Surgical management of isthmic spondylolisthesis: A comparative study of postoperative outcomes between ALIF and TLIF.

INTRODUCTION: Circumferential fusion by the anterior (ALIF) or transforaminal (TLIF) approach combined with posterior instrumentation is currently used for the surgical treatment of low-grade isthmic spondylolisthesis. But few studies have compared the clinical and radiological outcomes of various interbody fusion techniques. The objective of this study was to compare the clinical and radiological results at 2 years postoperative of two fusion techniques-TLIF versus ALIF plus posterior instrumentation-for low-grade isthmic spondylolisthesis in adults. MATERIALS AND METHODS: This was an observational multicenter study done at nine French healthcare facilities specialized in spine surgery. The inclusion criteria were minimum age of 18 years, grade 1-3 isthmic spondylolisthesis, ALIF+posterior fixation (ALIF+PS) or TLIF, minimum follow-up of 2 years. Clinical and radiological evaluations were done preoperatively and at 2 years of follow-up. A lumbar CT scan was done at 1 year postoperative to evaluate fusion. RESULTS: The cohort consisted of 89 patients (50 women, 39 men) with a mean age of 47.7±12.3 (18-79) years. The patients in the ALIF groups (n=71) had a significantly longer hospital stay than those in the TLIF group (n=18): 5.7 days versus 4.6 days (p=.04). However, their medical leave from work was significantly shorter: 31.0 weeks versus 40.7 (p=.003). Lumbar pain VAS diminished faster in the ALIF groups, with a significantly larger drop than the TLIF group in the first 3 months postoperative. Only the increase in lumbar disc lordosis was larger in the ALIF group: 11.7°±12.0° versus 6.0°±11.7° (p=.036). There was a significant correlation between the increase in global lordosis and reduction in lumbar VAS at 2 years postoperative (ρ=-0.3295; p=.021). CONCLUSION: ALIF+PS provides a faster relief of postoperative low back pain than TLIF but there are no significant clinical differences between techniques at 2 years of follow-up. Despite better restoration of disc lordosis in the ALIF+PS group, there was no difference in the restoration of global lordosis. LEVEL OF EVIDENCE: III; multicenter comparative study.

Fusion and clinical outcomes of lumbar interbody fusion for low-grade isthmic spondylolisthesis.

INTRODUCTION: Low-grade isthmic spondylolisthesis (ISPL) is generally treated by circumferential fusion with interbody graft, although there is no consensus on technique. HYPOTHESIS: The various interbody fusion strategies provide satisfactory fusion rates and clinical results. METHODS: A multicenter retrospective study analyzed lumbar interbody fusion for low-grade ISPL performed between March 2016 and March 2019. Techniques comprised: circumferential fusion on a posterior or a transforaminal approach (PLIF, TLIF: n=57), combined anterior (ALIF)+posterolateral fusion (ALIF+PLF: n=60), and ALIF+percutaneous posterior fixation (ALIF+PPF: n=55). Function was assessed on a lumbar and a radicular visual analog scale (AVS-L, VAS-R), Oswestry Disability Index (ODI) and Short Form 12 (SF12). RESULTS: Among the 129 patients, 85.3% showed fusion (Lenke 1 or 2), with no significant differences between the ALIF-PLF or ALIF-PPF groups and the PLIF or TLIF groups (p=0.3). Likewise, there was no difference in fusion rates between the ALIF-PPF and ALIF-PLF subgroups (p=0.28). VAS-L (p<0.001) and VAS-R (p<0.0001), ODI (p<0.001) and SF12 physical (PCS) (p<0.01) and mental component sores (MCS) (p<0.001) all showed significant improvement at 12months. Combined approaches provided greater clinical efficacy than TLIF or PLIF for lumbar (p<0.0001) and radicular pain (p<0.05), ODI (p<0.0001) and SF12 PCS (p<0.01). At 12months, there was no clinical difference between the ALIF-PPF and ALIF-PLF subgroups. However, patents with interbody non-union (Lenke 3 or 4) had lower SF12 PCS scores (p<0.004) and VAS-L ratings (p<0.001) than Lenke 1-2 patients. CONCLUSION: Low-grade ISPL treated by circumferential arthrodesis and interbody graft showed 85.3% consolidation at 2years, with equivalent outcomes between anterior and posterior techniques. Successful fusion was associated with better clinical results. LEVEL OF EVIDENCE: IV.

