remains difficult to evaluate. Partial surgery could be used to decrease intracranial pressure and to minimize residual tumours in order to enable treatment by chemotherapy and radiotherapy. The value of temozolomide treatment was confirmed.

Spontaneous resolution of arachnoid cysts: review and features of an unusual case.

Most intra-cranial arachnoid cysts are quiescent and remain asymptomatic throughout life. Within the natural course of arachnoid cyst evolution, spontaneous resolution has been known to occur rarely, but its frequency is probably underestimated due to lack of systematic detection and long-term observation. We illustrate the spontaneous regression of arachnoid cysts with a patient which was conjointly diagnosed with an arachnoid cyst and a post-traumatic epidural haematoma. Cyst regression was observed 16 months later, upon examination following a second benign cranial trauma. Mechanisms underlying the resolution of the arachnoid cyst are discussed.

[Capillary hemangioma of the ethmoid sinus. Case report and review of the literature]. / Hémangiome capillaire ethmoïdal. Cas clinique et revue de littérature.

We report the rare observation of a 38-year-old man diagnosed with capillary hemangioma exclusively involving the ethmoid sinus. Complete resection was obtained via ethmoid endoscopy combined with an intracranial approach. Capillary hemangioma is a rare and benign vascular tumor in adults primarily developing in the skin and subcutaneous tissues of the head and neck, and/or within oral and nasal cavities. No hemangioma exclusively involving the ethmoid sinus has been previously reported. Complete resection is the treatment of choice, providing a favorable prognosis with low risk of recurrence.

[Dumbell hemangioblastoma of the eighth cervical nerve root]. / Hémangioblastome "en sablier" de la huitième racine cervicale.

Hemangioblastomas involving cervical nerve roots are extremely rare. Only one case has been previously reported in the literature. We report the case of a 33-year-old man presenting with a 6-month history of upper limb pain. MRI and cervical angiography demonstrated the presence of a dumbell (intra and extradural) and highly vascularized tumor of the right C7-T1 foramina. Histological examination eventually confirmed the diagnosis of hemangioblastoma. Total removal of such a lesion may require combined (anterior and posterior) approaches and preoperative embolization.

[Cost-benefit evaluation of spinal cord stimulation treatment for failed-back surgery syndrome patients]. / Evaluation coût/bénéfice du traitement des lombosciatalgies post-operatoires par stimulation médullaire.

BACKGROUND AND PURPOSE: Spinal cord stimulation is a well-known treatment of rigorously selected failed-back surgery syndrome patients. Efficacy levels over 50% of pain relief have been reported in long-term studies. The objective of this multicenter prospective evaluation was to analyze the cost to benefit ratio of spinal cord stimulation treatment for failed back surgery syndrome patients. METHODS: Nine hospitals (pain evaluation and treatment centers) were involved in the study. Forty-three patients were selected and implanted between January 1999 and January 2000. For each patient, pre- and post-operative evaluations (6, 12 and 24 months after implantation) were performed to assess pain relief and economical impact on pain treatment costs. RESULTS: After 24 months, mean 60% pain relief was achieved as assessed with the neuropathic pain score using a Visual Analog Scale (success rate=70%), whereas low-back pain was moderately reduced (29%). The Oswestry Disability questionnaire score was improved by a mean 39%. Costs of pain treatment (medication, consultation, other) are reduced by a mean 64% (1705 Euro) per patient per year. CONCLUSIONS: This study confirms a clear analgesic effect on neuropathic sciatalgia, and moderate attenuation of low-back pain. One particular interest of this study is the medico-economic prospective evaluation showing that the initial cost of the implanted device is compensated by a significant, early, and stable reduction in the cost of associated pain therapies.

Experimental bypass surgery between the spinal cord and caudal nerve roots for spinal cord injuries.

Spinal cord injuries often cause permanent neurological deficits and are still considered as inaccessible to efficient therapy. Injured spinal cord axons are unable to spontaneously regenerate in adult mammalians. Re-establishing functional activity especially in the lower limbs by reinnervating the caudal infra-lesional territories could represent an attractive therapeutic strategy. For several years, we have studied and developed surgical bypasses using peripheral nerve grafts bridging the supra-lesional rostral spinal cord to the caudal infra-lesional lumbar roots. Main objectives were: 1- to overcome the spinal cord lesion and the consecutive glial barrier blocking the axonal regeneration; 2- to find and bring an alternative source of regenerating axons; 3- to guide those axons toward precisely definite targets (for example, lower limb muscles). We report here the results of our experimental research, which led us from animal experimental models (rodents, primates) to the first human experimentation. Limitations of the method (especially technical pitfalls) are numerous. However, we have obtained encouraging results in our attempts to "repair" the motor pathway. Functional recovery with strong evidence of centrifugal axonal regeneration from the spinal cord to the periphery has been observed. Regarding the sensory pathway, we have found evidence of centripetal axonal regeneration from the periphery toward the spinal cord. Further studies are obviously advocated, but our experimental model of spinal cord - nerve roots bypasses may be integrated in future "repair" strategies of both motor and sensory pathways following spinal cord injury.

