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.

Operative and Perioperative Durations in O-Arm vs C-Arm Fluoroscopy for Lumbar Instrumentation.

BACKGROUND: Intraoperative 3-dimensional fluoroscopy (eg, O-arm) has been shown to improve accuracy of pedicle screw placement over 2-dimensional fluoroscopy (C-arm), but its effect on surgery duration remains unclear. OBJECTIVE: To compare the durations of operative and perioperative times between O-arm and C-arm procedures for degenerative lumbar disorders. METHODS: We analyzed 198 patients representing 987 pedicle screws treated in a single center by 4 different surgeons between 2013 and 2015. Accuracy of pedicle screw placement was assessed using the Laine classification on postoperative CT scans. Operative and perioperative durations were prospectively reported on the procedure sheet by anesthesiologists. RESULTS: As expected, placement of pedicle screws using O-arm navigation was overall more accurate compared to C-arm fluoroscopy (strictly intrapedicular screws: 549/663 = 82.8% vs 239/324 = 73.8%, P = .008). This benefit did not depend on surgeon individual performance (P = .17). Average operative duration per instrumented level was significantly shorter in the O-arm group (57.3 min vs 66.1 min, P = .02) but also depended on the surgeon, indication, and interbody fusion. However, only surgeon individual performance remained significantly associated with surgery duration in multivariate analysis (P < .001). Similarly, the only factor that remained significantly associated with longer perioperative durations in multivariate analysis was the indication of surgery (P < .001). CONCLUSION: This study shows that O-arm navigation does not independently decrease operative duration, nor increases perioperative time, while improving accuracy of pedicle screw placement.

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.

Two patients with a solitary fibrous tumor of the thoracic spinal cord.

We report two patients with thoracic spinal solitary fibrous tumor (SFT). This report includes a patient with the first secondary SFT arising in the central nervous system from a pleural origin to our knowledge. The diagnosis was confirmed by histological and immunohistochemical analysis. Both patients underwent gross total resection of their tumors and did not show signs of local recurrence. The patient with the secondary lesion later presented with visceral dissemination. We review the reports of spinal SFT and discuss the diagnosis and therapeutic management of this intriguing entity.

Bilateral orbital and optic nerve endoscopic endonasal decompression for nonspecific inflammatory orbital disease: case report.

BACKGROUND: Endoscopic endonasal optic nerve decompression (EEOND) is indicated in traumatic and endocrine orbitopathies as well as in idiopathic intracranial hypertension. CASE: We present a patient with bilateral nonspecific inflammatory orbitopathy (NSIO) and optic nerve compression presenting with acute severe visual loss. Bilateral orbital and optic nerve decompression was performed as an emergency procedure with a favorable ophthalmological result. CONCLUSION: EEOND is an effective and safe technique in acute orbitopathies and should be taken in consideration in atypical clinical settings causing severe acute visual loss.

[Changing the teaching of neurosurgery with information technology]. / Campus numérique de neurochirurgie: mobiliser une discipline des sciences médicales autour d'un projet pédagogique fédérateur.

A digital campus is a distance learning site that uses the potential of information and communication technologies to disseminate and improve educational services. This website, with open and free access, is built from free software with Web 2.0 technology. It is hosted at the University of Limoges. It functions as a digital library, containing scanned books, slide shows, more than 200 hours of recorded courses and round tables accessible by streaming video. The site is indexed according to the users' needs, by level of knowledge, specialty, keywords, and supplementary MeSH terms. The campus is organized as the College of Neurosurgery (http://college.neurochirurgie.fr). The durability of this type of training (in existence for 9 years now) is made possible by a powerful and committed consortium: the French Society of Neurosurgery, which has created high-quality intellectual and scientific resources, the University of Limoges, the Dupuytren University Hospital Center in Limoges, the region of Limousin, and the French-language Virtual Medical University, which have provided logistic and financial support. To target appropriate levels at various users, we distinguished four groups: medical students, neurosurgery students, neurosurgeons (continuing medical education), and students in allied health fields. All areas of neurosurgery are concerned. All the courses, including tests for self-evaluation and scientific meetings (organized with information and communication technologies) are digitally recorded for the site. The principles that make it possible for a medical discipline to organize around an online project are: a pedagogical conception of projects built in the form of models reusable by other health specialties; a stronghold within professional societies of the relevant specialties able to create high-quality intellectual and scientific resources; an organization by educational levels that can be extended transversally to other health disciplines; and free access to the digital campus, the durability of which depends on the dissemination and dynamism of its consortium.

Respiratory outcome of mid-face advancement with distraction: a comparison between Le Fort III and frontofacial monobloc.

Upper airway stenosis in patients with faciocraniosynostosis is very common and often severe. Mid-face advancement, either with a Le Fort III or concomitantly to a monobloc frontofacial advancement, may prevent a tracheotomy or result in its ablation. The amelioration of respiratory function appears to be much better if the mid-face advancement is combined with distraction osteogenesis, although large studies with long-term follow-up are rare. In this study we reviewed the respiratory outcome between Le Fort III with distraction and monobloc advancement with distraction in 55 faciocraniosynostotic patients. Early respiratory results of both procedures were very good and stable at long-term follow-up. The choice between a Le Fort III and a monobloc procedure is made based on presenting morphology, previous surgery, and age. Both can be expected to give a long-lasting improvement of upper airway obstruction.

Respiratory outcome of midface advancement with distraction: a comparison between Le Fort III and frontofacial monobloc.

Upper airway stenosis in patients with faciocraniosynostosis is very common and often severe. Midface advancement, either with a Le Fort III or concomitantly to a monobloc frontofacial advancement, may prevent a tracheotomy or result in its ablation. The amelioration of respiratory function appears to be much better if the midface advancement is combined with distraction osteogenesis, although large studies with long-term follow-up are rare. In this study, we reviewed the respiratory outcome between Le Fort III with distraction and monobloc advancement with distraction in 54 faciocraniosynostotic patients. Early respiratory results of both procedures were very good and stable at long-term follow-up. The choice between a Le Fort III and a monobloc procedure is made on the basis of presenting morphology, previous surgery, and age. Both can be expected to give a long-lasting improvement of upper airway obstruction.

[Forensic pediatric autopsy and medical responsibility]. / Responsabilité du médecin légiste dans l'autopsie pédiatrique.

The integrity of the human body is an intangible human right acknowledged to persist after death. Violating the integrity of the human corpse is a penal act sanctioned by the 1994 version of the French Penal Code. There are only three exceptions: for science (medical autopsy), for public health (organ removal for graft), and for justice (forensic autopsy). The parents' written agreement is needed to perform a pediatric medical autopsy but not for a forensic autopsy. For the forensic pathologist, taking oath does not imply an authorization to override the precepts of humanity nor the Hippocratic Oath. The forensic pathologist remains subject to civil and penal law. This is why forensic pathologists have an obligation of excellence besides their obligation of means. A pediatric autopsy is a specific procedure compared with an adult autopsy and requires specific training. Forensic pathologists, like all pathologists, who does not have sufficient expertise should not perform pediatric autopsy but rather call in a qualified pediatric pathologist. Tissues or organs removed during a forensic autopsy can be used only for diagnostic purposes, and the parents' agreement must be obtained for any other use.