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Intracranial meningiomas are sometimes located anteriorly to the foramen magnum and can cause disabling long tract symptoms. The far-lateral approach has been developed to provide an extensive view over the bulbopontine junction and the surrounding lower cranial nerves and upper spinal nerves with a good control on the vertebral artery, allowing the safe resection of such tumors. It is the report of a case with anatomical study before and after the removal of the meningioma. The use of the far-lateral approach allowed us to (1) control the vertebral artery in its V3 (Atlantic extradural) and V4 (intradural) portion (2) have an optimal visibility on the lower cranial nerves, the upper spinal nerves, and the bulbopontine junction, and (3) perform a Simpson 2 resection of the tumor that was inserted between the lower clivus and the upper odontoid process. Beyond its interest for the safe resection of tumors located anteriorly to the foramen magnum, the far-lateral approach is of particular anatomical interest. It allowed us to review the anatomy of the craniocervical junction.

Background The benefits of decompressive craniectomy (DC) have been demonstrated in malignant ischemic stroke and traumatic brain injuries with refractory intracranial hypertension (ICH) by randomized controlled trials. Some reports advocate the potential of DC in the context of ICH due to meningoencephalitis (ME) with focal cerebral edema but its interest remains controversial especially when there is diffuse cerebral edema. The aim of this study is to assess the benefits of DC in meningoencephalitis with malignant cerebral edema whether it is focal or diffuse. Methods We report two cases successfully treated in our instution, plus we conducted a systematic literature review focused on cases of DC in ME in compliance with prisma guidelines. Results the first patient is a 36-years-old woman who suffered from fulminant pneumococcal meningoencephalitis (ME) with refractory ICH following a transphenoidal removal of pituitary adenoma. The second patient is a 20-years-old man suffering from neuromeningeal cryptococcosis with refractory ICH. In both cases DC led to major clinical improvement with a GOS-E 8 at one year. These results are consistent with the literature review which reports a favorable outcome in 85% of cases. Conclusions DC appears to be a promising therapeutic option in cases of ME with refractory ICH. Thus, reliable criteria will have to be defined to guide us in our practice in emergency cases where DC has not been part of the therapeutic arsenal yet.

PFS6 and PFS12 depending of the in intention-to-treat or per protocole analyses as investigator or central review analyses.

Study of correlation between SSTR2A receptor expression and growth rate (GR) before and under treatment as with progression. No significant correlation was observed. Immunohistochemical detection of SSTR2A protein was performed on 5 µm thick formalin fixed paraffin embedded (FFPE) tissue sections with Ventana Benchmark XT. The monoclonal SSTR2A antibody (clone UMB1, Abcam) was used at 1/4000 dilution.

Purpose:Aggressive meningiomas that progress after surgery/radiotherapy represent an unmet medical need. Strong and constant expression of SSTR2A receptors and activation of the Pi3K/Akt/mTOR pathway have been demonstrated in meningiomas. The combination of everolimus, an mTOR inhibitor, and octreotide, a somatostatin agonist, has shown additive antitumor effect in vitro. The phase II CEVOREM trial investigated the efficacy of this combination on recurrent meningiomas.Patients and Methods:Patients with documented recurrent tumor progression ineligible for further surgery/radiotherapy were eligible to receive octreotide (30 mg/d, day 1) and everolimus (10 mg/d, days 1–28). The primary endpoint was the 6-month progression-free survival rate (PFS6). The secondary endpoints were overall survival, response rate, tumor growth rate according to central review, and safety.Results:A total of 20 patients were enrolled, including 2 with World Health Organization (WHO) grade I tumors, 10 with WHO grade II tumors, and 8 with WHO grade III tumors; furthermore, 4 patients harbored NF2 germline mutation. The overall PFS6 was 55% [95% confidence interval (CI), 31.3%–73.5%], and overall 6- and 12-month survival rates were 90% (95% CI, 65.6%–97.4%) and 75% (95% CI, 50.0%–88.7%), respectively. A major decrease (>50%) was observed in the growth rate at 3 months in 78% of tumors. The median tumor growth rate decreased from 16.6%/3 months before inclusion to 0.02%/3 months at 3 months (P < 0.0002) and 0.48%/3 months at 6 months after treatment (P < 0.0003).Conclusions:The combination of everolimus and octreotide was associated with clinical and radiological activity in aggressive meningiomas and warrants further studies. Decrease in the tumor volume growth rate should be considered a complementary and sensitive endpoint to select potentially effective drugs for recurrent meningiomas.

Introduction Deformity associating coronal and sagittal malalignment can severely impair quality of life in Parkinson's disease (PD). Realignment using patient-specific rods (PSRs) is useful for achieving alignment goals. Methods This was a retrospective single-center analysis of a prospectively maintained database of all PD patients who underwent surgery between January 2013 and January 2017. Clinical evaluation, preoperatively and at 1 year's follow-up, used the Oswestry Disability Index (ODI). Radiological evaluation used systematic preoperative and 1-year postoperative full-spine radiographs. Results Twelve patients were included: 6 female, 6 male; mean age, 68.4 years. Mean follow-up was 40.8 months [range 12–70]. On average, 14 levels were fused [range 10–18]. Unplanned revision surgery was necessary for 8 patients at a mean 15.625 months after index surgery. Mean preoperative ODI score was 64% preoperatively [range 56–70] versus 52% [range 28–64] at 1 year's follow-up (P = 0.004). Lumbar lordosis improved significantly, from −16.7° preoperatively to −41.4° at 1 year (P = 0.006). Pelvic tilt was the least effectively corrected parameter, with a mean preoperative value of 31.6° vs. 27.8° at 1 year (P = 0.19). Mean preoperative sagittal vertical axis was 149.7 mm versus 73.6 mm at 1 year (P = 0.013). Mean preoperative coronal tilt was 68.2 mm versus 22.9 mm at 1 year (P = 0.007). Conclusion Parkinson's disease is a degenerative disease frequently associated with major spine malalignment. The severity of the postural disorders in these patients needs special precautions to avoid complications.

