A child dural-based occipital cavernoma with an accessory venous sinus.

BACKGROUND: The diagnosis of extra-axial cavernoma and surgical decision-making can be difficult on children. REPORTED CASE: In this report we present the case of a 33-month-old child for whom the work up done for asthenia, anorexia and psychomotor regression reveals a well-defined occipital extra-axial lesion. A follow up MRI was performed two months later, revealing an increase in the size of the lesion associated with hemorrhagic changes. The surgical decision is performed after an arteriography; it allows the total removal of the lesion contained in a duplication of the dura mater, by placing a vascular clip on an accessory venous sinus draining the lesion, respecting the integrity of the lateral sinus. Histology confirms a cavernoma. No complication resulted from the surgical procedure. This atypical case of pediatric dural cavernoma associated with a well-defined accessory venous sinus in arteriography is to our knowledge the first description in the literature. CONCLUSION: Extra-axial cavernomas have a misleading presentation. The management of these lesions is of twofold interests: to avoid a repercussion on the development of these children, and to obtain histological confirmation.

Upward vectors for osteogenic distraction treatment in secondary chronic intracranial hypertension in children undergoing scaphocephaly surgery: 2 cases reported.

The occurrence of secondary synostosis of coronal sutures at distance from H-craniectomy surgery for scaphocephaly concerns about 10% of children. Intracranial hypertension in these children remains exceptional but generally requires a surgical reoperation. Two children aged 3 and 5- months- old had been operated for scaphocephaly by H-craniectomy in two different hospital centers. Their clinical follow-up described a partial persistence of dolichocephalic deformity and an impression of parietal stenosis. During their growth, chronic headaches appeared with a complaint expressed at the ages of 4 and 5 years. In both cases, ophthalmic examination revealed significant bilateral papillary edema without loss of visual acuity. The imaging assessment (CT-scan and MRI) showed the absence of Chiari malformation and venous abnormality. For both, there was a compression image of the parietal lobes in relation to the persistence of a temporoparietal synostosis. An osteogenic parietal distraction permitted a volumetric brain expansion consecutive to the skull and meninges remodeling in only 6 months, associated with a leap forward acquisition, a normalization of the ophthalmic examination, and a complete loss of headaches. In conclusion, this new approach could be used in the case of chronic intracranial hypertension consecutive to a secondary parietal synostosis after a scaphocephaly surgery.

Craniosynostosis and oculomotor disorders.

Simple, complex or syndromic craniosynostosis may be responsible for ocular and especially oculomotor pathologies. Among simple craniosynostosis, anterior plagiocephaly is the most frequently associated with oculomotor disorders. Oculomotor disorders encountered in craniosynostosis are specific to this pathology. They may be related to orbital deformities or oculomotor muscle malformations. Early craniofacial surgery reduces the onset and severity of these oculomotor disorders which is very important for ophtalmological patient care. Indeed, these oculomotor disorders are difficult to treat for the ophthalmologist with most of the time several surgeries needed, and lead to amblyopia if neglected.

C1-C2 type Harms internal fixation for unstable C2 fracture in a 6-year-old boy: Case report.

BACKGROUND: Decision-making is often difficult in odontoid fracture in children. CASE REPORT: We present the case of a 6-year-old boy who sustained cervical trauma on falling out of a tree. Initial cervical X-ray and CT-scan did not find any traumatic lesion. Three-week check-up revealed an unstable C2 fracture in the synchondrosis at the base of the odontoid bone, with anterior displacement (type IC on the classification of Hosalkar et al.), without neurological symptoms except for cervical pain and limitation of head rotation. MRI confirmed the absence of medullary lesion. The Harms technique was used to fix C1 and C2, using adult instrumentation without bone graft. Bone fusion was obtained at 8 months. Hardware was removed at 10 months. No complications were reported. CONCLUSIONS: Posterior internal fixation for unstable C2 fractures in children can be effective and relatively safe.

L1 burst fracture with associated vertebral angioma.

Vertebral angioma is a common bone tumor. We report a case of L1 vertebral angioma revealed by type A3.2 traumatic pathological fracture of the same vertebra. Management comprised emergency percutaneous osteosynthesis and, after stabilization of the multiple trauma, arterial embolization and percutaneous kyphoplasty.

Superior sagittal sinus reconstruction using a femoral venous graft after total removal of a meningioma. Case report.

