Simplified supine modified park bench / lateral decubitus position using a shoulder pad and a Mayfield head clamp for neurosurgical approach to lesions located in the occipital lobe or the posterior fossa: technical note.

Neurosurgical approach to lesions located in the occipital lobes or in the posterior fossa require very specific and time-consuming patient installations, such as the park bench position, the prone position, or the sitting position. Nevertheless, each of these position present major drawbacks regarding specific installation-related adverse events and potentially serious neurosurgical complications such as venous air embolism, iatrogenic intracranial hypertension, and supratentorial remote hematoma just to cite a few. In order to provide neurosurgeons with a simpler, physiologically-respective, easily tolerated, less time-consuming, and less provider or specific adverse events patient installation, Ochiai (1979) introduced the supine modified park-bench / lateral decubitus position. Given that this patient position has not gained wide visibility among the neurosurgical community despite its obvious numerous advantages over its classic counterparts, we provide our experience using this installation for neurosurgical approach to lesions located in the occipital lobes and in the posterior fossa.

Ultrasound-guided needle aspiration of immediate postoperative symptomatic spinal epidural hematoma after lumbar stenosis surgical decompression in the elderly: a proof-of-concept case.

BACKGROUND: Symptomatic spinal epidural hematoma (SSEH) is one of the most feared complications and source of litigation in spine surgery. Its occurrence rises up to 2% in minimally invasive spine surgery. In parts of the world where the population is aging, more fragile patients are expected to undergo degenerative spine surgery. Management of the SSEH includes emergent spine MRI, though some experts advocate for direct second-look surgery without imaging. Then, an urgent revision surgery under general anesthesia for hematoma evacuation is warranted. We report the case of a threatening SSEH in an 88-year-old patient after lumbar spine stenosis surgery. In order to spare a second general anesthesia for this fragile patient, we opted for a percutaneous ultra-sound guided drainage of the hematoma under local anesthesia as a first line treatment. The procedure was successful, we report an instant relief of his neurological deficit while performing the procedure. CONCLUSION: Ultra-sound guided percutaneous drainage of hyperacute SSEH successfully avoided a revision surgery. It spared a second general anesthesia in a fragile patient. This procedure could be an alternative first-line treatment of SSEH for fragile patients.

Contemporary History of Spine Fractures Following Deck-Slap Injury: From Deck Blast During World War II Naval Battles to Axial Trauma During Touristic Speedboat Sea Cruise in 21st Century.

In large-scale naval battles during World War II, sailors sometimes sustained serious lower limb injuries when explosion blast of sea mines was transmitted from underneath through the metal deck of the ships. Some of these sailors were thrown in the air due to the blast and sustained axial trauma of the spine when they landed on the hard deck, which was thus called a deck slap by Captain Joseph Barr in 1946, among others. Nowadays, this peculiar mechanism has shifted to the civilian setting. Tourists unaware of the danger may sustain spine compression fractures when they sit at the bow of speed boats while underway on a calm sea. When the craft unexpectedly crosses the wake of another ship, tourists are thrown a few feet in the air before suffering a hard landing on their buttocks. This historical vignette is presented as a preventive message to help to reduce this poorly known yet avoidable "summer wave of vertebral fractures."

How I do it: single-staged emergency neurosurgical management of frontal penetrating craniocerebral injury with depressed skull fracture.

CONTEXT: Penetrating craniocerebral injury associated with depressed skull fracture is an infrequent yet timely neurosurgical emergency. Such injury frequently occurs in the frontal region during traffic accident or stone throw in the civilian setting. As military neurosurgeons, we present our experience in the surgical debridement and reconstruction of this peculiar type of traumatic brain injury. METHODS: The patient lies supine, the head in neutral position heal by a Mayfield head clamp. The first step is the debridement of the frontal wound. Then, the depressed skull fracture is operated on using a tailored coronal approach through Merkel dissection plane, in order to keep a free pericranial flap. The bone flap is cut around the depressed skull fracture. Neuronavigation allows to locate the frontal sinus depending on whether it has been breached and thus requires cranialization. Brain and dura mater debridement and plasty are performed. Cranioplasty is performed using either native bone fragments fixed with bone plates or tailored titanium plate if they are too damaged. CONCLUSION: Performing wounded skin closure first and then a tailored coronal approach with free pericranial flap and a craniotomy encompassing the depressed skull fracture allows to treat frontal penetrating craniocerebral injury in an easy-to-reproduce manner.

Kernohan-Woltman Notch Phenomenon Following Acute Subdural Hematoma.

A 72-year-old right-handed female patient was operated on for left-sided acute subdural hematoma responsible for coma. Two weeks afterward, her neurological status had improved with a Glasgow Coma Scale score of 14 and a paradoxical left-sided hemiparesis. The brain magnetic resonance imaging displayed a diffusion-restricting, hyper fluid-attenuated inversion recovery lesion of the right cerebral peduncle facing the tentorial notch, and the patient was diagnosed with Kernohan-Woltman notch phenomenon. This allowed to focus the neurological rehabiliation on the ipsilateral motor deficit as well as the hemineglect.

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.

Prognostic Factors of Mortality and Functional Outcome for Acute Subdural Hematoma: A Review Article.

Acute subdural hematoma (ASDH) is the most frequent intracranial traumatic lesion requiring surgery in high-income countries. To date, uncertainty remains regarding the odds of mortality or functional outcome of patients with ASDH, regardless of whether they are operated on. This review aims to shed light on the clinical and radiologic factors associated with ASDH outcome. A scoping review was conducted on Medline database from inception to 2023. This review yielded 41 patient series. In the general population, specific clinical (admission Glasgow Coma Scale [GCS], abnormal pupil exam, time to surgery, decompressive craniectomy, raised postoperative intracranial pressure) and radiologic (ASDH thickness, midline shift, thickness/midline shift ratio, uncal herniation, and brain density difference) factors were associated with mortality (grade III). Other clinical (admission GCS, decompressive craniectomy) and radiologic (ASDH volume, thickness/midline shift ratio, uncal herniation, loss of basal cisterns, petechiae, and brain density difference) factors were associated with functional outcome (grade III). In the elderly, only postoperative GCS and midline shift on brain computed tomography were associated with mortality (grade III). Comorbidities, abnormal pupil examination, postoperative GCS, intensive care unit hospitalization, and midline shift were associated with functional outcome (grade III). Based on these factors, the SHE (Subdural Hematoma in the Elderly) and the RASH (Richmond Acute Subdural Hematoma) scores could be used in daily clinical practice. This review has underlined a few supplementary factors of prognostic interest in patients with ASDH, and highlighted two predictive scores that could be used in clinical practice to guide and assist clinicians in surgical indication.

How I do it: simplified craniotomy for acute subdural hematoma in the elderly.

CONTEXT: Acute subdural hematoma (ASH) is responsible for significant morbidity and mortality in the elderly. As military neurosurgeons, we perform a simplified technique using a linear skin incision and a small craniotomy bone flap in order to ease perioperative tolerance. METHODS: The patient lies supine, a pad under the shoulder ipsilateral to the ASH, the head completely rotated on the other side and placed on a circular pad, without head clamp. The linear frontotemporal skin incision should be twice the size of the bone flap's diameter, allowing to access the whole subdural space. Care is taken to obtain complete decompression of the temporal fossa in order to alleviate uncal herniation. A subdural drain can be placed, and the subdural space is filled with warm saline solution in order to create a closed drainage system. CONCLUSION: The patient is allowed to sit at postoperative day 1 and to walk at postoperative day 2. Simplified craniotomy for ASH allows to reduce operative time and provides faster functional recovery.