Assessment of the effectiveness of SFCR patient information sheets before scheduled spinal surgery.

INTRODUCTION: Patient information is an essential component of any surgical procedure as it allows the surgeon to collect informed consent. This is a legal obligation in the civil code and a professional obligation in the code of medical ethics. As a result, the French spinal surgery society (SFCR) decided to make a model information sheet available on the Internet. The goal of this prospective study was to evaluate the impact of this information sheet when given to patients before scheduled spinal surgery. METHODS: This was a single-centre prospective study performed between November 2014 and February 2015. Seventy patients filled out two questionnaires. The first was about the quality of the medical information given orally by the surgeon; it was administered to patients after the preoperative consultation. The second was about the quality of the medical information contained in the information sheet; it was administered after patients had read this sheet. For each of the questions, patients could either select "yes" if they found the information to be correct/useful (1 point) or "no" if not (0 point). RESULTS: The mean patient age was 56.7 years (range: 28-86). The average number of "yes" answers was 7.07 (out of 12) in the first questionnaire. The average number of "yes" answers was 10.3 (out of 12) after reading the information sheet. This indicates that patients were significantly better informed after reading the SFCR sheet. The written document was deemed to be understandable (mean: 8/10). It answered the patients' questions (mean: 6.7/10) and helped them understand how the surgical procedure would be carried out (mean: 7.3/10). The patients' level of education did not significantly alter these findings. CONCLUSION: Adding a written SFCR information sheet to the preoperative consultation improved patients' understanding before scheduled spine surgery. LEVEL OF EVIDENCE: Low-powered prospective study.

Aim and indications of spinal angiography for spine and spinal cord surgery: Based on a retrospective series of 70 cases.

AIM: For spinal surgery, computerized tomography (CT scan) and magnetic resonance imaging (MRI) have clear indications and are easily accessible. In contrast, the indications and the use of spinal angiograms (SA) remain unclear, and many centres performing spinal surgery do not have an access to SA. Based on a retrospective study, the role of SA in spinal surgery is assessed and their indications are discussed. MATERIAL AND METHODS: A retrospective series of 72 SA in 70 patients is presented. No procedural accident occurred. SA was performed under general anaesthesia in 57 cases (82%). In 61 patients, locating the radiculomedullary arteries (RMA) was obligatory and performed in all cases: for 14 patients (21%), RMA were identified using the forecasted surgical approach (4 patients with degenerative disc disease out of 10 in the entire series were included), and modified. No ischaemic complications were observed in the series. Thirty-nine patients were treated for a tumour that was considered hypervascular (based on a histological hypothesis or the MRI data): 20 of them (51%) were preoperatively embolised and in only 8 cases was the operation considered "haemorrhagic" by the surgeon (among which, 3 intramedullary hemangioblastomas were included). No accident was observed during the embolisations. Thirteen patients presented with a vascular or haemorrhagic lesion (4 arteriovenous malformations, 6 dural arteriovenous fistulas, 3 intramedullary cavernomas): in all these cases, the SA was indispensable for the diagnosis and the decision-making process. Seven patients were treated by embolisation. In the last 8 cases, SA was considered for the diagnosis of a clinical worsening myelopathy with a non-contributive MRI, but it was not useful in providing a positive diagnosis. CONCLUSIONS: SAs were performed with different goals: (i) localization of RMA when a surgical approach between T4 and L2 involved the intervertebral foramen, or when an anterior approach was considered in order to avoid severe ischaemic complications (40% of the degenerative disc patients and 33% of the extramedullary tumour patients in this series); (ii) preoperative embolisation in cases of extramedullary tumours probably considered hypervascular (51% of the cases in the series) or in cases of arteriovenous shunt lesions (7 of 13 patients were treated by embolisation); (iii) as a diagnostic tool, SA is indispensable when MRI can reveal vascular abnormalities; it also provides information about the vascularisation as well as the endovascular possibilities in extramedullary tumours. In contrast, SA was not useful for intramedullary tumours because the RMA preoperative localisation is not mandatory (posterior approach), and embolisation seemed ineffective. SA was also not useful for the diagnosis of myelopathy with normal MRI. In the future, angiograms and MR angiography of the spinal cord may be useful in order to avoid general anaesthesia for a diagnostic procedure, but not practical to obtain access for endovascular treatment.