Objective The aim of this study was to describe progestin-associated meningiomas’ characteristics, outcome and management. Material and methods We included 53 patients operated on and/or followed in the department for meningioma with progestin intake longer than one year and with recent drug discontinuation. Results Cyproterone acetate (CPA), nomegestrol acetate (NomA), and chlormadinone acetate (ChlA) were involved in most cases. Mean duration of progestin drugs intake was 17.5 years. Tumors were multiple in 66% of cases and were located in the anterior and the medial skull base in 71% of cases. Transitional subtype represented 16/25 tumors; 19 meningiomas were WHO grade I and 6 were grade II. The rate of transitional subtype and skull base location was significantly higher compared to matched operated meningioma general population. No difference was observed given WHO classification. But Ki67 proliferation index tends to be lower and 5/6 of the WHO grade II meningiomas were classified as WHO grade II because of brain invasion. Strong progesterone receptors expression was observed in most cases. After progestin discontinuation, a spontaneous visual recovery was observed in 6/10 patients. Under CPA (n = 24) and ChlA/NomA (n = 11), tumor volume decreased in 71% and 18% of patients, was stabilized in 25% and 64% of patients, and increased in 4% and 18% of patients, respectively. Volume outcome was related to meningioma location. Conclusions Outcome at progestins discontinuation is favorable but different comparing CPA versus ChlA-NomA and comparing tumor location. Long-term follow-up is required. In most cases, simple observation is recommended and surgery should be avoided.

Resume Introduction Les desequilibres rachidiens peuvent fortement impacter la qualite de vie des patients. Differents parametres sagittaux sont utilisees comme objectifs de realignement, cependant environ 50 % des patients sont insuffisamment corriges en postoperatoire. Afin d’ameliorer la correction, il existe des tiges pre-cintrees dont les rayons de courbures sont definis en fonction de l’equilibre sagittal « ideal » du patient. Mais il n’existe pas d’etude portant sur la modification du rayon de courbure en fonction du type de connexions entre les vis pediculaires et les tiges. L’objectif de cette etude experimentale etait de quantifier l’effet d’aplatissement de tiges pre-cintrees en fonction du mode de connexion vis-tige : vis a chargement superieur vs. vis a dome avec connecteur lateral. Materiel et methode Les tests etaient realises dans une machine de compression axiale sur 3 montages utilisant 2 tiges fixee a l’aide de vis a chargement superieur, puis sur 3 montages utilisant 2 tiges fixees a l’aide de vis a dome avec connecteur lateral. Les mesures d’angulation maximales etaient realisees apres mise en charge et apres suppression de la charge. Le critere de jugement principal etait la comparaison de la moyenne d’angulation de chaque type de montage a chaque etape. Resultats L’angulation moyenne des montages avec des vis a chargement superieur en charge a 500 N significativement reduit par rapport aux montages utilisant des vis a dome avec connecteur lateral (En moyenne 18,6° vs 24,5° respectivement, p Conclusion In vitro, les vis a chargement superieur ont un effet d’aplatissement significativement superieur a celui des vis a dome avec connecteur lateral. Ces resultats devront etre confirmes in-vivo, cependant la connaissance du comportement des tiges en fonction du type de connexion avec les vis peut etre un element important afin de limiter le risque de sous-correction dans le plan sagittal. Niveau de preuve III.

International audience; PurposeTo report our experience of endoscopic endonasal obliteration of symptomatic sellar arachnoid cyst (SAC).MethodsFrom 2002 to 2019, we retrospectively reported the data of 17 cases of SAC operated in Timone University Hospital, Marseille, France. Preoperative clinical findings were collected including main symptoms, visual function and endocrinological assessment. Surgical procedure was homogeneous and consisted in endonasal fully endoscopic surgical obliteration of the cyst cavity with fat graft. Post-operative outcomes, complication and follow-up was reported.ResultsVisual disorders and/or headaches were the main symptoms. Our technique provided improvement for 83.3% of the patients suffering from visual disturbance and for 87.5% of those suffering from headaches. We reported 2 cases of cerebrospinal fluid (CSF) leakage (11.8%), but no meningitis. One case of definitive diabetes insipidus occurred and one case of postoperative syndrome of inappropriate antidiuretic hormone secretion was temporary. There was one case of recurrence reported. The mean follow-up was 39 months.ConclusionPatients with symptomatic SAC can be treated successfully by endoscopic endonasal obliteration of the cyst. This simple technique offers true benefits for the patients without craniotomy, but the complication rate remains high especially with the risk of CSF leakage. Special attention to skull base opening and closing could reduce this risk.