Anterior Longitudinal Ligament Flap Technique: Description of Anterior Longitudinal Ligament Opening During Anterior Lumbar Spine Surgery and Review of Vascular Complications in 189 Patients.

BACKGROUND: One of the main concerns of anterior lumbar spine approaches are vascular complications. The aim of our study is to provide technical details about a flap technique using the anterior longitudinal ligament (ALL) when approaching the lumbar spine via an anterior corridor. This can help decrease complications by protecting the adjacent vascular structures. We also include a retrospective cohort review. METHODS: This is a retrospective bicentric study: 189 patients with a mean age of 44.2 years underwent anterior lumbar spine surgery using the ALL flap technique. Patients were diagnosed with degenerative pathologies. We treated 239 lumbar levels primarily at the L4-5 and L5-S1: 88 single-level anterior lumbar interbody fusions, 9 two-level ALIFs, 51 total disk replacements (TDR), and 41 hybrid constructs (i.e., ALIF L5S1 and TDR L4L5). Anterior approaches were performed by two senior spine surgeons. The ALL flap technique was utilized in all of these cases, by carefully dissecting the ALL, with the flap suspended using sutures. As such, this ALL flap provided a "safe corridor" to avoid any potential vascular laceration. RESULTS: The operative and early surgical complication rate was 3.2%. There was no arterial injury. There were only 2 minor venous lacerations (1.05%). No blood transfusion was required. Neither lacerations happened during disk space preparation. CONCLUSIONS: Here, we provide technical details about a simple and reproducible technique using the ALL as a flap, which may help spine surgeons minimize vascular injuries during ALIF or even TDR surgeries.

Segmental Lordosis Gain Is a Prognostic Radiological Factor of Good Functional Outcome After the Implantation of a Single-Level Prosthesis or a Hybrid Construct for Lumbar Disc Degeneration.

OBJECTIVE: To identify radiological factors and functional outcomes associated with good results after implantation of a single lumbar disc prosthesis or a hybrid construct (anterior lumbar interbody fusion and lumbar disc prosthesis) in the setting of painful degenerative lumbar discopathy. METHODS: This single-center, retrospective 10-year study included 92 patients ˃18 years old with chronic low back pain evolving for at least 1 year. The patients had degenerative disc disease and had failed conservative treatment and underwent lumbar arthroplasty. Radiographic and clinical outcomes were assessed preoperatively and 1 year after surgery. Functional evaluation was based on the Oswestry Disability Index (ODI) and a numerical rating scale. Radiological analysis was based on lumbar x-rays and magnetic resonance imaging parameters. Patients were assigned to 2 groups according to the reduction in ODI score (>15 points or <15 points), and statistical analysis was done in both groups to find predictive radiological factors for a satisfactory functional outcome. RESULTS: Clinically, 60 patients (65.2%) had a satisfactory functional result and 32 patients (34.8%) had a poor outcome according to ODI score. Radiographically, gain in segmental lordosis was statistically associated with good functional outcomes (8.9° for ODI decrease >15 vs. 3.2° for ODI decrease <15). CONCLUSIONS: This study determined that gain in segmental lordosis is associated with a satisfactory functional outcome after a single-level lumbar disc prosthesis or a hybrid construct. Our study demonstrates that segmental lordosis gain may represent a significative useful positive predictor factor of patient outcome.