Vascular abnormalities in the neck associated with intracranial aneurysms.

In 102 cases of ruptured intracranial aneurysms, the cervical as well as the cranial areas were explored by angiography. Loops in the course of the cervical vessels were present in 28 patients; features of fibromuscular dysplasia were present in 31 patients; and in 50 patients, no abnormalities were observed. In 7 patients, both cervical anomalies were present. Loops were associated with single aneurysms (95%), located primarily on the anterior communicating artery (76%), predominantly in men (M/F = 1.6). Aneurysms with fibromuscular dysplasia affected women more than men (F/M = 7), were frequently multiple (58%), and were located mainly on the intracranial part of the internal carotid and vertebral arteries (51%). These data suggest new concepts of aneurysm formation from inherited diseases and should permit the detection of some aneurysms before rupture.

Intradural perimedullary arteriovenous fistulae: results of surgical and endovascular treatment in a series of 35 cases.

A series of 35 patients treated for an intradural perimedullary arteriovenous fistula (AVF) between 1970 and 1990 is reported. Angiography was performed on all of the patients, leading to the diagnosis. The patients were classified into Type I (4 patients), Type II (9 patients), and Type III (22 patients). One Type I patient was not treated, two others underwent surgery, and the last one was embolized. All of the Type II AVFs were treated, two by embolization, four by direct surgery, and three by surgery after incomplete embolization. All of the Type III AVFs were treated by endovascular detachable silicone balloon. Complete occlusion of the AVF was achieved in all treated cases of Types I and II AVF and in 15 cases of Type III AVF; for the 6 other cases of Type III AVF, incomplete occlusion was achieved. In the Types I and II AVFs, partial improvement was clinically observed in only half of the patients; the others remained unchanged. The 15 patients whose Type III AVF was completely embolized recovered completely, and four patients with Type III AVF who were incompletely embolized remained unchanged; 2 other patients with Type III AVF worsened after incomplete occlusion, and 1 additional patient died a few hours after an attempt of endovascular occlusion of a cervical Type III AVF. The place of the perimedullary AVFs among the other vascular malformations involving the spinal cord is discussed according to this classification into three types. Their specific diagnostic and therapeutic difficulties are discussed, resulting in a simplified classification including two types of perimedullary AVF.

Intraforaminal neurinoma in the lumbosacral region.

A series of 12 patients with intraforaminal neurinomas in the lumbosacral space was reviewed. Our classification according to tumor extension relative to the affected root into intradural intra-arachnoid, intraforaminal extra-arachnoid, and extraforaminal types was useful in determining the best surgical approach to achieve root preservation and minimal postoperative deficits. Where sacrifice of roots was unavoidable, surprisingly few neurological deficits occurred.

[Intracranial cavernoma. 30 cases]. / Les cavernomes intracrâniens. 30 observations.

During the last few years, as a result of improved neurodiagnostic procedure there has been an increase in the number of intracranial cavernous angioma. We present 30 cases totalling 32 cavernous angiomas. Twenty-one received a successful surgical treatment. Twenty-four angiomas were supratentorial (75 percent) and 8 subtentorial (25 percent). Cavernous angiomas are congenital vascular malformations, usually of small size, with multiple vascular cavities surrounded by fibrous walls. They are often found in young adults (mean age 35 years in our series), most frequently located in the supratentorial white matter. The presenting symptoms were epilepsy, haemorrhage and an expanding mass syndrome. In this series, 16 patients had epilepsy (53 percent), 7 had haemorrhage (23.5 percent) and 7 had a mass syndrome (23.5 percent). The diagnosis of this lesion, usually obtained with angiography, has been dramatically improved by CT scan and, particularly, MRI. The natural history of cavernous angiomas is still poorly understood: the major complication is haemorrhage. Total surgical excision is the treatment of choice: it avoids a possible haemorrhage and is effective in relieving epileptic seizures. The indication for surgery depends on the clinical symptom and the location of the lesion. The post-operative morbidity in our 21 operated cases was fairly low due to minor sequelae. In only 2 of the 16 patients who had epilepsy the clinical seizures persisted after surgery, but they were less frequent. The literature is reviewed.