Resume La prise en charge des lesions posterieures de l’anneau pelvien sans complication neurologique ne fait pas encore l’objet d’un consensus. Differentes fixations ont ete decrites et, plus recemment, des montages pouvant associer fixation lombo-iliaque et fixation iliosacree. Ces fixations sont particulierement indiquees en cas de dissociation spinopelvienne avec un deplacement fracturaire important dans le plan sagittal. Cependant, ces techniques exposent a des complications, notamment infectieuses et cutanees importantes en postoperatoire. Aussi, nous proposons une technique de fixation lombo-iliaque et iliosacree mini-invasive des lesions posterieures de l’anneau pelvien. L’intervention est menee en decubitus ventral et comporte un vissage pediculaire L4 ou L5 et une vis iliaque sous controle fluoroscopique, une distraction peroperatoire est possible en fonction de l’importance du deplacement. Une vis iliosacree est ensuite mise en place en percutane afin de permettre une reduction dans le plan transversal et assurant ainsi un montage en triangulation. En moyenne, sur 5 patients operes selon cette technique, le deplacement vertical moyen etait de 11,9 ± 6,9 mm (SD) en preoperatoire (min = 1,3, max = 19,7) versus 3,7 ± 3,2 mm en postoperatoire (min = 0,3, max = 6,7) et le deplacement frontal de 7,46 ± 3,7 mm en preoperatoire (min = 4,2, max = 12,4) versus 2,56 ± 2 mm en postoperatoire (min = 0,3, max = 4,3). La fixation lombo-iliaque et iliosacree mini-invasive constitue une alternative dans la prise en charge des lesions de l’anneau pelvien posterieur sans troubles neurologiques et notamment les dissociations spinopelviennes.

Cervical MRI is the gold standard for surgical planning of degenerative cervical myelopathy; however, the symptomatic postoperative recurrence rate is high in the medium and long term (9.1% to 10.7%) and may bring into question the quality of the preoperative surgical plan. The objective of this study was to evaluate cervical spinal stenosis and intramedullary hyperintensity with dynamic cervical MRI to determine the recurrence rate and clinical improvement in a cohort of patients who had dynamic cervical MRI incorporated into their surgical plan.This was a prospective, single-center study. Upon enrolment and at each follow-up visit, patients completed the mJOA score, NDI, cervical pain on visual analog scale (VAS) and radicular pain on VAS. Every enrolled patient underwent dynamic cervical MRI (in neutral, flexion and extension positions). Five levels were measured in the three positions, resulting in 915 levels for analysis.Sixty-one patients were included. Eighty-four levels had an intramedullary hyperintensity in neutral position, 93 in extension and 112 in flexion. The mean sagittal diameter varied the most at C4-C5, going from 7.13 mm (SD 2.32) on average in neutral to 6.30 mm (SD 2.22) in extension and 8.29 mm (SD 2.10) in flexion, a variation of -12% and +16%, respectively. A Mühle grade ≥ 2 was found in 134 levels in neutral position versus 189 in extension and 110 in flexion. None of the patients had worse neurological symptoms following the dynamic cervical MRI. The mean postoperative follow-up was 4.4 years (SD 0.88). Two patients (3.1%) required surgical revision because the implants had shifted. One patient developed symptomatic adjacent segment disease.Preoperative surgical planning that incorporates dynamic cervical MRI before the surgical treatment of degenerative cervical myelopathy appears to be a safe and reliable method and one that helps reduce symptoms in the long term.IV.

International audience; BackgroundAccurate screw placement remains challenging, especially in the cervical spine. We present our first experience of minimally invasive posterior cervical and upper thoracic pedicle screw fixation in the lower cervical spine.MethodsThis study reports a case series of patients, undergoing posterior percutaneous pedicle fixation using Cirq robotic assistance coupled to the Airo intraoperative computed tomography scan and Brainlab navigation system. Routine computed tomography was performed on postoperative day 2 to evaluate pedicle screw placement. The effective dose was calculated.ResultsBetween February 2020 and December 2020, 7 patients (4 men and 3 women) were treated. The mean age was 58.8 years (range, 29–75 years). Fixation was performed with a cannulated PASS OCT Reconstruction System (Medicrea). Overall, 28 screws were placed within cervical and upper thoracic pedicles. According to the Neo and Heary classification, 85.7% were rated as acceptable and 14.3% as poor. The radiation dose received by the patient was 9.1 mSv (range, 7.7–10.6 mSv). The radiation dose received by the surgical staff was 0 mSv. The postoperative course was excellent.ConclusionsPosterior miniopen fixation using Cirq robotic assistance coupled with an intraoperative computed tomography navigation system is a major innovation that can improve the accuracy of pedicle screw positioning, with acceptable patient radiation and reduced surgical team exposure.

Introduction Complex spinal surgery is known to be at risk of complications. Surgical site infection is a serious complication in spine surgery and its frequency is significantly increased in adult spinal deformity correction. The aim of this study is to identify patients’ characteristics and risk factors of surgical site infection (SSI) following an osteotomy. Methods This is a single-center retrospective study of patients who underwent an osteotomy between January 2015 and December 2017. Surgical site infection diagnosis was based upon patient's clinical evidence of infection, biologic parameters, microbiological criteria and/or image findings. Results In total, 102 patients were eligible and 70 were women (68.6%). Mean age was 65 years old (27–83 years) and mean body mass index (BMI) was 26.14 kg.m−2 (18.4–44.1). Eleven patients were in the SSI group and 91 in the No-SSI group. The mean Schwab grade was 1.5 (1–4) in the SSI group vs. 1.4 (1–5) in the No-SSI group (P = 0.435). The mean operative time was on 201.9 minutes (67–377). Mean length of stay was 20.6 days (10–73) in the SSI group vs. 15 days (5–44) in the No-SSI group (P = 0.041). Favorable outcome was found in 10 patients (90.9%) in the SSI group. Conclusion Correction surgery for adult spinal deformity with osteotomies carries a high risk of complications specially SSI. Identification of risk factors, prevention and medical management of SSI should be well assessed.