Horseradish peroxidase retrograde labeling of primary sensory neurons: a comparison of four intraspinal application methods.

The purpose of this study was to optimize the methods of retrograde labeling of sensory neurons in demonstrating the continuity of post-ganglionic primary sensory axons. This was accomplished by comparing four different methods of horseradish peroxidase (HRP) application into the lower thoracic spinal cord of adult rats (level T11). HRP application with a piece of Gelfoam via a dorsal myelotomy (group 1, n = 8), stereotactic injections with a 0.72-mm tip diameter needle (group 2, n = 8), with a 0.24-mm tip needle (group 3, n = 8), and with a 0.08-mm tip glass micropipette (group 4, n = 5). Histological examination of the application site showed that the extent of spinal cord injury was directly proportional to the diameter of the needle tip. The mean number of dorsal root ganglia (DRG) sensory neurons retrogradely stained by HRP differed among the four experimental groups: 77 +/- 45 (SEM) per DRG in group 1, 106 +/- 24 in group 2, 652 +/- 90 in group 3, and 238 +/- 60 in group 4. A significant difference was found between group 3 and the other ones (P < 0.05). Intraspinal injection of HRP with a fine needle (0.24-mm tip diameter) using a stereotactic approach can achieve effective and reliable retrograde labeling of primary sensory neurons. This reproducible method may be useful in studies dealing with regeneration of post-ganglionic primary sensory axons.

[Spontaneous regression of paraplegia caused by spontaneous cervico-thoracic epidural hematoma]. / Régression spontanée d'une paraplégie par hématome épidural cervico-thoracique spontané

Spontaneous spinal epidural hematoma is a rare condition that usually requires surgical treatment in emergency. We report the unusual and well-documented case of a spontaneous spinal epidural hematoma, extending from C6 to T2, occurring in a 56-year old man and causing paraplegia. Without surgery, the paraplegia spontaneously and completely recovered within the first 24 hours. Serial MRI studies demonstrated the remitting course of the spinal epidural hematoma. Emergency surgical evacuation should still be the standard treatment for patients with disabling and/or persistent neurologic deficit. A conservative approach under close neurologic observation may be recommended for patients with no or mild deficits, for patients who show early and continuous clinical improvement within the first 24 hours and for patients with small and/or non-compressive spinal epidural hematoma. Reported cases of spontaneous remission are very rare.

Concurrent spinal dural and intradural arteriovenous fistulas. Case report.

Among spinal arteriovenous malformations (AVMs), dural arteriovenous fistulas (DAVFs) should be distinguished from intradural AVMs. The authors report the unusual and well-documented case of a 49-year-old man who suffered from a rapidly progressive myelopathy. Two concurrent spinal AVMs (one DAVF and one intradural direct AVF [Anson-Spetzler Type IV-B AVM]) were found located in the midthoracic region and in the conus medullaris, respectively. Both AVMs were successfully treated by surgery. To the authors' knowledge, the association of these two pathological entities has not been previously described. Clinically, if the patient fails to improve or deteriorates after the treatment of a spinal AVM, the presence of another AVM should be investigated by repeated angiography, especially if a complete spinal angiography study was not initially performed.

[Dysphagia and cervical bony spurs]. / Dysphagie et éperons osseux cervicaux.

A 74-year-old man had acute complete dysphagia due to esophageal compression cause by a degenerative osteophye on C4-C5. Functional improvement was immediate after surgical removal of the osteophyte via an anterior cervical approach. Reports in the literature show that vertebral hypertrophic spurs causing dysphagia result from bony degeneration or idiopathic causes (diffuse idiopathic skeletal hyperosteosis: DISH). Surgery is mandatory if medical care fails and dysphagia is complete. Discetomy-graft is indicated for degenerative lesions and simple removal of the bony spur for ossification of the anterior longitudinal ligament in DISH. In DISH, the cervical disc is not implicated but in degenerative disease it is the most important factor in the development of osteophytes.

[Horseradish peroxidase retrograde labeling of primary sensory axons in rats: a comparison between three different intraspinal injections methods]. / Marquage rétrograde des axones sensitifs primaires par la peroxydase du raifort chez le rat: mise au point de la technique d'injection intramédullaire.

