Shunt failure in adult hydrocephalus: flow-controlled shunt versus differential pressure shunts--a cooperative study in 289 patients.

BACKGROUND: In order to assess the efficiency of flow-controlled shunts in reducing shunt failure in the treatment of adult hydrocephalus (with a special focus on overdrainage complications), a series of 289 patients was analyzed through a retrospective and comparative study performed in three neurosurgical departments. METHODS: A group of 142 adult patients suffering from hydrocephalus were operated on using a conventional differential pressure (DP) shunt and compared with a group of 147 adult patients operated on using flow-controlled (FC) system (Orbis-Sigma, Cordis). Only the first complication, which required a surgical revision within the first 2 years after shunt implantation, was taken into account for each patient and analyzed using life-table methods. RESULTS: The actuarial risk of shunt infection in the two groups is respectively 8.3% and 10.9% at 1 year (nonsignificant difference). The actuarial risk of mechanical complications at 1 year is 38% for the DP patients and 10% for the FC patients (p = 0.0001); this difference is largely due to a decrease of complications related to overdrainage phenomenon (14/142 subdural collections were observed in the DP group versus 1/147 in the FC group) (p = 0.0001). CONCLUSION: The conclusion of this cooperative and retrospective study is that the use of a flow-controlled system decreases the risk of mechanical complications related to the hydrodynamic properties of the shunts used in the treatment of adult hydrocephalus, especially those related to overdrainage.

[Treatment of chronic hydrocephalus in adults by flow-regulated shunt. Apropos of a series of 46 patients]. / Traitement de l'hydrocéphalie chronique de l'adulte par dérivation à débit régulé. A propos d'une série de 46 patients.

46 patients, 24 males and 22 females (mean age: 68.3 years), with chronic hydrocephalus were operated on by a variable-resistance, flow-regulated shunt. The selecting criteria before surgery were essentially clinical (association of gait disturbances, dementia and urinary incontinence, positive lumbar puncture withdrawal test) in consideration with the retrospective and cooperative study of this series. Hydrocephalus had an etiology in 23 cases (50%): 4 cases of trauma (8%), 9 cases of tumors (20%), 9 cases of subarachnoid haemorrhage (20%) and 1 case of infection (2%). The average follow-up is 17 months (median: 12 months). 20 patients (43.5%) have an excellent result (normal life), 16 patients (34.8%) have a good result (residual symptomatology compatible with a self-governing life), 5 patients (10.9%) have a poor result (residual symptomatology non compatible with a self-governing life), 2 patients (4.3%) have a bad result (unchanged symptomatology). 3 patients died after the surgical procedure. 3 patients had an infectious complication of their shunt (actuarial risk of infectious complication at one year and a half: 7%). 2 patients presented a non infectious complication, one chronic subdural hematoma and one bad insertion of the proximal catheter (actuarial risk of mechanical complication at one year and a half: 4.4%).

[Synovial cysts of the lumbar interapophyseal joints. Apropos of 2 cases and review of the literature]. / Kystes synoviaux des articulations interapophysaires lombaires. A propos de 2 cas et revue de la littérature.

The authors report two cases of low back pains with sciatica caused by a synovial cyst of the interapophyseal joint of the lumbar spine. Analysis of only 23 cases found in the literature, point to their rarity, the lack of specific clinical signs, the importance of the CT scan for the diagnosis and the excellent results of surgical treatment.

[Surgery for lumbar disk hernia after chemonucleolysis. Results and analysis. Apropos of 100 cases]. / La chirurgie des hernies discales lombaires après chimionucléolyse. Résultats et analyse. A propos de 100 cas.

We studied the clinical results of 100 patients operated after failure of chemonucleolytic treatment with chemopapain for lumbosciatica caused by disk herniation. Secondary surgical procedures were performed because of persistence of sciatic pain and disk herniation visible on CT scan. Post-operative follow-up was done at a minimum of one year. Clinical results were analyzed according to the criteria of Mac-Naff. Out of 100 patients who were re-operated, there were: 14% excellent results, 38% good results, 26 mediocre results, and lastly 22% failures or worsening of the condition. Thus 52% satisfactory compared to 75-95% when surgery is done immediately; 48% of the results were unsatisfactory or worse than before. We analyzed the mechanism of action of papain and suggested a pathophysiological explanation for these results. We concluded that chemonucleolysis with chemopapain cannot be an intermediary step between systematic medical treatment and surgical treatment.

[Surgical problems arising from ethmoid adenocarcinomas]. / Problèmes chirurgicaux posés par les adénocarcinomes de l'ethmoïde.

Adenocarcinomas are the most frequent ethmoid tumors. The only curative treatment at present is surgery. Potential extensions of these tumors require a wide exeresis. This is best ensured with an approach that is cranial and of the Cairns type at first, then in some cases facial and patterned on the Moure-Sebileau course of approach. This procedure demands the immediate reconstruction of the 3 levels involved: the dura mater, the bone and the mucosa of the nasal fossae. We reconstruct the dura mater with a pericranial flap, the bone with bone grafts, and the mucosa with a flap from the galea.