Traumatic fractures of the thoracolumbar spine are common. Their management considers the fracture type according to the various classifications in existence, as well as the patient's background and age. In some cases, the occurrence of a fracture on a spine with an unoperated scoliotic deformity can be observed. This entity, not described in the literature, can pose a therapeutic challenge and is not present in any existing treatment algorithm. The main objective of this work was to describe the characteristics and management of vertebral fractures in patients with unoperated idiopathic scoliosis.We carried out a monocentric retrospective study in all patients operated on for a spinal fracture between May 2011 and August 2020, with a history of unoperated adolescent idiopathic scoliosis. We collected epidemiological data including the surgical course of each patient and the final result. The patients were categorized according to the surgical strategy (extensive fusion and correction of the deformity, short osteosynthesis without considering the scoliosis, vertebroplasty, orthopedic treatment) and the final clinical and radiological result evaluated at the last follow-up.Ten patients were included in this study with a total number of 16 fractured vertebrae. The population was 80% female, with an average age of 36.3 years. The majority of fractures were type A, at the thoracolumbar junction. The curves were classified as Lenke 1A in 5 cases, 1B in 2 cases, 1C in 1 case and 5C for 2 patients. Ultimately, 3 patients underwent extended fusion with correction of scoliosis, 6 localized osteosynthesis and 1 percutaneous vertebroplasty. In 50% of cases, a change of surgical strategy had to be made, due to worsening of the deformity or hyperalgesia. The last follow-up was at 19.7 months on average. Five patients had a good final clinical result, 5 patients had persistence of significant pain (lower back pain or cruralgia).This is the first study investigating the association of vertebral fractures and the presence of unoperated idiopathic scoliosis. The results of our study highlight the management challenges and difficulties in therapeutic decision making. The presence of a pre-existing curve is thus an important parameter to consider, and should lead to the discussion of performing an extended fusion secondarily in view of the risk of poor results from localized surgery.IV.

Resume Introduction Les fractures-eclatement de L5 representent un faible pourcentage de l’ensemble des fractures de la colonne vertebrale dont la strategie de traitement n’est pas encore standardisee. Les caracteristiques anatomiques et biomecaniques lombo-sacrees creent des types de fractures qui different de celles de la jonction thoraco-lombaire. L’objectif de cette etude etait d’evaluer les resultats du traitement chirurgical des fractures-eclatement de L5 apres stabilisation posterieure et reconstruction de la colonne anterieure. Patients et methodes Six patients avec une fracture instable de L5 isolee ont ete inclus. Les dossiers medicaux, les radiographies et des scores cliniques etaient analyses. Les resultats portaient sur la restauration de la hauteur du corps vertebral, de la lordose/cyphose vertebrale, la stenose canalaire et les parametres de l’equilibre sagittal a differentes phases de la prise en charge. Resultats Aucun patient n’a presente d’aggravation neurologique. La hauteur vertebrale anterieure mediane preoperatoire etait de 41 mm vs 48 mm en postoperatoire. La cyphose traumatique moyenne preoperatoire, mesuree par l’angle de Cobb (local et regional), etait de 21,5 degres et 33 degres avec une amelioration respective de 7,5 et 5,5 degres apres instrumentation. La stenose canalaire moyenne, liee a la retropulsion du fragment osseux dans le canal, etait mesuree a 67 % en preoperatoire et a 35 % en postoperatoire. Au dernier recul, une fusion anterieure etait obtenue dans tous les cas et il etait note une restauration de l’equilibre sagittal. Cliniquement, tous les patients avaient une incapacite minimale a moderee en utilisant l’indice d’Oswestry. La capacite de retour au travail montrait des resultats a long terme consideres comme bon a excellent. Discussion Les resultats du traitement des fractures instables de L5 avec stabilisation posterieure et reconstruction de la colonne anterieure montrent un benefice sur le resultat fonctionnel a long terme, la stabilisation de la colonne vertebrale et les parametres radiologiques. Niveau de preuve IV, etude retrospective.

Resume Introduction La survenue d’une metastase vertebrale constitue un tournant evolutif d’une maladie tumorale et, malgre leur incidence croissante, la prise en charge n’est pas standardisee. Differents scores pronostiques ont ete proposes, mais la progression des therapeutiques anti-tumorales, ainsi que les progres chirurgicaux, ont rendu ces differents scores moins precis et parfois discordants pour un meme patient. Il apparait donc utile de trouver de nouveaux outils de determination pronostique. L’objectif de cette etude etait de determiner les facteurs de risque biologique de survenue de complications et de deces postoperatoires chez des patients operes d’une metastase vertebrale. Materiel et methodes Il s’agit d’une etude multicentrique, prospective. Tous les patients operes d’une metastase vertebrale, entre novembre 2015 et mai 2017, ont ete inclus. Les donnees epidemiologiques principales et les parametres biologiques etaient recueillis en preoperatoire : CRP, albuminemie et calcemie preoperatoires. La strategie chirurgicale, la survenue d’un deces et/ou d’une complication postoperatoire etaient colligees de maniere prospective. Resultats Sur les 264 patients initialement inclus, 5 sont decedes en postoperatoire immediat, 107 sont decedes dans les 6 premiers mois. Au total, 57 patients etaient vivants a 1 an postoperatoire, 26 patients (10 %) etaient perdus de vue. L’albuminemie inferieure a 35 g/L (29 % des patients en preoperatoire), la calcemie superieure a 2,6 nmol/L (8 % des patients) et la CRP superieure a 10 mg/L (47,5 % des patients) etaient associees a un risque de survenu de deces significativement superieur. Seule l’elevation de CRP etait correlee a une augmentation des complications postoperatoires. Conclusion Cette etude confirme la valeur pronostique des trois parametres biologiques (taux de CRP, albuminemie, calcemie) concernant la survie de patients operes d’une metastase vertebrale. La creation d’un score hybride, prenant en compte non seulement des parametres cliniques mais egalement des parametres biologiques, devrait etre envisagee afin de preciser l’estimation de la survie de ces patients.

