Neurosurgical work during the Napoleonic wars: Baron Larrey's experience.

OBJECTIVES: Considered as the most famous French military surgeon, Dominique-Jean Larrey (1766-1842), who joined all the campaigns of Napoleon, wrote his memoirs and several medical articles. This paper discusses how in the Napoleonic times, Larrey dealt with neurosurgical diseases or injuries. PATIENTS AND METHODS: We reviewed four main publications of Larrey published between 1812 and 1838 and analyzed the type of neurosurgical cases presented and their treatment. RESULTS: These works include his practice of what we call now "neurosurgery" since most injuries described concern the skull or spine. He seemed to treat patients with humanity, integrity and perseverance. Larrey dealt with many aspects of neurosurgery, such as cranial or spinal trauma surgery, and also infectious diseases. He saw many head injuries inflicted not only by muskets or artillery, but also with spears and sabers. Unlike some others, Larrey advocated the use of trepanation in many situations as practiced, for instance, in the treatment of depressed fractures or in presence of subdural collections. On the other hand, this surgeon who saw thousands of amputees during his career did not mention the phantom limb phenomenon in his memoirs. Similarly, the issue of cerebral localizations is only mentioned in his last work, published in 1838. CONCLUSIONS: In his work, Larrey (and all his contemporaries) dealt essentially with "cranial" surgery, as in skull fractures where the brain could potentially have been injured by bone fragments. The time for brain surgery had not come yet.

Segregation of lexical and sub-lexical reading processes in the left perisylvian cortex.

A fundamental issue in cognitive neuroscience is the existence of two major, sub-lexical and lexical, reading processes and their possible segregation in the left posterior perisylvian cortex. Using cortical electrostimulation mapping, we identified the cortical areas involved on reading either orthographically irregular words (lexical, "direct" process) or pronounceable pseudowords (sublexical, "indirect" process) in 14 right-handed neurosurgical patients while video-recording behavioral effects. Intraoperative neuronavigation system and Montreal Neurological Institute (MNI) stereotactic coordinates were used to identify the localization of stimulation sites. Fifty-one reading interference areas were found that affected either words (14 areas), or pseudo-words (11 areas), or both (26 areas). Forty-one (80%) corresponded to the impairment of the phonological level of reading processes. Reading processes involved discrete, highly localized perisylvian cortical areas with individual variability. MNI coordinates throughout the group exhibited a clear segregation according to the tested reading route; specific pseudo-word reading interferences were concentrated in a restricted inferior and anterior subpart of the left supramarginal gyrus (barycentre x = -68.1; y = -25.9; z = 30.2; Brodmann's area 40) while specific word reading areas were located almost exclusively alongside the left superior temporal gyrus. Although half of the reading interferences found were nonspecific, the finding of specific lexical or sublexical interferences is new evidence that lexical and sublexical processes of reading could be partially supported by distinct cortical sub-regions despite their anatomical proximity. These data are in line with many brain activation studies that showed that left superior temporal and inferior parietal regions had a crucial role respectively in word and pseudoword reading and were core regions for dyslexia.

Microsurgical management of postoperative disc space infection.

We analysed seventeen patients with septic postoperative spondylodiscitis (POD) who were managed by early microsurgical removal of the infected necrotic tissue, application of a closed suction-irrigation system (for a mean of 6.7 days), and early mobilisation. The POD was diagnosed clinically by elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) values and radiographically by computerised tomography scanning or magnetic resonance imaging. According to the sensitivity studies of the obtained pathogens, systemic antibiotics were given, followed by early mobilisation of all patients in a light cast corset. Immediate pain relief was noted in all patients except one, who required a third operation that was followed by rapid clinical improvement. Bacteriological diagnosis was obtained in 88% of the patients. Excellent or good clinical long-term results were achieved in 82% of the patients, whereas 18% had poor results. Elevated ESR/CRP values returned to normal ranges within 6 to 44 days (mean 15 days) after reoperation. All but one patient tolerated early mobilisation (within 2 to 4 weeks) well without any complication. Early microsurgical removal of the necrotic and infected tissue and application of a closed suction-irrigation system supported by specific antibiotic therapy should be considered an effective means to treat POD, thereby avoiding a prolonged period of unpleasant immobilisation for the patient.