OBJECTIVE: Resection of a parasagittal meningioma invading the superior sagittal sinus (SSS) needs the reconstruction of the sinus by a patch or a venous graft depending of sinus invasion degree. METHOD: We present here a case of a 21-year-old man who underwent radical removal of a radio-induced parasagittal meningioma totally invading the posterior third of the sinus. For its reconstruction, we used the patient's left superficial femoral vein without valves as an autograft, by realizing two end-to-end anastomoses between the sinus and the graft after an en-bloc removal of the meningioma and the invaded sinus. RESULTS: Two years after surgery, clinical examination of the patient was strictly normal and the femoral venous graft was still patent on CT angiograms. CONCLUSION: The superficial femoral vein without valves seems to be convenient for SSS reconstruction.

Anterior minimally invasive extrapleural retroperitoneal approach to the thoraco-lumbar junction of the spine.

BACKGROUND: The anterior approach to the thoraco-lumbar junction of the spine allows therapeutic interventions on post-traumatic, infectious, and neoplastic vertebral lesions from T11 to L2 combining spinal cord decompression, corporectomy, and vertebral body fusion. However, this approach also has a reputation for damaging the intervening anatomic structures (lungs, peritoneum, and diaphragm). The objective of this study was to show that both nervous structure decompression and anterior vertebral reconstruction can be achieved via an anterior minimally invasive extrapleural retroperitoneal (AMIER) approach. MATERIAL: We describe each of the steps of the AMIER approach to the thoraco-lumbar junction of the spine. RESULTS: The AMIER approach ensures excellent exposure that allows full decompression and satisfactory anterior anatomic reconstruction. The main difficulties and complications relate to the lungs, and a painstaking and rigorous technique limits the complications compared to conventional thoraco-phreno-lumbotomy.

[Fracture of macroporous hydroxyapatite prosthesis]. / Fracture précoce d'une cranioplastie en céramique macroporeuse d'hydroxyapatite.

Different prosthesis implants are offered to perform a cranioplasty after a decompressive craniectomy when autologous bone graft cannot be used. The authors report the case of a 25-year-old man who benefited a unilateral decompressive craniectomy after a severe head trauma. Seven months later, a cranioplasty using custom macroporous hydroxyapatite prosthesis was performed. The postoperative course was marked by a generalized seizure leading to a traumatic head injury. The CT-scan showed a comminutive fracture of the prosthesis and an extradural hematoma. The patient underwent a removal of the fractured prosthesis and an evacuation of the extradural clot. The postoperative course was uneventful with a Glasgow outcome scale score at 5. A second cranioplasty using a polyether ether ketone (PEEK) implant was performed. Among cranioplasty prosthesis solutions, hydroxyapatite implants seem to have similar property to the bone. However, its weak mechanic resistance is an actual problem in patients susceptible to present generalized seizures with consecutive head impact. Hence, in patients with decompressive craniectomy who are exposed to potential brain injury, we favor the use of more resistant implant as PEEK prosthesis.

[Minimally invasive extrapleural retroperitoneal approach for thoracolumbar junction. Prospective study of 40cases]. / Abord mini-invasif de la charnière thoracolombaire du rachis par voie extrapleurale, rétropéritonéale. Étude prospective sur 40cas.

STUDY DESIGN: Prospective study. BACKGROUND AND PURPOSE: The anterior spinal cord decompression and spinal interbody fusion is considered an effective therapeutic procedure for thoracolumbar spine junction (TLSJ) (T11 to L2) fractures and tumors. However, it is also known to be associated with considerable surgery-related trauma. The purpose of this study was to show that neural elements decompression and anterior reconstruction at the TLSJ can be performed via a minimally invasive extrapleural retroperitonal approach (MIERA). METHODS: The authors studied prospectively the hospital records and radiological data obtained in 40 patients (mean age: 43.6 years, range: 16-74 years) who all underwent first a posterior fixation followed by a thoracic (T11 or T12) or lumbar (L1 or L2) corpectomy and spinal fusion via a MIERA. RESULTS: The MIERA provided excellent exposure to facilitate complete decompression and anterior reconstruction in all patients, as verified on follow-up radiographic studies. More than 2years follow-up record is available for 24 patients, a one year follow-up record for 14 others, and six months follow-up for the last two ones. Radiography demonstrated anatomically correct reconstruction in all patients, as well as a solid fusion or a stable compound union in the 24patients for whom a minimum of 2years follow-up records was available. CONCLUSIONS: The MIERA allows the surgeon to perform anterior thoracolumbar spine surgery via a less invasive approach. The authors demonstrate the efficacy and safety of this technique and its potential to reduce perioperative morbidity compared with conventional retroperitoneal lumbar spine surgery or thoracophrenolombotomy.