Resume La presence d’une symptomatologie radiculaire est un motif de consultation frequent en pathologie rachidienne. La realisation d’infiltrations epidurales, bien que largement utilisees, reste encore sujette a discussion. Il est ainsi possible d’approcher l’espace epidural par une voie transforaminale, interlamaire ou en passant par le hiatus sacro-coccygien. L’objectif de ce travail est donc de decrire la technique d’infiltration epidurale par le hiatus sacro-coccygien et d’en rapporter notre experience. Au-dela de l’effet therapeutique, l’infiltration du hiatus sacro-coccygien peut avoir un interet en tant que test diagnostique ou en solution d’attente. Un guidage pour un positionnement optimal de l’aiguille sous S3 est recommande. L’infiltration par le hiatus sacro-coccygien constitue donc une alternative interessante dans la prise en charge de la radiculopathie lombaire chez l’adulte.

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 41 mm and postoperative was 48 mm. 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.

Spinal dural arteriovenous fistula (d-AVF) is the most common spinal vascular malformations. Management includes endovascular embolization, and/or surgical obliteration of the shunt.Applied to spinal d-AVF, mini-invasive surgical (MIS) obliteration is described as a mini-open approach using Mast Quadrant™ system. Important anatomical landmarks are reviewed. Indications, advantages, and limitations are discussed, and a step-by-step description of the procedure is presented.MIS is a good solution to treat d-AVF with a good outcome.

Low-grade isthmic spondylolisthesis (ISPL) is generally treated by circumferential fusion with interbody graft, although there is no consensus on technique.The various interbody fusion strategies provide satisfactory fusion rates and clinical results.A multicenter retrospective study analyzed lumbar interbody fusion for low-grade ISPL performed between March 2016 and March 2019. Techniques comprised: circumferential fusion on a posterior or a transforaminal approach (PLIF, TLIF: n=57), combined anterior (ALIF) + posterolateral fusion (ALIF+PLF: n=60), and ALIF + percutaneous posterior fixation (ALIF+PPF: n=55). Function was assessed on a lumbar and a radicular visual analog scale (AVS-L, VAS-R, Oswestry Disability Index (ODI) and Short Form 12 (SF12).85.3% of the 129 patients showed fusion (Lenke 1 or 2), with no significant differences between the ALIF-PLF or ALIF-PPF groups and the PLIF or TLIF groups (p=0.3). Likewise, there was no difference in fusion rates between the ALIF-PPF and ALIF-PLF subgroups (p=0.28). VAS-L (p0.001) and VAS-R (p0.0001), ODI (p0.001) and SF12 physical (PCS) (p0.01) and mental component sores (MCS) (p0.001) all showed significant improvement at 12 months. Combined approaches provided greater clinical efficacy than TLIF or PLIF for lumbar (p0.0001) and radicular pain (p0.05), ODI (p0.0001) and SF12 PCS (p0.01). At 12 months, there was no clinical difference between the ALIF-PPF and ALIF-PLF subgroups. However, patents with interbody non-union (Lenke 3 or 4) had lower SF12 PCS scores (p0.004) and VAS-L ratings (p0.001) than Lenke 1-2 patients.Low-grade ISPL treated by circumferential arthrodesis and interbody graft showed 85.3% consolidation at 2 years, with equivalent outcomes between anterior and posterior techniques. Successful fusion was associated with better clinical results.IV.

Purpose Nocardia farcinica is an opportunistic pathogen causing mainly pneumonia in immunocompromised patients, complicated in almost one-third of the cases by a thick-walled multiloculated cerebral abscess which induces significant morbidity and mortality. This review aims to assess the optimal treatment strategy for N. farcinica cerebral abscess. Methods Report of a case. Medline database was used to conduct a systematic review from inception to January 2020 looking for English-language articles focused on N. farcinica cerebral abscess, in accordance with the PRISMA guidelines. Results The research yielded 54 articles for a total of 58 patients. N. farcinica cerebral abscess displayed three different neuroimaging patterns: a single multiloculated abscess in half of the cases, multiple cerebral abscesses, or a small paraventricular abscess with meningitis. The patients who benefited from surgical excision of the abscess showed a trend towards a lower risk of surgical revision (8% versus 31%, P = 0.06) and a lower mortality rate (8% versus 23%, P = 0.18) than patients who benefited from needle aspiration. Twenty-two percent of the patients benefited from microbiological documentation from another site with a mortality rate of 23%. Conclusion Urgent multimodal MRI is necessary in face with clinical suspicion of cerebral nocardiosis. In case of single or multiple small cerebral abscesses, microbiological documentation can be obtained with puncture of pseudotumoral visceral lesions. In case of large or symptomatic cerebral abscess, an aggressive surgical excision seems a reliable option and can be preferred over needle aspiration. Long-term antibiotic therapy with cotrimoxazole is necessary thereafter.

Background Odontoid fractures are the most common lesions of the upper cervical spine in patients >70 years old. These fractures are associated with frequent comorbidities, and minimally invasive techniques might have the potential to reduce postoperative complications while ensuring better precision. The aim of this study was to report an innovative technique and preliminary results of minimally invasive atlantoaxial fixation using a three-dimensional intraoperative navigation system and percutaneous approach. Methods This retrospective study included 5 consecutive patients with an acute traumatic odontoid type II fracture managed using a percutaneous Harms fixation under three-dimensional intraoperative navigation guidance. Results C1 lateral mass screws and C2 isthmus screws were successfully placed in all patients. In all cases (100%), adequate screw positioning with no medial breach and no transverse foramen obstruction was observed. No intraoperative complications, such as injury of the vertebral artery, spinal nerve root, or spinal cord, occurred. None of the 5 patients received blood transfusion during or after the procedure. During the follow-up period (mean, 11.2 months; range, 5-16 months), 4 patients (80%) demonstrated a favorable clinical recovery, and only 1 patient required occasional medication for moderate pain. Mean radiation exposure was 4.83 mSV for each patient and 0 mSv for surgical staff. Conclusions Minimally invasive atlantoaxial fixation using an intraoperative three-dimensional navigation system is a safe and effective alternative to the conventional approach that reduces postoperative morbidity.