[Cerebral blood flow in the determination of vasospasm and surgical decision]. / Le débit sanguin cérébral dans la détermination du vasospasme et la décision opératoire.

The interest of C.B.F. studies performed on patients with subarachnoid haemorrhage is discussed on the basis of the literature and of our experience of 142 cases. C.B.F. results in basic condition are influenced by many factors which make its use very limited and especially during the first days after haemorrhage (J0-J3). However, the analysis of the evolution of C.B.F. values in the same patient and moreover the C.B.F. reactivity to acetazolamide are good indicators of the occurrence of a vasospasm; progressive drop of the C.B.F. or poor reactivity are generally observed before clinical signs of vasospasm. Our policy is therefore to decide the date of surgery according to C.B.F. values but only for patients planned for delayed surgery (after the 3rd day).

[French language Society of Neurosurgery. 44th Annual Congress. Brussels, 8-12 June 1993. Tumors of the foramen magnum]. / Société de neurochirurgie de langue française. 44e congrès annuel. Bruxelles, 8-12 juin 1993. Pathologie tumorale du foramen magnum.

Since what seems to be the first reported case of foramen magnum (F.M.) tumor by Hallopeau in 1874, literature on tumoral pathology of this region is rather scarce; beside reports of single cases or short series, there are very few large series and most of them are not recent (Meyer et coll., Yasuoka et coll., Guidetti and Spallone). The present report includes 230 cases of extramedullary tumors collected from 21 french departments over the last ten years (series of the French Speaking Society of Neurosurgery = S.N.C.L.F. series). Delimitation of what is called the F.M. region is rarely given in the literature. In this report, the inferior limit is put at the C2 level and the superior one at the ponto-medullary junction and the lower third of the clivus. To belong to the F.M. region, tumor must have its main part or its insertion within these limits even if it extends beyond them. On the contrary, if the gross development is out of these limits but with some extension into the F.M. region, the case is rejected. A chapter of this report deals with the anatomy of the F.M. with emphasis on the points useful for the management of the tumors. Some details are given on the dimensions of the different parts of the F.M. as given by anatomical studies and also by measurements on C.T. scanner and M.R.I. including during flexion and extension of the head. The S.N.C.L.F. series is then analyzed as a whole. It includes 106 meningiomas (M), 49 neurinomas (N), 28 chordomas (Ch), 32 osseous tumors (T.Os) (19 primary and 13 metastasis) and 15 cases considered as uncommon tumors. (T. Part.) (4 melanomas, 3 hemangioblastomas, 3 dermoid or epidermoid cysts, 2 ependymomas, 1 cavernoma, 1 angiomyolipoma and 1 cholesterin cyst). Mean age is 47 years, with a sex ratio F/M of 1.5/1. Duration of symptoms before diagnosis is of 27 months. Topography is classified into 3 groups anterior (70 cases), lateral (142 cases) and posterior (24 cases). A particular definition is given to these localizations, essentially referring to surgical difficulties and specially for meningiomas. The localization of a tumor is defined by the point of attachment to any structure (dura, spinal root, spinal cord); anterior tumors are attached to the F.M. on both sides of the midline; lateral tumors between the midline and the dentate ligament and posterior ones behind the dentate ligament. According to this way of classification, N are always lateral even if they present anterior or posterior extensions.(ABSTRACT TRUNCATED AT 400 WORDS)

[Cervical spondylosis. Resection by oblique transcorporeal approach]. / Uncodiscarthose cervicale. Resection par abord oblique transcorporéal.