Trans-isthmic pars interarticularis screw fixation under CT and fluoroscopic guidance: technical success and clinical outcome in patients with symptomatic low-grade lumbar isthmic lysis.

OBJECTIVES: To assess the technical success of trans-isthmic screw fixation with simultaneous CT and fluoroscopic guidance in patients with symptomatic low-grade isthmic spondylolisthesis. METHODS: Fifty patients (28 women and 22 men; mean age ± standard deviation: 50 years ± 18.9) presenting with symptomatic low back pain with isthmic spondylolisthesis refractory to medical management were treated by means of trans-isthmic pars interarticularis percutaneous screw fixation. The procedure was performed under local anesthesia with double CT and fluoroscopic guidance. Primary outcome was technical success of the procedure, which was assessed with a post-procedure CT using the same success criteria as surgical screw placement with regard to entry point, trajectory, and screw tip. Secondary outcome was pain decrease assessed by the Visual Analog Scale (VAS). RESULTS: Ninety-nine procedures were performed in 50 patients and 99 screws were inserted. Postoperative CT assessment showed satisfactory screw placement in 96 cases, reflecting a technical success rate of 96.9%. No complications occurred during or after the procedure. Pain assessment showed a pain decrease of VAS score from a median of 7 (min 5, max 10; MAD 1.4) to 2 (p < 0.0001) (min 0, max 7, MAD 1.7) with a mean follow-up of 39 months. CONCLUSION: Trans-isthmic screw fixation performed under CT and fluoroscopic guidance presents a high technical success and appears as a safe procedure and effective procedure in patients with symptomatic low-grade isthmic lysis. KEY POINTS: • Trans-isthmic pars interarticularis percutaneous screw insertion is feasible under double CT and fluoroscopic guidance by a radiologist with a high technical success. • This technique can be performed under local anesthesia only. • In patients with chronic low back pain, isthmic screwing allows long-term pain improvement.

Corticosteroids as an Adjuvant Treatment to Surgery in Chronic Subdural Hematomas: A Multi-Center Double-Blind Randomized Placebo-Controlled Trial.

Chronic subdural hematoma (CSDH) is a common condition necessitating surgery; however, recurrence occurs in 15-25% of cases despite surgical management. The HEMACORT trial was a prospective randomized, double-blind, placebo-controlled, multi-centric study (NCT01380028). The aim of this trial was to determine the effect of corticosteroids as an adjuvant treatment to surgery on CSDH recurrence at 6 months. After surgery, participants were assigned by block-randomization to receive either placebo or oral prednisone at a dose of 1 mg/kg/day followed by weekly stepwise tapering in steps of 10 mg/day. The primary outcome was CSDH recurrence, defined by the need for reoperation and/or radiological progression of CSDH. Secondary outcomes were one-year death, radiological changes, safety, neurological status, and quality of life. The trial was discontinued at midpoint of expected inclusions: 78 participants received prednisone and 77 received placebo controls. In an intention-to-treat analysis, CSDH clinicoradiological recurrence was not different between prednisone and placebo groups (21.8% vs. 35.1%, respectively; hazard ratio 0.56; 95% confidence interval 0.30-1.02; p = 0.06), although post hoc analyses concluded to statistical significance (p = 0.02). Earlier radiological resolution was observed after prednisone administration, but reoperation rates (reaching 5.8% overall) and functional outcomes were not different at 6 months. Among adverse events, sleep disorders occurred more often in the prednisone group (26.1% vs. 9.1%, p = 0.02). The HEMACORT trial data suggest that prednisone, as an adjuvant treatment to surgery, may reduce early radiological recurrence of CSDH, although clinical benefits are unclear. In view of these findings, the authors suggest that shorter treatment duration should be assessed for safety and efficacy in future trials.

Transfacet screws using spinal navigation in addition to anterior or oblique lumbar interbody fusion: technical note and preliminary results.

