Isolated unstable burst fractures of the fifth lumbar vertebra: functional and radiological outcome after posterior stabilization with reconstruction of the anterior column: About 6 cases and literature review.

INTRODUCTION: L5 burst fractures represent a small percentage of all spine fractures. Treatment strategy has not yet been standardized. Anatomical features and their biomechanical characteristics create fracture patterns which differ from those at the thoracolumbar junction. The objective of this study was to evaluate L5 burst fracture surgical treatment outcomes after posterior stabilization and reconstruction of the anterior column. PATIENTS AND METHODS: Six patients with fifth lumbar isolated unstable burst fractures were analyzed. Medical records, radiographs, and clinical scores were obtained. The results were evaluated based on restoration of vertebral body height, spinal lordosis/kyphosis, canal compromise and sagittal alignment at several phases of treatment. RESULTS: No patient showed neurologic deterioration, regardless of treatment. The median preoperative anterior vertebral height was 41mm and postoperative was 48mm. The median preoperative kyphotic angle as measured by Cobb angle (local and regional) was 21.5 degrees and 33 degrees which improved respectively by 7.5 and 5.5 degrees following instrumentation. The median amount of backward protrusion of bony fragment into the canal was measured at 67% preoperatively and at 35% postoperatively. There were no pseudarthrosis and anterior arthrodesis solid fusion was visible in all cases. There were a sagittal alignment restoration. At one year of follow up, fusion was obtained in all the cases, all patients had minimal to moderate disability using Oswestry Disability Index. The ability to return to work revealed a good-to-excellent long-term result. DISCUSSION: The results of treatment of 5th lumbar unstable burst fractures with posterior stabilization and reconstruction of the anterior column show benefit on durable functional outcome, spine stabilization and radiologic parameters. LEVEL OF EVIDENCE: IV, retrospective study.

Is there any benefit from short-term perioperative antiepileptic prophylaxis in patients with chronic subdural haematoma? A retrospective controlled study.

BACKGROUND: Chronic subdural haematoma is a common pathology, which can be complicated by seizures. Seizures may worsen the outcome of patients presenting with a chronic subdural haematoma. However, since the overall and postoperative incidence of seizures and their impact on patients' outcome has been diversely appreciated in the literature, the interest of routine antiepileptic prophylaxis remains a controversial question. METHODS: We retrospectively investigated 99 patients who were surgically treated for a chronic subdural haematoma in two French academic hospitals: 48 patients received antiepileptic prophylaxis (group A) and were compared with a group of 51 patients who did not receive any antiepileptic prophylaxis (group B). Incidence of perioperative seizures was determined, and potential risk factors for epilepsy were analysed. RESULTS: Overall postoperative seizure incidence was 5.1%. There was a slight trend towards a lower incidence of seizures in patients who had received antiepileptic prophylaxis, but no significant difference was found between the two groups (4.2% in group A versus 5.9% in group B, P=0.697). Seizures were not correlated with increased death. No risk factor for seizures was identified. CONCLUSIONS: Our retrospective data showed there is no benefit of perioperative antiepileptic prophylaxis in patients surgically treated for chronic subdural haematoma. Since other authors have shown conflicting results, sufficiently powered prospective randomized study should be conducted in order to confirm these results.

Postsurgical Pantoea calida meningitis: a case report.

INTRODUCTION: Pantoea calida, a recently described environmental Enterobacteriaceae organism, has not yet been associated with human infection. CASE PRESENTATION: We report a case of postoperative meningitis caused by P. calida. After pituitary adenoma resection, a 52-year-old Caucasian woman developed febrile meningitis confirmed by cerebrospinal fluid analysis. P. calida was grown in pure culture from this fluid and was firmly identified with partial rpoB gene sequencing. She was cured by a 14-day course of meropenem. CONCLUSIONS: P. calida must be added to the list of opportunistic Enterobacteriaceae pathogens responsible for postsurgical meningitis. It is easily identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry.

The epidural approach to the Meckel's cave: a how I do it.

BACKGROUND: Meckel's cave (MC) is a meningeal cleft lying in the middle fossa laterally to the cavernous sinus. Tumours that develop inside the MC may require a surgical resection. The authors describe the surgical technique of the intracranial epidural approach to the MC. METHODS: Based upon anatomical dissection showing the relevant surgical anatomy, and illustrated by the video of an operated case, the authors detail the surgical procedure. The key point is to shave the floor of the middle fossa and skeletonize the superior orbital fissure, rotundum and ovale foramen in order to delineate the plane of dural elevation and expose the lateral wall of the MC. The rules of exposure and resection of the tumour are then shown. Variations and limitations of the approach are discussed. CONCLUSION: Conducted in a stepwise manner and following relevant landmarks, the epidural anterolateral approach offers a safe and reliable exposure to the diseases that develop within the MC.