Spondylosis at the cervical level inducing anterior spinal cord compression is generally treated by anterior transcorporeal resection of the osteophytic spurs. We report on 12 cases over 2 years in which a new technique has been applied; it uses the lateral approach exposing and retracting laterally the vertebral artery; then, the vertebral bodies are drilled out obliquely from the anterolateral corner to the posterolateral one on the opposite side. The vertebral bodies were drilled using this technique on 1 level in 2 cases, on 2 levels in 4, on 3 levels in 5 and on 4 levels in 1; the C4-C5, C5-C6 and C6-C7 levels were the most frequent sites involved in 9, 8 and 6 cases respectively. No graft or arthrodesis was used since the stability of the spine was never compromised. Improvement of the neurological symptoms was observed in all the cases with the best results achieved on the motor deficit and sphincter disturbances. Every case was controlled by dynamic standard radiographies (flexion-extension), CT scan and MRI. The results were good in all cases in terms of osteophytes resection, spinal cord decompression and spinal stability. This technique of oblique resection of the cervical bodies seems quite efficient to alleviate spondylotic compression of the spinal cord; moreover, it appears simpler and safer than the anterior route since the operative field is much wider with all the vital structures protected and retracted medially and bone grafting is never necessary.

[Value of the measurement of cerebral blood flow in choosing the operative time of ruptured intracranial aneurysm]. / Intérêt de la mesure du débit sanguin cérébral dans le choix de la date opératoire des anévrysmes intracrâniens rompus.

The authors report a series of 135 patients treated between 1984 and 1987, for a ruptured intracranial saccular aneurysm in the Department of Neurosurgery at the Lariboisiere Hospital. The value of C.T. scan and cerebral blood flow measurements (C.B.F.) in predicting the development of vasospasm was studied on 99 cases. The analysis confirmed that the C.T. Scan findings are closely related to vasospasm. A low C.B.F. between the fourth and the eight day following the bleeding was significantly associated with the development of delayed cerebral ischaemia. On the contrary, no relation was found between vasospasm and the C.B.F. measured during the three days following the bleeding. The authors propose to operate without delay on clinical grounds on patients referred during the first three days after the hemorrhage and to decide, on clinical and C.B.F. data, the timing of the intervention for patients admitted after this data, i.e. 35% of their patients.

[Endovascular treatment of intracranial aneurysms. Value and prospects based on a series of 92 cases]. / Traitement endovasculaire des anévrysmes intracrâniens. Intérêt et perspective d'après une série de 92 cas.

Endovascular treatment of intracranial aneurysms is a recent technique which needs to be evaluated in large series. From 1978 to 1988, 92 cases of aneurysms were balloon-treated at Lariboisière Hospital either by parent vessel occlusion (O.V.P.) (N = 48) or by selective obliteration (O.S.A.). Treatment in all but 5 cases was performed 3 weeks after S.A.H. since the main reason for choosing endovascular technique was contraindication of early surgery. Giant aneurysms account for 31 cases, vertebro-basilar for 38 and cavernous carotid for 27. In O.V.P. group, there were 17 patients referred after subarachnoid hemorrhage and 30 after tumoral symptoms, while in O.S.A. group, 30 bled and 5 presented with oculomotor palsies. Results in the O.V.P. group are good with 8% morbidity and mortality. In O.S.A., they are worse: 16% (morbidity and mortality) and 22% of secondary balloon deflation; however, because of the features of these aneurysms (size and location), the results seem quite acceptable. Endovascular treatment of intracranial aneurysms is a promising technique which should already replace parent vessel ligation when indicated, and progressively supplant surgical clipping when the remaining technical problems are resolved.

[Intraforaminal lumbosacral neurinoma]. / Neurinomes lombo-sacrés intra-foraminaux.

Twelve cases of intra-foraminal localization of lumbosacral neurinoma are reported including 9 schwannomas, 2 neurifibromas and 1 melanotic schannoma. According to their extension, they are classified in type II strictly intra-foraminal and extra-arachnoïdal: N = 6, type I-II, extending into the subarachnoïdal space; N = 5, type II-III, extending out of the spine. There were 7 men and 5 women with mean age of 49.5 years and a 5.2 years delay before diagnosis. The most common, though not permanent, symptom was radiculalgia; a generally weak sensorimotor deficit was noticed in 4 cases and hypoesthesia in two cases. Diagnosis was sometimes doubtful using myelography for the oldest cases, but is now made easily with CT scan and M.R.I. Microsurgery allows to dissect out the tumor inside the perineural sheath and to preserve the nervous root in most cases even in extra-arachnoïdal forms (N = 8). However, in cases of neurofibromas and of large tumors, the root had to be divided (N = 4) with rather surprisingly no new post-operative deficits. Intra-foraminal localization of lombo-sacral neurinomas is rare but now easily identified; it should be cured surgically with the goal, often reached, of maximum preservation of the nervous root.