Transfacet screws (TFS) are an alternative to the classic bilateral pedicular screws (BPS) in addition to anterior (ALIF) or oblique (OLIF) lumbar interbody fusion. Spinal navigation could help the surgeon in technically demanding procedures in order to avoid screw malposition. Although spinal navigation is commonly used in BPS, its contribution in TFS remains unclear. Our aim here was to assess the feasibility of TFS using spinal navigation in addition to anterior lumbar fusion. Five patients suffering from lumbar degenerative disc disease were included. During the same general anaesthesia, we performed successively an ALIF or OLIF and then a TFS according to Boucher technique using spinal navigation (O-arm). No peri-operative complication occurred, and all the screws were successfully positioned (n = 10). All clinical scores (ODI, VAS L and VAS R) improved at 6-month follow-up. Segmental lordosis increased from 6° [2.4°-12°] to 13.6° [8°-17°]. Fusion was achieved for the five patients. TFS using O-arm in addition to ALIF/OLIF is feasible. To confirm our early favourable outcomes on clinical and radiological data, this technique must be evaluated on larger samples of patients.

Management of Incidental Durotomy: Results from a Nationwide Survey Conducted by the French Society of Spine Surgery.

OBJECTIVE: To obtain real-life data on the most common practices used for management of incidental durotomy (ID) in France. METHODS: Data were collected from spinal surgeons using a practice-based online questionnaire. The survey comprised 31 questions on the current management of ID in France. The primary outcome was the identification of areas of consensus and uncertainty on ID follow-up. RESULTS: A total of 217 surgeons (mainly orthopaedic surgeons and neurosurgeons) completed the questionnaire and were included in the analysis. There was a consensus on ID repair with 94.5% of the surgeons considering that an ID should always be repaired, if repairable, and 97.2% performing a repair if an ID occurred. The most popular techniques were simple suture or locked continuous suture (48.3% vs. 57.8% of surgeons). Nonrepairable IDs were more likely to be treated with surgical sealants than with an endogenous graft (84.9% vs. 75.5%). Almost two thirds of surgeons (71.6%) who adapted their standard postoperative protocol after an ID recommended bed rest in the supine position. Among these, 48.8% recommended 24 hours of bed rest, while 53.5% recommended 48 hours of bed rest. The surgeons considered that the main risk factors for ID were revision surgery (98.6%), patient's age (46.8%), surgeon's exhaustion (46.3%), and patient's weight (21.3%). CONCLUSIONS: This nationwide survey reflects the lack of a standardized management protocol for ID. Practices among surgeons remain very heterogeneous. Further consensus studies are required to develop a standard management protocol for ID.

French Spine Surgery Society guidelines for management of spinal surgeries during COVID-19 pandemic.

Since the outbreak of coronavirus disease 2019 (COVID-19) in December 2019 in China, various measures have been adopted in order to attenuate the impact of the virus on the population. With regard to spine surgery, French physicians are devoted to take place in the national plan against COVID-19, the French Spine Surgery Society therefore decided to elaborate specific guidelines for management of spinal disorders during COVID-19 pandemic in order to prioritize management of patients. A three levels stratification was elaborated with Level I: Urgent surgical indications, Level II: Surgical indications associated to a potential loss of chance for the patient and Level III: Non-urgent surgical indications. We also report French experience in a COVID-19 cluster region illustrated by two clinical cases. We hope that the guidelines formulated by the French Spine Surgery Society and the experience of spine surgeons from a cluster region will be helpful in order optimizing the management of patients with urgent spinal conditions during the pandemic.

rhBMP-2 (Recombinant Human Bone Morphogenetic Protein-2) in real world spine surgery. A phase IV, National, multicentre, retrospective study collecting data from patient medical files in French spinal centres.