Sulfonamide resistance in a disseminated infection caused by Nocardia wallacei: a case report.

INTRODUCTION: Nocardial infections, although rare, are challenging for clinicians to treat. Recent contradictory reports of sulfonamide resistance have raised concerns about using this drug to treat nocardial infections. CASE PRESENTATION: A 62-year-old immunocompetent Caucasian woman showed disseminated pulmonary nodules and a brain abscess by chest computed tomography and brain magnetic resonance imaging, respectively. Multidrug-resistant Nocardia wallacei was cultured from a stereotactic brain biopsy and confirmed by 16S ribosomal ribonucleic acid gene sequencing. After the first-line treatment failed, a long course of trimethoprim-sulfamethoxazole was prescribed with no evidence of recurrence. To the best of our knowledge, this is the first report of a Nocardia wallacei disseminated infection in an immunocompetent patient, and it is the first detailed description of successful treatment with trimethoprim-sulfamethoxazole despite the resistance observed in vitro. CONCLUSION: Species identification of clinical isolates is critical for diagnosis, a prediction of antimicrobial susceptibility and epidemiological tracking. In the case of Nocardia wallacei, the clinical outcome suggests that sulfonamides can be used for treatment despite ambiguous results from in vitro susceptibility tests.

Management of radiation/radiosurgical complications and failures.

To describe the incidence and the course of complications after the radiosurgical treatment of vestibular schwannomas, the authors reviewed their own experience and reviewed the literature. Failure is described in less than 3% of cases, and this had to be distinguished from transient enlargement of tumor volume. In case of failure, microsurgical resection or another radiosurgical procedure should be discussed. The risk of radio-induced tumorigenesis is not clearly established with single-dose radiosurgical technique. Incidence and management of potential complications should be explained at the time of decision making in the management of vestibular schwannomas.

Decision making for the surgical approach of posterior petrous bone meningiomas.

OBJECT: The authors undertook this study to examine the surgical approaches used to treat posterior petrous bone meningiomas at a single institution and retrospectively evaluate their surgical strategy based on a previously published classification. METHODS: Cases in which craniotomies were performed to treat posterior petrous bone meningiomas between 2002 and 2010 were retrospectively reviewed. Data were examined from 57 patients who were treated for 59 tumors. The tumors were classified into 3 types according to the location of their primary dural attachment: Type A, located around the porus trigeminus (33 tumors); Type M, located at the level of the porus of the internal auditory canal (IAC) (12 tumors); and Type P, located laterally to the IAC (14 tumors). The median tumor diameter was 34 mm (range 20-67 mm). RESULTS: The choice of the approach was based on tumor location, as the displacement of vascular structures and cranial nerves was primarily determined by the site of dural attachment on the posterior petrous bone. An anterior petrosectomy was performed in 82% of Type A meningiomas, and a retrosigmoid approach was used in 86% of Type P meningiomas. The spectrum of approaches was less uniform for Type M meningiomas. Overall, total resection was obtained in 39% of all cases, and in 18%, 50%, and 86% of Type A, Type M, and Type P tumors, respectively. The postoperative mortality rate was 8.8% (5 deaths among 57 patients), and all 5 patients who died during the early postoperative period had large Type A tumors. At last follow-up, the functional preservation of the facial nerve was excellent in 49 (94%) of the 52 surviving patients. CONCLUSIONS: The authors believe that proper selection of the approach favorably impacts functional outcome in patients undergoing surgery for the treatment of skull base tumors. In the authors' case series of posterior petrous bone meningiomas, Type P and most Type M tumors were safely managed through a regular retrosigmoid approach, whereas Type A tumors were optimally treated via an epidural anterior petrosectomy.

How I do it: epidural anterior petrosectomy.

BACKGROUND: Among the potential approaches to access the petroclival area, epidural anterior petrosectomy (EAP) appears to be the most direct and conservative transpetrous route. In this article, we aim to detail the relevant surgical steps necessary to perform EAP in a reproducible and safe manner. METHOD: The temporo-pterional bone flap is tailored to access the floor of the middle fossa and expose the foramen ovale and foramen spinosum. Elevation of the dura covering the upper surface of the petrous apex is conducted medially toward the level of the petrous ridge. Identification of the landmarks of the rhomboid fossa delineates the limits of the drilling zone (necessary for removal of the petrous apex)-beneath Meckel's cave and just anterior to the anterior margin of the internal auditory meatus. The tentorium is divided at its free edge and is followed by opening of the posterior fossa dura. CONCLUSION: Epidural anterior petrosectomy is a conservative trans-petrous approach that offers an excellent direct surgical corridor for exposure of disease processes involving Meckel's cave, the petroclival area and the ventrolateral pons.