[Double traumatic cervical spine lesion (odontoid fracture and spinal cord injury) and Klippel-Feil syndrome]. / Double lésion traumatique du rachis cervical (fracture de l'odontoïde et contusion médullaire C5-C6) et syndrome de Klippel-Feil.

Klippel-Feil syndrome (KFS) is defined as a congenital fusion of at least two cervical vertebrae. Patients with KFS are known to be at high risk for spinal cord injury in case of cervical trauma even with weak kinetic. We report the case of a patient with C4-C5 and C6-C7 congenital fusion, harbouring C5-C6 post-traumatic spinal cord injury, associated with an odontoid fracture type 2 of Anderson and D'Alonzo classification following a motorbike accident.

Modified posterior atlantoaxial screw-rod fixation in a case of persistent first intersegmental artery. Case report and literature review.

OBJECTIVE: This case reports atlantoaxial stabilization in case of V3 segment anomaly. PATIENT: We report the case of a patient who was victim of a complex C2 fracture requiring atlantoaxial stabilization whereas the initial cervical 3D CT angiography showed a persistent first intersegmental artery consisting in a V3 segment of the vertebral artery penetrating dura-mater in the spinal canal below the C1 posterior arch without passing through the C1 foramen transversarium. RESULTS: This rare vascular anomaly described in 2 to 5% of the patients led us to modify the screw entrance over the C1 posterior arch in order to obtain a satisfactory stabilization and to limit the risk of vertebral artery injury.

[Cerebrospinal fluid rhinorrhea following endocopic trans-sphenoidal pituitary surgery: Experience from 337 patients]. / Rhinorrhée cérébrospinale après chirurgie hypophysaire endoscopique trans-sphénoïdale : réflexions après 337 patients.

INTRODUCTION: Cerebrospinal fluid (CSF) leak is a frequent complication after trans-sphenoidal pituitary surgery. We try to determine the incidence, risk factors, diagnostic procedures, and management of CSF leaks following trans-sphenoidal pituitary macroadenoma surgery. METHODS: A retrospective analysis of 337 patients data. RESULTS: Postoperative CSF leaks occurred in 11 patients (3,1%). Ten patients had to be reoperated. Three patients had meningitis. Intraoperative CSF leak is the only significant predictive factor of postoperative CSF leak. Revision surgery, wide opening of the sella turcica and insufficient reconstruction of the sellar floor also seem to play a role (for six cases of postoperative CSF leak, the closure material had been excluded). CONCLUSION: Prevention of the postoperative CSF leak needs screening of intra-operative CSF leak. The strength of the sellar floor is essential in order to avoid the ejection of the closure material, related to the intracranial pression.

[Eyelid approach and pediatric orbital tumors: indications and surgical technique. About three children]. / Voie trans-palpébrale et chirurgie des lésions intraorbitaires pédiatriques : indications et technique chirurgicale. À propos de trois enfants.

Interdisciplinary collaboration can offer unusual approaches for the treatment of orbital pathologies. The authors report their experience with the eyelid incision in treating three children with epidural orbitary hematoma, dermoid cyst of the upper outer quadrant and a dermoid cyst of the internal inferior quadrant. For all the children, removal was complete and cosmetic results satisfying. The authors discuss the indications and complications of this surgical approach.

Anterolateral kyphoplasty in the management of cervical spinal metastasis.

Management of spinal metastasis is still controversial and must take into account various parameters. The aim of this study is to report the technical feasibility of a less invasive anterior cervical balloon kyphoplasty for vertebral body reinforcement. Six consecutive patients with an osteolytic cervical metastasis, without neurologic compromise, and for whom a curative treatment was not indicated, were retrospectively reviewed. All patients underwent balloon kyphoplasty through a small anterolateral cervicotomy. Evaluation of the technique outcomes was clinical and radiologic with a systematic CT-scan. During the follow-up period (6 months average), neurologic examination was normal in all cases with reduced cervical pain and without reported loss of motion of the cervical spine. A cement leakage was noticed in two cases without clinical consequences. This less invasive procedure was feasible and provided satisfactory preliminary results. It can therefore be a valuable alternative in selected cases where a curative treatment is not indicated.

Minimally invasive transforaminal lumbar interbody fusion through a unilateral approach and percutaneous osteosynthesis.