Objectives To update the French guidelines on the management of trauma patients with spinal cord injury or suspected spinal cord injury. Design A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Methods The committee studied twelve questions: (1) What are the indications and arrangements for spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few days in hospital? (4) What is the best way to manage these patients to improve their long-term prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® Methodology. Results The experts’ work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/−) and 12 have a low level of evidence (GRADE 2+/−). For 5 recommendations, the GRADE method could not be applied, resulting in expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. Conclusions There was significant agreement among experts on strong recommendations to improve practices for the management of patients with spinal cord injury.

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.

Although the reduction of traumatic fractures of the thoracolumbar spine is of good quality during conventional so-called open procedures, the alternative minimally invasive approach also appears to confer good results. The aim of this study was to measure the radiological parameters before and after minimally invasive surgery, in order to assess the quality of the reduction of thoracolumbar compression fractures.This retrospective, monocentric study included 112 patients with a mean age of 48.9 years, presenting with 135 type A thoracolumbar compression fractures treated by a posterior minimally invasive surgical approach comprising vertebral augmentation or posterior osteosynthesis or a mixed procedure.The parameters analyzed were significantly lower whatever the procedure in the immediate postoperative period. Mean regional and local kyphosis, posterior wall displacement, and mean vertebral height were significantly lower (p0.01). Fracture reduction was better when osteosynthesis was associated with vertebral augmentation. In the osteosynthesis subgroup with osteosynthesis hardware removal but without vertebral augmentation, we found a significant worsening of the regional kyphosis (p0.05).The management of thoracolumbar compression fractures by a posterior minimally invasive approach allows excellent fracture reduction with a restoration of the spinal canal, vertebral height and kyphosis.IV.

Owing to recent advances in cancer therapy, updated data are required for clinicians counselling patients on treatment of spinal metastases. To analyse the outcomes of surgical treatments of spinal metastases. Prospective and multicentric study that included consecutively patients operated on for spinal metastases between January 2016 and January 2017. Overall survival was calculated with the Kaplan-Meier method. Cox proportional hazard model was used to calculate hazard ratio (HR) analysing mortality risk according to preoperative Karnofsky performance status (KPS), mobility level and neurological status. A total of 252 patients were included (145 males, 107 females) aged a mean 63.3 years. Median survival was 450 days. Primary cancer sites were lung (21%) and breast (19%). Multiple spinal metastases involved 122 patients (48%). Concomitant skeletal and visceral metastases were noted in 90 patients (36%). Main procedure was laminectomy and posterior fixation (57%). Overall, pain and mobility level were improved postoperatively. Most patients had normal preoperative motor function (50%) and remained so postoperatively. Patients “bedbound” on admission were the less likely to recover. In-hospital death rate was 2.4% (three disease progression, one septic shock, one pneumonia, one pulmonary embolism). Complication rate was 33%, deep wound infection was the most frequent aetiology. Higher mortality was observed in patients with poorest preoperative KPS (KPS 0–40%, HR = 3.1, p

La cirugia de columna vertebral es cada vez mas frecuente e incluye una amplia variedad de procedimientos, desde intervenciones menores que pueden realizarse de forma ambulatoria (hernia discal) hasta cirugias mayores con riesgo de hemorragia (cirugia de metastasis, osteosintesis). En todos los casos, los riesgos relacionados con la postura estan en primer plano. Esto requiere detectar durante la consulta todas las limitaciones de amplitud de las articulaciones que puedan interferir con la postura, en particular la evaluacion de la rigidez o deformacion de la columna cervical y las condiciones de intubacion. La cirugia minimamente invasiva (CMI) esta experimentando un rapido desarrollo que permite usar estrategias de recuperacion mejorada despues de la cirugia (RMDC). Independientemente del procedimiento, el dolor postoperatorio es una constante y justifica una estrategia analgesica que depende del tipo de cirugia y de los pacientes, con una alta frecuencia de pacientes con dolor cronico dificil de tratar. Las complicaciones son comunes despues de cirugias mayores. Durante la intervencion, siempre existe el riesgo de lesion de los nervios o de la medula espinal. Para la cirugia de escoliosis, se ha demostrado el interes de monitorizar los potenciales provocados somestesicos (PPS) y motores (PPM). Para obtener un beneficio se necesita un equipo medico y quirurgico avezado que trabaje en estrecha colaboracion. En el periodo postoperatorio, la complicacion mas temida es la infeccion. La infeccion de los tejidos blandos debe detectarse y tratarse rapidamente para evitar la aparicion de la espondilodiscitis, que con frecuencia requiere una reintervencion y un tratamiento antibiotico prolongado. La multiplicidad de los procedimientos, la rapida evolucion de las tecnicas quirurgicas, el desarrollo de la cirugia guiada por tomografia computarizada (TC) y las frecuentes comorbilidades de los pacientes, a menudo ancianos, requieren una estrecha colaboracion entre los equipos de anestesia y de cirugia.