BACKGROUND: This is a Phase IV, national, multicentre, retrospective study to observe the real-world use of rhBMP-2 in France. HYPOTHESIS: There was no statistical hypothesis, the statistical analyses were descriptive in nature. PATIENTS AND METHODS: Data was collected from patient medical files in 10 French spinal centres. Primary objectives were to understand which patients were treated with rhBMP-2, commercialised in Europe as InductOs™ and how rhBMP-2 was used during spinal fusion surgery in France between 2011 and 2012. RESULTS: Four hundred patients (634 levels) treated with rhBMP-2 were included in the analysis. The most frequent primary diagnostic indication for rhBMP-2 use was degenerative disc disease (DDD; 129/400; 32.3% of patients) followed by spondylolisthesis (119/400; 29.8%), deformity (59/400; 14.8%) and pseudoarthrosis (29/400; 7.3%). The most frequently treated level was L4-L5 (33.8% of levels in 53.5% of patients); followed by L5-S1 (29.8%, 47.3%), L3-L4 (16.7%, 26.5%), and L2-L3 (7.3%, 11.5%), all other levels (less than 5% of patients). No interbody fusion device was used in 42.7% of levels. Wetted matrix of rhBMP-2 was placed in the interbody space in 58.4% of levels (370/634). The most common procedure for rhBMP-2 treatment was posterior lumbar fusion (PLF) (221/634; 34.9% of levels), followed by anterior lumbar interbody fusion (ALIF) (188/634; 29.7%), posterior lumbar interbody fusion (PLIF) (111/634; 17.5%), lateral lumbar interbody fusion (LLIF) (106/634; 16.7%), transforaminal lumbar interbody fusion (TLIF) (4/634; 0.6%) and 'other' (4/634; 0.6%). Thirty-one adverse events of Interest (AEI) were recorded in 27 patients. One AEI was considered related to rhBMP-2. Unplanned secondary spine interventions at index level treated with rhBMP-2 were required in 4 patients. DISCUSSION: In years 2011 and 2012 when the surgeries captured in this retrospective study were done, rhBMP-2 was indicated for single level (L4-S1) anterior lumbar spine fusion as a substitute for autogenous bone graft in adults with DDD. The most common procedure for the treatment with rhBMP-2 was PLF (off-label use), followed by ALIF (on-label use). The safety findings confirm a predictable and manageable safety profile. LEVEL OF EVIDENCE: IV.

Serious Neurological Complication Resulting from Inadvertent Intradiscal Injection During Fluoroscopically Guided Interlaminar Epidural Steroid Injection.

We describe the case of a 30-year-old patient who was referred for lumbar epidural corticosteroid injection due to right L5 radiculopathy. Two months earlier, MRI demonstrated a right large paracentral L4-L5 disk extrusion causing disabling L5 radiculopathy. The L4-L5 level was selected for interlaminar injection, using fluoroscopic guidance. During injection, the patient developed severe pain in both lower extremities. Thus, the procedure was immediately terminated. Paraplegia occurred within several minutes. Urgent lumbar spine CT and MRI demonstrated contrast material in a massive extruded disk fragment and substantial increase in size of the disk extrusion compared to pre-injection MRI. Emergency surgery was performed for lumbar decompression and discectomy. Although rare, serious neurological complication can result from inadvertent intradiscal injection of contrast material during lumbar epidural injection. This case illustrates the importance of recognizing the possibility of dynamic change in the size of an extruded disk fragment when the MRI precedes injection by a substantial time interval. LEVEL OF EVIDENCE: IV, Case Series.

Lumbar interbody fusion with utilization of recombinant human bone morphogenetic protein: a retrospective real-life study about 277 patients.

The purpose of this study was to report an independent real-life experience about the use of recombinant human bone morphogenetic protein 2 in lumbar interbody fusion with a special focus on complications. This is a retrospective single-center cohort study between 2007 and 2013 including 277 patients treated for anterior or posterior lumbar fusion with recombinant human bone morphogenetic protein 2. We report the complications occurring during the 12 first postoperative months and analyze the fusion rate on X-rays. There are 58 cases (22.8%) of clinical complications. In 15 cases (5.9%), these complications were related to the use of recombinant human bone morphogenetic protein 2. Only one patient (0.4%) required a new intervention due to recombinant human bone morphogenetic protein 2. Fusion rate at 1 year was 98%. The low rate of specific complication suggests that recombinant human bone morphogenetic protein 2 can be safe and effective in anterior and posterior interbody fusion when used with simple precautions.