[Cisternal cysticercosis of the cerebellopontine angle. A surgically-treated case and review of the literature]. / Cysticercose cisternale de l'angle ponto-cérébelleux. Observation d'un cas opéré et revue de la littérature.

Most neurocysticercosis (N.C.C.) cases reported occur in undeveloped countries where contaminated food by Taenia solium gives rise to human infection. People of developed countries are exposed by migrations and travels. We report a case of a 36 years old french woman living at La Reunion. Her symptomatology consisted of left unilateral hypoacusis progressing over a two years period accompagnied by intermittent headaches. CT scan showed a hypodense mass with a ring enhancement in the left cerebello pontine angle (C.P.A.). M.R.I. showed multicystic arrangement of vesicles in a racemous fashion that spread out to peduncular and carotid cisterns. Parenchymatous or ventricular involvement was not observed. A lateral suboccipital craniectomy was carried up in the sitting position. After division of a thickened arachnoid in the C.P.A., the vesicles were dissected an pulled out easily because the membranes had not any adhesions. Progressive improvement of hearing was observed in the next week. Primary cisternal involvement of N.C.C. is rare and, in literature, there is not any other reported case in the C.P.A. Different mechanisms of invasion to the C.N.S. are discussed.

[Value of the measurement of cerebral blood flow before and after diamox injection in predicting clinical vasospasm and final outcome in aneurysmal subarachnoid hemorrhage]. / Intérêt de la mesure du débit sanguin cérébral avant et après injection de diamox dans la prédiction du vasospasme clinique et du résultat clinique final des hémorragies méningées anévrysmales.

The timing for surgery on ruptured intracranial aneurysms remains a difficult question and the choice of the day of operation depends greatly from the occurrence of a vasospasm. On a previous paper, the value of the cerebral blood flow (CBF) measurement by intravenous injection of Xenon 133 was demonstrated to be efficient for the prediction of vasospasm only when done between day 4 and day 8 after bleeding. Moreover the efficiency of the measurement was much greater if the evolution of the CBF values between D0 and D8 was considered, but this method was incompatible with early surgery. It suggested the interest of a dynamic study of the CBF by the same method. On a series of 43 patients, the comparison between basal CBF values and reactivity of CBF values to intravenous injection of 1 gram of acetazolamide for the prediction of clinical vasospasm is presented. The series comprises 32 early admitted patients (74%) and 31 operated patients (16 of them between D0 and D3 after bleeding, 15 others after D4). The efficiency of the CBF reactivity study for the prediction of the clinical vasospasm appears much greater than that of the basal CBF value, even during the first three days after bleeding, but not for the prediction of the final clinical outcome. The method is immediate and compatible with early surgery. What precisely is evaluated by this method on the physiopathology of the vasospasm remains disputable, but the operability of the patients seems to be explored.

[Orbital tumors. Neurosurgical activity]. / Tumeurs orbitaires. Activité neurochirurgicale.

In this chapter, we report the results of orbital tumor management in a few neurosurgical departments and compare it to a Paris neurosurgical department that has developed a close relation with an ophthalmological department. These departments' activity is quite low, treating mainly sphenoorbital meningiomas. Other tumor groups are unequally and sporadically managed.

[Hemodynamic and metabolic effects of thiopental in patients with severe head injuries]. / Effets hémodynamiques et métaboliques du thiopental chez le traumatisé cranien grave.