La chirurgia del rachide e sempre piu frequente e comprende una vasta gamma di procedure, da atti minori che possono essere eseguiti ambulatorialmente (ernia del disco) a importanti interventi chirurgici a rischio di emorragia (chirurgia delle metastasi, osteosintesi). In ogni caso, i rischi legati alla postura sono in primo piano. Cio richiede, al momento della visita, di individuare i limiti di escursione articolare che possono interferire con la postura, in particolare di valutare la rigidita o la deformazione del rachide cervicale e le condizioni di intubazione. La chirurgia mini-invasiva (MIS) sta subendo un rapido sviluppo che consente strategie di recupero migliorato dopo chirurgia (RMDC). Qualunque sia la procedura, il dolore postoperatorio e una costante e giustifica una strategia di analgesia che dipende dal tipo di chirurgia e dai pazienti, con un’alta frequenza di pazienti con dolore cronico difficili da trattare. Le complicanze sono frequenti dopo le chirurgie maggiori. Durante l’intervento, il rischio di lesioni nervose o midollari e sempre presente. Per la chirurgia della scoliosi e stato dimostrato l’interesse del monitoraggio dei potenziali evocati somatosensoriali (PES) e motori (PEM). Esso richiede un’abitudine e una buona collaborazione dell’equipe medicochirurgica per trarne beneficio. Nel postoperatorio, la complicanza piu temuta e l’infezione. L’infezione dei tessuti molli deve essere individuata e trattata rapidamente per evitare il passaggio alla spondilodiscite, che spesso impone una revisione chirurgica e una terapia antibiotica prolungata. La molteplicita delle procedure, la rapida evoluzione delle tecniche chirurgiche, lo sviluppo della chirurgia TC-guidata e le frequenti comorbilita di pazienti spesso anziani richiedono, in questa chirurgia, una stretta collaborazione tra le equipe di anestesia e chirurgia.

Resume Introduction Les fractures bi-isthmiques de C2 representent 15 a 20 % des fractures du rachis cervical et la strategie de prise en charge de ces fractures reste encore sujette a debat, reposant principalement sur la classification d’Effendi modifiee par Levine et Edwards. L’objectif de cette etude prospective, multicentrique et observationnelle etait de recenser la prise en charge initiale des fractures bi-isthmiques de C2 en France. Les complications et les taux de consolidation etaient analyses en fonction du type de fracture et du traitement propose. Materiel et methode Il s’agit d’une etude multicentrique prospective conduite sous l’egide de la Societe francaise de chirurgie rachidienne. Pour inclure un patient dans l’etude, le diagnostic de fracture bi-pediculaire de C2 devait etre pose sur un examen tomodensitometrique du rachis cervical. Le suivi etait realise de facon prospective, la consolidation etait confirmee sur un scanner 3 mois apres le traumatisme puis 1 an de suivi. Le type de traitement et les complications etaient systematiquement notes. Resultats Trente-quatre patients ont ete inclus, selon la classification d’Effendi modifiee Levine, 68 % presentaient des lesions de type 1, 29 % presentaient des lesions de type 2, un seul patient presentait une lesion de type 3 (3 %). Vingt et un patients de notre cohorte (62 %) ont beneficie d’un traitement orthopedique, 11 patients ont beneficie d’un traitement chirurgical (32 %). A 1 an post-prise en charge une consolidation etait consideree comme acquise pour 28 patients, 6 patients etait perdus de vue. Conclusion Les taux de mortalite et de complications neurologiques sont faibles apres une fracture bi-pediculaire de C2. Les fracture de type 1 peuvent beneficier d’un traitement orthopedique qui presente des taux de consolidation de 100 % dans cette serie, Les types 2 ou 3 correspondant a des fractures avec lesions disco-ligamentaires constituent une indication chirurgicales par voie anterieure de type arthrodese C2–C3 ou par voie posterieure par vissage C1–C3. Niveau de preuve III.

Resume Introduction Les fractures en flexion-distraction du rachis representent environ 15 % des fractures thoraco-lombaire avec 25 % de troubles neurologiques. Leur prise en charge chirurgicale ne fait toujours pas consensus. En l’absence de troubles neurologiques, la fixation percutanee presente un interet en permettant une stabilisation rapide avec une reduction satisfaisante, completee si necessaire par un temps anterieur mini-invasif. Cette etude presente les resultats de 28 cas de fractures du rachis thoraco-lombaire en flexion-distraction sans complication neurologique pris en charge par technique mini invasive. Materiel et methodes Il s’agit d’une etude monocentrique retrospective conduite entre 2008 et 2015, les patients inclus etaient âges de plus de 16 ans, sans troubles neurologiques. L’analyse des fractures s’effectuait par tomodensitometrie en preoperatoire avec mesure de la cyphose regionale post traumatique. La technique operatoire comprenait une fixation posterieure percutanee eventuellement associee a un geste mini-invasif anterieur en cas de lesions discale a l’IRM ou en cas de forte comminution corporeale. Le temps operatoire, les pertes sanguines et les complications postoperatoire etaient colligees. La cyphose regionale et la fusion osseuse etaient evaluees par une nouvelle tomodensitometrie a 1 an postoperatoire. Resultats Dix-sept hommes et 11 femmes ont ete inclus (âge moyen 29,2 ans). Un temps anterieur complementaire etait realise dans 11 cas (39 %) : pour 5 cas dans des fractures de type B1 en raison d’une importante comminution corporeale (corporectomie et arthrodese par cage expansible remplie d’os et de BMP-2) et pour 6 cas dans des fractures de type B2 en raison d’une atteinte discale a l’IRM (discectomie et arthrodese intervertebrale par greffon iliaque). La cyphose regionale etait significativement reduite (17,3° vs 5,7°, p Conclusion Chez les patients sans troubles neurologiques initial, une prise en charge par chirurgie mini invasive soit par fixation posterieure isolee soit associe a un geste anterieur mini invasif permet une excellente consolidation au prix d’un traumatisme operatoire et d’un saignement faible. Niveau de preuve IV.