Unusual cauda equina syndrome due to multifocal ependymoma infiltrated by lymphoma.

Myxopapillary ependymoma is a rare tumour of the central nervous system (CNS); this subtype of ependymoma occurs most frequently in cauda equina, conus medullaris or filum terminale. The treatment consists of complete removal of the tumour including its capsule when possible since it is usually a solitary lesion. Non-Hodgkin lymphoma of the CNS is found in only 1.3% of cauda equina tumours. We report the case of a 62-year-old man who presented to our institution with progressive weakness of his right lower extremity, with numbness and paresthesia of both feet. He was suffering from one month of right sciatica. Lumbosacral MRI displayed two intradural extramedullary lesions, the first one was located posteriorly to L1-L2 and the second one was spreading from L4 to S2 presenting as a mucoid cyst in its superior part with hyperintense T2 signal, isointense on T1-weighted with high and homogeneous contrast enhancement in the inferior solid component. Imaging also found three additional intradural, extramedullary tumor formations with contrast enhancement, located respectively at C5-C6, C7 and T4. A L1-L2 and S1-S2 laminectomy was performed in emergency and total removal was achieved. Neuropathologist concluded that the tumor was a myxopapillary ependymoma infiltrated by large B-cell lymphoma. Although rare, this phenomenon (coexisting tumors within the same lesion) should be known by neurosurgeons because the occurrence of collision tumors affects the treatment and the patient's prognosis. In our case, two different types of tissue were mingled in the same location-this finding is very uncommon and has, to our knowledge, never been reported before.

Single-use instrumentation in posterior lumbar fusion could decrease incidence of surgical site infection: a prospective bi-centric study.

PURPOSE: Single-use surgical instruments were recently introduced to improve OR efficiency and reduce infection risks. This study aimed to investigate clinical results 1 year after instrumented lumbar fusion, with the aid of single-use surgical instruments, with particular attention to surgical site infection and Oswestry Disability Index (ODI). METHOD: This prospective bi-centric study included 21 men and 28 women, aged 61.6 ± 12.8 years, that underwent short instrumented lumbar fusion for degenerative disc disease, canal stenosis, or degenerative spondylolisthesis. All patients underwent posterior or transforaminal lumbar interbody fusion, using the SteriSpine™ PS Pedicle Screw System, available in multiple traceable sterile kits. RESULTS: Instrumented fusion was performed at one level in 31, two levels in 11, three levels in 5, and four levels in 2 patients. The mean follow-up was 16.4 ± 2.1 months, during which the ODI improved by 20 or more points in 28 patients (57 %), improved by less than 20 points in 17 patients (35 %), and remained unchanged or worsened in 4 patients (8 %). Only one infection (2 %) was observed in a 60-year-old man with previous spine surgery and two additional risk factors (diabetes mellitus and BMI 38). Compared to an older series, using reusable instrumentation, performed by the same team for the same indications, the clinical outcomes were similar but the infection rate was 6 %. DISCUSSION: Single-use instrumentation could reduce the incidence of surgical site infections following lumbar fusion to acceptable levels as in hip and knee arthroplasties. The preservation of screws and rods in sterile packs until ready for insertion reduces their exposure to air-borne bacteria in the OR and eliminates their contamination through repetitive hospital sterilization. The short operation time and minimal blood loss achieved could also contribute to the reduction in infection risks. LEVEL OF EVIDENCE: Level II, prospective randomized bi-centric study.

Maverick total disc replacement in a real-world patient population: a prospective, multicentre, observational study.