Endoscopic anterior cervical foraminotomy for unilateral radiculopathy: anatomical morphometric analysis and preliminary clinical experience.

OBJECT: Cervical radiculopathy is typically caused by posterolateral disc herniation or spondylotic foraminal stenosis, either of which may compress the ventral aspect of the nerve root. The authors undertook a study to establish the feasibility of performing an endoscopic approach for anterior cervical foraminotomy (ACFor) in a clinical setting. METHODS: Application of this method on cadavers was conducted to verify the practicability of this technique. The clinical study included 16 patients (eight men and eight women; mean age 46.6 years) all presenting with unilateral radicular symptoms (one at two adjacent ipsilateral levels), which were associated with various degrees of neck pain. Disc herniations and/or uncovertebral osteophytes were confirmed on magnetic resonance imaging and high-resolution computerized tomography scanning. A total of 17 endoscopic ACFors (one two-level procedure) were performed using a rigid glass endoscope (25 degrees angled, 3-mm diameter, 10-mm length) mounted on a tubular retractor. No major surgery-related complications were encountered. During a mean follow-up period of 13.8 months an average absolute improvement of 44% (p > 0.05) in the neck disability index score and of 96% (p > 0.05) in the visual analog scale score for radicular pain (compared with the preoperative score) was observed. During the follow-up period strength improved to normal in 84% and sensory deficit in 80% of the patients. The overall subjective patient satisfaction rate was 87.6%; the return-to-work rate after 4 weeks was 81.4%. CONCLUSIONS: The advantages of endoscopic ACFor include minimial surgical exposure, improved intraoperative visualization, direct decompression of the nerve root, and the preservation of the intervertebral disc and the motion segment.

Recurrent angiofibroma invading the skull base--case report.

A 16-year-old male presented with a massive nasopharyngeal angiofibroma arising in the nasopharynx, nasal cavity, pterygopalatine fossa, and infratemporal fossa, and eroding the pterygoid process of the sphenoid bone. Neuroimaging showed the tumor had infiltrated the parasellar region from the middle cranial fossa and reached the cavernous sinus. The tumor was almost completely removed macroscopically by a modified transbasal approach.

Social and economic outcome after posterior microforaminotomy for cervical spondylotic radiculopathy.

Between 1993 and 1998, the surgical technique of posterior cervical foraminotomy as described by Frykholm, with individual cervical nerve root decompression had been applied at the Neurosurgical Department of the University of Vienna. We conducted a retrospective study to assess the functional and socio-economic outcome. Thirty-two patients were included in this study, 21 men and 11 women with a median age of 48 years (range 30 to 70 years). Prior to surgical management, median duration of symptoms had been 7 weeks (range 1-50 weeks), with cervicobrachialgia in 28 of the patients, 27 of the patients had sustained radicular sensory loss, and in 25 of the patients radicular paresis occurred. Measured by the Prolo Functional Economic Outcome Rating Scale, 64% of the patients were classified with a good outcome (scale 8-10), 18% of the patients were classified with a moderate outcome (scale 5-7), and 18% of the patients were classified with a poor outcome (scale < 5). Two of the patients required additional anterior cervical discectomy and one patient suffered a superficial wound infection which needed surgical drainage. This study confirms that posterior microforaminotomy is a useful technique for degenerative disease causing cervical radiculopathy with the advantage of avoiding fusion and immobilisation. Criteria for evaluating the results of treating cervical spinal disorders vary widely. Comparative analyses of outcome among different therapy protocols are compromised by the diversity among the groups studied, as well as by the varying methods of measuring success. We propose a scale based on the socio-economic and functional status of the patient before and after treatment This scale is easily applicable and can delineate pre- and postoperative conditions of patients. A more universal acceptance of common criteria for judging the outcome of spinal operations should facilitate comparisons among various methods of treatment.

Traumatic arteriovenous fistula of the vertebral artery.

A 22-year-old woman sustained a stab wound injury of the right vertebral artery. Initial treatment with endovascular embolization using platinum coils in a local hospital could not stop the bleeding. The patient was transferred to our department in hypovolemic shock. Further angiography revealed an arteriovenous fistula. Open surgical revision occluded the vertebral artery and the patient recovered without neurological deficit.