The effect of pentobarbital was evaluated in 12 comatose brain injured patients (Glasgow coma scale < 7 at admission). Mean hemispheric cerebral blood flow (CBF) was studied following intravenous administration of 133Xenon. The results indicated a decrease in CBF, mean arterial pressure (MAP), intracranial pressure (ICP) and cerebral metabolic rate of oxygen (CMRO2). The increase in cerebral perfusion pressure (PP) was found only in patients with diffuse brain injury. The results supports the hypothesis that barbiturate therapy is more effective at reducing ICP while preserving CPP when the cause is a diffuse lesion.

Ruptured intracranial aneurysms. The influence of sex and fibromuscular dysplasia upon prognosis.

From a statistical analysis of a series of 214 cases of ruptured intracranial aneurysms, it was demonstrated that only four parameters among those collected on the admission day, are predictive of the final functional result: sex (p less than 0.001); age (p less than 0.02); clinical grade (p less than 0.001) and angiographic spasm (p less than 0.01). The surprisingly poor prognosis in women was explained by the higher frequency of spasm (p less than 0.005). Aneurysms in women predominated on the intracranial carotid artery (38%) and were frequently multiple (12%). A further angiographic study on 87 cases was then carried out including a systematic investigation of the cervical part of the vessels; it permitted one to identify angiographic features of fibromuscular dysplasia (FMD) on the cervical vessels in 20 cases. In those cases it was also observed that there was a marked female predominance (F/M = 5.6), a frequent localization on the internal carotid artery (50%), a high rate of multiple aneurysms (60%) and a poor prognosis related to spasm (50%). Therefore, intracranial aneurysms appear far more frequently than usually reported, to be related to FMD. The worse prognosis of ruptured intracranial aneurysms in females can be, at least partly explained by the association with FMD and the frequent occurrence of spasm. A careful investigation of patients exhibiting features of FMD in order to detect intracranial aneurysms before rupture, is suggested.

Superolateral approach to orbital tumors.

The conventional lateral approach to the orbit (Krönlein) does not allow a satisfactory view of the superior part of the orbit and the operative field is rather narrow. Therefore, large tumors which have developed not only laterally but also superiorly are usually approached transcranially. The craniotomy and exposure of the dura may be avoided when the tumor does not extend too far posteriorly and medially, by turning a larger orbital bone flap than the Krönlein's one. This technique was described by Nakamura as "type I orbitotomy" and can be referred to as a superolateral approach. After a bicoronal skin incision, a free orbital bone flap is cut. It includes the lateral orbital rim, a large external part of the superior orbital rim, and the lateral orbital wall. From 1985 to 1990 this approach was performed on 23 patients presenting with lacrimal gland tumors in 14 cases (11 pleomorphic adenomas, 2 adenoid cystic carcinomas, 1 adenocarcinoma), schwannomas in 2 cases, dermoid cyst in 1 case, hydatic cyst in 1 case, cavernous hemangiomas in 2 cases, inflammatory pseudotumor in 1 case, and mucoceles in 2 cases. This superolateral approach provides a wider exposure to the superolateral orbit than the classical Krönlein's approach and avoids the drawbacks of a craniotomy. A direct incision through the eyebrow can be used for bald people or for patients in poor condition.

Spinal dural arteriovenous malformations with perimedullary drainage. Indications and results of surgery in 30 cases.

70 patients were treated for spinal dural arteriovenous fistula in the same centre, during a period of 10 years. Conus medullaris and cauda equina syndromes were observed in all patients as the clinical stereotyped presentation. Diagnosis was based on myelography in the first instance and then on angiography. 40 patients were treated by intravascular neuroradiological embolization, whereas the other 30 were operated on. Surgery was proposed because embolization was contraindicated (7 cases of hazardous catheterisation) of inefficient (23 cases = 38%). The results of the operative series are presented, and compared with those of embolization. Improvement was observed in 50% of the 20 patients with follow up, but a complete recovery to an asymptomatic state was never obtained. For the other patients (47%) complete stabilization of the disease could be obtained, whereas in one of the patients (3%), who was operated upon because of failure of embolization, surgery was also completely ineffectual. The long-term results of patients treated surgically are comparable with those patients efficiently embolized. 5 patients of the operative series were submitted to MRI before and after surgery: the results and the place of MRI are discussed.