PURPOSE: Controlled trials have shown that total disc replacement (TDR) can provide pain and disability relief to patients with degenerative disc disease; however, whether these outcomes can also be achieved for patients treated in normal surgical practice has not been well documented. METHODS: This prospective, international study observed changes in disability and back pain in 134 patients who were implanted with Maverick TDR within the framework of routine clinical practice and followed for 2 years post-surgery. Primary and secondary outcomes were the differences from baseline to 6 months post-surgery in the means of the Oswestry Disability Index and the change in back pain intensity assessed on a 10-cm visual analogue scale, respectively. Mean patient age at surgery was 43 years, but ranged up to 65 years. RESULTS: One hundred twenty-three patients had an implant at one level, 10 patients at two levels, and one patient at three levels. Statistically significant improvements in mean disability (-25.4) and low back pain intensity (-4.0) scores were observed at 6 months postoperatively (P < 0.0001 for both) in the hands of experienced surgeons (>10 TDRs per centre). During the study, 56 patients (42 %) experienced a complication or adverse event. CONCLUSIONS: This is the first international observational study to report outcomes of TDR in real-world clinical settings. We showed statistically significant improvements in disability and pain scores at 6 months following Maverick TDR, which were maintained for 2 years alongside an acceptable rate of perioperative complications. The safety and tolerability shown in this observational study were comparable to those from controlled trials.

Intraventricular fibrinolysis for severe aneurysmal intraventricular hemorrhage: a randomized controlled trial and meta-analysis.

UNLABELLED: The aim of this study was to assess the safety and efficacy of intraventricular fibrinolysis (IVF) for aneurysmal subarachnoid hemorrhage (aSAH) with severe intraventricular hemorrhage (IVH). In this randomized controlled trial, between 2005 and 2009, patients with aSAH and severe IVH were randomly assigned into two groups: one treated with external ventricular drainage (EVD) combined with intraventricular recombinant tissue plasminogen activator (rt-PA) and the second with EVD alone. The primary end-point was mortality rate within the first 30 days. We performed meta-analysis including all published articles that compared IVF + EVD to EVD alone in patients with aSAH IVH. Eleven patients were included in the rt-PA group, eight in the control group. At 30 days, mortality rate was lower in the rt-PA group (45.5 vs. 62.5%), but results were not statistically significant (p = 0.65). Clearance of third and fourth ventricles was obtained previously in the rt-PA group (4.25 days) compared to the control group (10.67 days) (p = 0.001). There was no statistically significant difference concerning the occurrence of complications. The meta-analysis showed a better survival rate with IVF without raised statistical significance (odds ratio = 0.32 [95% confidence interval, 0.10-1.03]). This study shows that IVF is as safe as EVD alone for aSAH with severe IVH. It accelerates blood clot resolution in the ventricular system. Mortality rate could be improved by IVF but without significant results. Because of the severity and rarity of this pathology, a multicenter study is required. CLINICAL TRIAL REGISTRATION INFORMATION: www.clinicaltrials.gov (NCT00823485).

Dynamic model of communicating hydrocephalus for surgery simulation.

We propose a dynamic model of cerebrospinal fluid and intracranial pressure regulation. In this model, we investigate the coupling of biological parameters with a 3-D model, to improve the behavior of the brain in surgical simulators. The model was assessed by comparing the simulated ventricular enlargement with a patient case study of communicating hydrocephalus. In our model, cerebro-spinal fluid production-resorption system is coupled with a 3-D representation of the brain parenchyma. We introduce a new bi-phasic model of the brain (brain tissue and extracellular fluid) allowing for fluid exchange between the brain extracellular space and the venous system. The time evolution of ventricular pressure has been recorded on a symptomatic patient after closing the ventricular shunt. A finite element model has been built based on a computed tomography scan of this patient, and quantitative comparisons between experimental measures and simulated data are proposed.