Posterior fossa volume increase after surgery for Chiari malformation Type I: a quantitative assessment using magnetic resonance imaging and correlations with the treatment response.

OBJECT: The aim of this paper was to measure the posterior fossa (PF) volume increase resulting from a given-sized occipital craniectomy in Chiari malformation Type I surgery and to analyze its correlations with the PF size and the treatment response, with the perspective of tailoring the amount of bone removal to the patient-specific PF dimensions. METHODS: Between January 2005 and June 2006, 11 adult patients with symptomatic Chiari malformation Type I underwent a standardized PF decompression. A prospective evaluation with clinical examination, functional grading, and MR imaging measurement protocols was performed pre- and postoperatively. A method is reported for the measurement of PF volume (PFV) after surgery. The degree of PFV increase was compared with the preoperative size of the PF and with the clinical outcome. RESULTS: All 11 patients improved postoperatively, with complete and partial recovery in 4 and 7 patients, respectively. No postoperative complication occurred after a mean follow-up period of 45 months. The mean relative increase in PFV accounted for 10% (range 1.5%-19.7%) of the initial PFV; the increase was greater in cases in which the PF was small (r = -0.52, p = 0.09) and the basiocciput was short (r = -0.37, p = 0.2). A statistically significant positive correlation was found between the degree of PFV increase and the treatment response (p = 0.014); complete recovery was observed with a PFV increase of 15% and partial recovery with an increase of 7%. CONCLUSIONS: The treatment response is significantly influenced by the degree of PFV increase, which is dependent on the size of the PF and the extent of the craniectomy, suggesting that the optimal patient-specific PFV increase could be predicted on the basis of preoperative MR imaging and enhancing the perspective that the craniectomy size could be tailored to the individual PFV.

Incidence of basioccipital hypoplasia in Chiari malformation type I: comparative morphometric study of the posterior cranial fossa. Clinical article.

OBJECT: The chronic tonsillar herniation defining Chiari malformation Type I (CMI) is thought to result from overcrowding of a normally developing hindbrain within a congenitally small posterior cranial fossa (PCF) due to occipital hypoplasia. The goals in the present study were to authenticate the cranioencephalic disproportion in a group of patients with CMI and to discuss new developmental aspects according to which part of the occipital bone was underdeveloped. METHODS: The authors retrospectively examined a group of 17 patients with CMI. Measurements of osteotentorial and neural structures of the PCF were made on MR images of the brain. The results were compared with findings in 30 healthy controls by using the Mann-Whitney U-test. RESULTS: Dimensions of the neural structures did not differ between the 2 groups of patients. The mean length of the basiocciput was significantly shorter in the CMI group (19.4 mm) compared with the control group (25.7 mm; p = 0.0003). The mean diameter of the foramen magnum was larger in the CMI group, but this difference was not statistically significant. The dimensions of the supraocciput and the mean angle of the cerebellar tentorium were identical in the 2 groups. CONCLUSIONS: Data in this study support the idea that occipital hypoplasia is the main cause of overcrowding within the PCF. Basioccipital shortness is a cardinal feature of the resultant shallow PCF and could proceed from a congenital disorder of the cephalic mesoderm of the parachordal plate or occur later in the infancy because of premature stenosis of the sphenooccipital synchondrosis.

Transcranial resection of a large sinonasal juvenile psammomatoid ossifying fibroma.

INTRODUCTION: Juvenile psammomatoid ossifying fibroma (JPOF) is a benign but potentially locally aggressive fibroosseous lesion predominantly arising in the paranasal sinuses in children and young adults. Intracranial extension is rare but occurs sometimes. In such cases, tumor resection may often require the combination of neurosurgical and facial approaches. Histological diagnosis remains a challenge because the lesion can be easily mistaken for another fibroosseous lesion or for a meningioma. CASE REPORT: We report the case of a 12-year-old boy with a JPOF arising from the right paranasal sinuses and extension towards the anterior skull base and the orbit. Despite the tumor had eroded through nasal septum, medial orbit wall, and right maxilla, it could be entirely removed performing an extended frontobasal approach via a bifrontoorbital craniotomy, obviating the need for a transfacial approach. CONCLUSION: Radiologically and histologically, the lesion could be mistaken either for a meningioma or another type of ossifying fibroma. Histological aspects and alternative surgical approaches to these rare entities are discussed.

Fractionated stereotactic radiotherapy treatment of cavernous sinus meningiomas: a study of 100 cases.