Background: Cervical osteomyelitis following the treatment of pharyngeal cancer with laryngectomy and chemoradiotherapy is poorly reported. Methods: Six cases of cervical osteomyelitis occurring over a 1-year period are described herein. These are reviewed alongside four cases reported previously in the literature. Results: Among the total 10 cases, the average age of the patients was 58.7 years. The period between laryngectomy and the diagnosis of cervical osteomyelitis was on average 3 years and 1 month and the male to female sex ratio was 9:1. Two patients had a history of cervical fistula with an esophageal prosthesis, one had a spontaneous cervical fistula, one had a pharyngeal cutaneous fistula, and one had an esophageal prosthesis without any fistula. At the time of diagnosis, seven had a history of cervical pain (70%) and nine had a neurological deficit (90%). Seven patients (70%) underwent surgery; one (10%) was contraindicated for a general anesthetic and two (20%) died before any intervention. The indication for surgery was a neurological deficit for six patients (60%) and the requirement for lavage and debridement for two patients (20%). The average length of antimicrobial treatment was 12.7 weeks. The outcome was favorable for six patients. Four patients died. Conclusions: Cervical osteomyelitis is a serious but rarely reported complication following the treatment of pharyngeal cancer with chemoradiotherapy and laryngectomy. Cervical pain was the first sign to appear, sometimes 1 year before any other sign. Physicians should be aware of this dreaded complication, which is probably underdiagnosed and is related to an increased mortality rate. Keywords: Cervical osteomyelitis, Laryngectomy, Larynx carcinoma, Cervical cancer, Infection

Background Infectious aneurysm is a rare complication in intracranial aneurysm. Moreover, giant aneurysm is a rare entity in intracranial aneurysm. In the great majority of infectious intracranial aneurysms, vasculitis and/or endocarditis is associated. Case Description Here, we report the case of an 83-year-old man who developed a giant infectious intracranial aneurysm on the anterior communicating artery. This patient had never shown any intracranial bleeding. A surgery was performed, and purulent liquid and aneurysm wall were removed during procedure. The bacteriologic analyses reported Campylobacter fetus. Conclusions This bacterium seems to be more and more frequent in North America and Europe, according to the current literature. Moreover, cases of mycotic extracranial aneurysm were reported. Here we report the first case of intracranial giant infectious aneurysm in an adult patient, without any endocarditis or vasculitis. This new entity could be the cause of a bacterial graft on an asymptomatic giant preexisting intracranial aneurysm or a consequence of campylobacteriosis.

International audience; PurposeThe French Society of Spine Surgery (SFCR) conducted a prospective epidemiologic multicenter study. The purpose was to investigate mortality, complication, and fusion rates in patients with odontoid fracture, depending on age, comorbidities, fracture type, and treatment.MethodsOut of 204 patients, 60 were ≤ 70 years and 144 were > 70 years. Demographic data, comorbidities, treatment types and complications (general medical, infectious, neurologic, and mechanical), and death were registered within the first year. Fractures were classified according to Anderson–D’Alonzo and Roy–Camille on the initial CT. A 1-year follow-up CT was available in 144 patients to evaluate fracture consolidation.ResultsType II and oblique-posterior fractures were the most frequent patterns. The treatment was conservative in 52.5% and surgical in 47.5%. The mortality rate in patients ≤ 70 was 3.3% and 16.7% in patients > 70 years (p = 0.0002). Fracture pattern and treatment type did not influence mortality. General medical complications were significantly more frequent > 70 years (p = 0.021) and after surgical treatment (p = 0.028). Neurologic complications occurred in 0.5%, postoperative infections in 2.0%, and implant-related mechanical complications in 10.3% (associated with pseudarthrosis). Fracture fusion was observed in 93.5% of patients ≤ 70 years and in 62.5% >70 years (p

Background: Most of tuberculum sellae meningiomas (TSM) show asymmetric growth. They are usually resected through ipsilateral approaches. The access of the inferior–medial side of the ipsilateral optic nerve might be challenging, which result in increased manipulation of the compromised optic nerve. The contralateral approach has been described to avoid these technical difficulties.Objective: Assessing the long term visual and olfactory outcome, as well as recurrence rate in patients operated for TSM through ipsi- or contralateral approaches.Methods: Single center retrospective cohort study about 94 patients operated on between March 2000 and April 2018.Results: 70% of the preoperative visual acuity loss totally resolved (44%) or showed varying degrees of improvement (26%) after surgery. Seventy-two percent of the preoperative visual field defects evolved favorably (44% recovery, 28% improvement). Eight patients showed aggravated visual disturbances (9%). A contralateral approach seemed to be predictive of visual field defects improvement after surgery (OR=0.4), with borderline significant results (p=.08). There was a higher rate of postoperative olfactory nerve impairment after a contralateral approach (37%vs17%, p=.03). Total removal of the tumor fragment entering the optic canal was accomplished in 96% in the contralateral vs 75% in the ipsilateral group (p=.04). The 2-, 5- & 7-year tumor progression free survival were 100% in the Simpson Grade 2 group, and 85% (n=17), 74% (n=11) & 67% (n=5) in the Simpson Grade 4 group, respectively (p=.00). Conclusion: Resection of tuberculum sellae meningiomas through a contralateral approach seems to provide better visual outcome and tumor control at the cost of increased olfactory nerve disorders.