OBJECTIVES: To assess a surgical technique and the postoperative outcomes of a consecutive series of 22 patients treated for degenerative lumbar spondylolisthesis (DLS) through a minimally invasive unilateral approach associating interbody fusion and percutaneous osteosynthesis. PATIENTS AND METHODS: Twenty-two patients were included in this study, with a mean age of 60 years (range, 35-77 years). All had low-grade single-level DLS. In all cases, the technique included a posterior unilateral paramedial approach through a tubular retractor that decompressed the vertebral canal and transforaminal intervertebral cage arthrodesis. Osteosynthesis was then systematically put in place. The evaluation criteria were clinical (pain, spinal symptoms, duration of hospital stay) and radiological. The entire series was followed up for a mean of 24 months. RESULTS: In this series, the procedure was performed with no technical problems. The mean hospital stay lasted 4.5 days. Postoperative pain assessment showed a mean VAS of 2/10 at discharge and 75% of the patients were asymptomatic at 6 months. The radiological exams showed no extrapedicular screws and the fusion rate was 95% at the last follow-up (with one patient needing surgical revision for malunion). CONCLUSION: Transforaminal lumbar interbody fusion through a unilateral approach associated with percutaneous osteosynthesis is a reliable and effective technique in DLS surgery. The clinical and radiological results are encouraging, with low morbidity and a fusion rate comparable to conventional techniques. However, a longer follow-up will be necessary so as to assess the long-term results of this surgical strategy.

Percutaneous management of thoracolumbar burst fractures: Evolution of techniques and strategy.

INTRODUCTION: A number of techniques have been described in the management of thoracolumbar spinal fractures, testimony to the absence of consensus on their treatment. For the past few years, minimally invasive techniques have been developed to limit surgery-related iatrogenic injury. The objective of this study was to report the results of percutaneous management of these lesions and the technical progress made based on our experience. PATIENTS AND METHODS: Twenty-nine patients presenting an A3 fracture, with a mean age of 51 years, were included in this study. All had a balloon kyphoplasty and percutaneous osteosynthesis. Of the first 22 cases, kyphoplasty was the initial procedure performed associated with reduction maneuvers using distraction. Assessment was clinical (neurological status and pain intensity) and radiological (implant positioning, cement leakage, restoration of local kyphosis and any loss of correction). RESULTS: In the overall series, the mean local kyphosis correction was 11° with a 2° angle loss at the last follow-up. Pain assessment showed significant improvement, decreasing from 6/10 to 1/10 on discharge. The mean hospital stay lasted 4 days. On the follow-up radiological exams, no cases of extrapedicular screw migration were noted; in two cases, lateral cement leakage was found. The results were equivalent in terms of correction no matter which procedure was performed first, although for the second part of the series the technology was available to bend the spinal fixation rod to the desired curve. DISCUSSION: The results of this study support the growing interest in minimally invasive techniques in the management of spinal injuries with no neurological deficit. In addition, the evolving material makes it possible to come close to conventional techniques, including reduction maneuvers, while limiting muscle injury by using a purely percutaneous approach. Rigorous patient selection is necessary and the time to learn the procedure must be taken into account. Studies with a longer follow-up are required to confirm the stability of the correction over time. LEVEL OF EVIDENCE: Level IV. Retrospective observational study.

[Minimally invasive osteosynthesis in septic conditions]. / Ostéosynthèse mini-invasive en milieu septique.

BACKGROUND AND PURPOSE: Management of pyogenic spondylodiscitis in adults remains controversial. The aim of this study was to evaluate the results of a minimally invasive method for deformity correction and stabilization of these lesions with percutaneous osteosynthesis. METHODS: Ten patients were included in this study and treated with a two-step procedure: posterior percutaneous osteosynthesis completed by complementary intervertebral grafting via an anterior access. Postoperative evaluation was clinical and radiological with measurement of local sagittal deformity and restitution of vertebral body height. RESULTS: In this series, bacteriologic identification was possible and pain was controlled in every case. On postoperative evaluation, the implants were always properly positioned. The mean local sagittal deformation was +2.1° preoperatively and -8.4° postoperatively. The mean increase in vertebral body height was measured at 8mm postoperatively. At the last follow-up, a moderate loss of correction was noted (mean: 2° and 3mm) and all patients but one showed solid bony fusion. CONCLUSION: Percutaneous osteosynthesis in septic conditions in association with an anterior graft provides satisfactory clinical and radiographic results. It provides a valuable alternative for deformity correction and spinal stabilization with a minimally invasive access in patients with comorbidities.