PURPOSE: We discuss our experiences with fractionated stereotactic radiotherapy (FSR) in the treatment of cavernous sinus meningiomas. METHODS AND MATERIALS: From 1995 to 2006, we monitored 100 patients diagnosed with cavernous sinus meningiomas; 84 female and 16 male patients were included. The mean patient age was 56 years. The most common symptoms were a reduction in visual acuity (57%), diplopia (50%), exophthalmy (30%), and trigeminal neuralgia (34%). Surgery was initially performed on 26 patients. All patients were treated with FSR. A total of 45 Gy was administered to the lesion, with 5 fractions of 1.8 Gy completed each week. Patient treatment was performed using a Varian Clinac linear accelerator used for cranial treatments and a micro-multileaf collimator. RESULTS: No side effects were reported. Mean follow-up period was 33 months, with 20% of patients undergoing follow-up evaluation of more than 4 years later. The tumor control rate at 3 years was 94%. Three patients required microsurgical intervention because FSR proved ineffective. In terms of functional symptoms, an 81% improvement was observed in patients suffering from exophthalmy, with 46% of these patients being restored to full health. A 52% improvement was observed in diplopia, together with a 67% improvement in visual acuity and a 50% improvement in type V neuropathy. CONCLUSIONS: FSR facilitates tumor control, either as an initial treatment option or in combination with microsurgery. In addition to being a safe procedure with few side effects, FSR offers the significant benefit of superior functional outcomes.

Intracranial teratomas in children: the role and timing of surgical removal.

OBJECT: In this study, the authors report their experience with the surgical treatment of intracranial teratomas with an emphasis on the indications for delayed resection after oncological treatment. METHODS: The authors retrospectively reviewed the cases of 14 children with intracranial teratomas. The mean age at diagnosis was 10.5 years (range 2 days-18 years), and 11 patients were male. The final histological analysis revealed pure mature teratoma in 5 cases, mixed teratoma with germinoma in 3 cases, and nongerminomatous malignant germ cell tumor in 6 cases. Thirteen patients underwent tumor resection, and these patients were divided into 2 subgroups according to the timing of surgery. In Group A, 10 patients underwent resection as the primary treatment because no tumor markers were detected in 4 patients, a teratomatous component was revealed on biopsy sampling in 3 patients, and a large tumor volume in 3 patients. In Group B, 3 patients underwent removal of residual pure mature teratoma after oncological treatment. RESULTS: Seven of the 8 patients (87.5%) with pure mature teratomas or with mixed teratoma and germinoma are currently alive (mean follow-up of 9 years); the eighth patient died of postoperative meningitis. Two of the 6 patients (33%) with mixed nongerminomatous malignant germ cell tumors died of tumor progression regardless of the timing of surgery. CONCLUSIONS: The results of this study support the belief that microsurgical removal is the only effective treatment for intracranial teratomas. Surgery may be performed as the primary therapy when there is evidence of a noninvasive teratoma, and as a secondary therapy if there is only a partial response to neoadjuvant therapy or if progression is observed in mixed malignant germ cell tumors.

Intramedullary spinal cord cavernous angioma in children: case report and literature review.

INTRODUCTION: Intramedullary cavernous angiomas (ImCA) of the spinal cord are very uncommon malformations especially in the pediatric population where only ten cases have yet been reported within the available literature. CASE REPORT: In this paper, the authors report the case of a 12-year-old girl presenting with a T11 level hematomyelia because of a cavernous angioma. Microsurgical excision was performed with good clinical outcome and no magnetic resonance imaging evidence of residual cavernoma 30 months later. DISCUSSION: Despite the small number of cases reported in children, this one contributes to the literature identifying special features of presentation and management of ImCA for pediatric patients. Because a higher risk of recurrent bleeding has been demonstrated for ImCA, with dramatic clinical consequences, microsurgical removal remains the only definitive treatment.

Intracranial ependymomas in childhood: recurrence, reoperation, and outcome.

INTRODUCTION: Intracranial ependymomas (IE) in children are aggressive tumors, and total resection (TR) is considered to be the most powerful predictor of outcome. The data regarding recurrent IE (RIE), in particular the role of reoperation, are scarce in the literature. METHODS AND RESULTS: We studied 70 cases of IE in children operated on for IE since the advent of computed imaging. TR was achieved at initial surgery in 38 out of 70 cases. After a mean follow-up of 76.1 months, 33 out of 70 tumors had progressed. Eighteen were reoperated, achieving TR in 12 out of 18 cases. The morbidity associated with reoperation was minimal, especially compared with the first operation. After a mean follow-up of 74.7 months after reoperation, 10 out of 18 patients had died of tumor progression, 1 had a stable tumor, and 7 were tumor free. When TR was achieved, the overall survival rate was 7 out of 12. CONCLUSION: Total resection is the only curative treatment for RIE and is often possible, especially when the initial resection was total.