STUDY AIM: In order to improve the results of intraspinal retrograde labeling of post-ganglionic primary sensory axons by horseradish peroxidase (HRP), the authors compared three different intraspinal injection methods of this tracer into the inferior thoracic spinal cord in the rat. MATERIAL AND METHOD: 'Open field' method (group 1, N = 8); stereotactic injection, needle tip diameter = 0.72 mm (group 2, N = 8); stereotactic injection, needle tip diameter = 0.24 mm (group 3, N = 8). Histological features of the spinal injection site showed that tissue damages due to injection was more extensive and deeper than expected. HRP transported in retrograde fashion from injection site to sensory body cells located in dorsal root ganglia (DRG) was revealed by the Mesulam histochemical technique. RESULTS: The mean number of labeled neurons per DRG was 652 in group 3, 116 in group 2, and 77 in group 1. Differences were statistically significant, especially between groups 1 and 3 (P = 4.10(-16)) and groups 2 and 3 (P = 2.10(-17)). CONCLUSION: Retrograde labeling of primary sensory axons by HRP (or another axonal tracer) with fine needle stereotactic intraspinal injection may represent an alternative to anterograde labeling. This reliable and reproducible method may be useful in studies dealing with regeneration of post-ganglionic primary sensory axons.

[Fotemustine (Muphoran) in 22 patients with relapses of high-grade cerebral gliomas]. / Fotémustine (Muphoran) chez 22 patients présentant des récidives de gliomes cérébraux de haut grade.

Fotemustine is a third-generation nitrosourea characterized by a phosphoalanine carrier group grafted onto the nitrosourea radical, which gives it a high lipophilicity and a better penetration through the cell membrane. Between September 1988 and December 1997, 22 patients with inoperable or incompletely resected recurrent high-grade gliomas of the brain were treated at the University Hospital in Brest (France). Treatment consisted of three weekly infusions of fotemustine (100 mg/m2 days 1, 8 and 15). If patients responded or were stabilized, fotemustine was continued at the same dose, but every three weeks only. Four patients responded to the treatment (18%), while 6 were stabilized (32%). Main toxicity was haematologic (leucopenia and, above all, thrombocytopenia); treatment was only interrupted in one patient for leucothrombopenia, and there was no toxic death. Medium duration of response and/or stabilisation was 6.5 months, and median survival 9.4 months in responding and/or stabilized patients, while it was only 5.0 months if tumour progressed under chemotherapy (median survival for all patients: 7.5 months). Besides, there was a difference in survival in favour of the young patients (< 50 years-median survival = 11.8 months) in comparison with patients between 50 and 60 years (median survival = 6.8 months; p = 0.0282) or elderly patients (> 60 years-median survival = 5.8 months; p = 0.0634). In our series, we did not found any difference in survival according to the initial performance status of patients before treatment. Therefore, fotemustine seems to represent an interesting well-tolerated treatment possibility in patients with inoperable recurrent malignant gliomas of the brain.

[Benign glial cysts of the pineal region]. / Les kystes gliaux bénins de la région pinéale.

A review of the pertinent literature regarding glial cysts of the pineal region is presented. Various pathogenic factors have been advocated such as the physiological involution of the pineal gland, a sequestration of the embryonic cavum pineale or the degenerative evolution of glial inclusions within the pineal gland. The pathological description is classical with three layers: an external fibrous capsule, an intermediate layer of pineal tissue and an internal glial wall. Imaging of these lesions is typical, namely the thin rim of peripheral contrast enhancement and the presence of calcifications. These cysts are more frequent in women in their third decade of life. They are almost always latent and their fortuitous disclosure at NMR examinations is common. Some of them will nevertheless cause intracranial hypertension due to hydrocephalus and hemorrhage. Those symptomatic cysts should be treated. Surgical excision has been the method of choice and the results are good. More recently a mere stereotactic needle aspiration has been performed with satisfactory long-term results.

[Benign hemorrhagic cyst of the pineal region. Treatment by stereotactic puncture. 4-year follow-up]. / Kyste bénin hémorragique de la région pinéale. Traitement par ponction stéréotaxique. Recul de quatre ans.

We report the case of a 27 year-old male patient in whom acute intracranial hypertension led to the diagnosis of a pineal hemorrhagic cyst as demonstrated by CT-scan and MRI examinations. Treatment consisted in stereotactic needle-aspiration following insertion of a ventriculo-peritoneal shunt. Pathological examination confirmed a benign glial lesion. The outcome was good as complete shrinkage of the cyst and complete relief of the signs and symptoms were achieved. These clinical and radiological results persisted over four years. Approximately 70 cases of symptomatic benign pineal cysts have been reported to-date. Surgical excision has been the method of choice. The present case and twelve other cases of stereotactic management of the condition in the literature suggest the interest of a mere stereotactic needle aspiration of these lesions.

The place of decompressive surgery in the treatment of uncontrollable post-traumatic intracranial hypertension in children.

The authors report two cases of post-traumatic uncontrollable intracranial hypertension in children (120 torr in case 1; 90 torr in case 2) who were treated within the first 12 h after trauma by surgery including decompressive craniectomy. The outcome was favourable in both children. Intracranial pressure (ICP) was recorded during the pre-, intra- and postoperative periods and during each specific step of the surgical procedure. Craniectomy alone induced a decrease in ICP of 45% (40 torr) in case 1 and 30% (35 torr) in case 2. Although this method remains controversial, given the lack of controlled trials, it can offer a salvage procedure in children with rapidly worsening intracranial hypertension, allowing survival without disabling neurological sequelae.