A Penetrating Lumbar Spine Injury With Misleading Neurological Symptoms

Penetrating spinal injuries require specific neurosurgical attention. To date, there are no guidelines regarding emergency neurosurgical management of such injuries and the decision whether to operate is made individually, based on the neurological examination and the analysis of any imaging available. We report the case of a 22-year-old patient who sustained two gunshots in the thighs and one in the lumbar spine. Clinical examination revealed neurological deficit in both legs prevailing on the right side. Discussion between the radiologist and the neurosurgeon concluded to an injury to the left S1 nerve root within the spinal canal, and to the right sciatic nerve. Thus, there was no need for a decompressive laminectomy. In the light of the current literature, penetrating spinal injuries rarely require an extensive surgical exploration; indications for such a procedure include incomplete neurological deficit with persistent neurological compression, cerebrospinal fluid leakage, and obvious instability. Furthermore, penetrating spinal injuries are rarely encountered, even for military neurosurgeons. Their surgical management and especially the need for laminectomy, stabilization, and dural sac watertight closure are still a matter of debate. An expert consensus statement would give food to surgeons facing penetrating spinal injuries.

Spinal metastases of bronchopulmonary cancers: interest of balloon kyphoplasty in the control of mechanical rachialgia

Introduction

Spinal metastases are a classic complication of lung cancer. New palliative treatment modalities have emerged. Among them are minimally invasive approaches such as balloon kyphoplasty. With the aim of evaluating the efficiency of balloon kyphoplasty in the control of spinal pain during these lesions, we report a series of 24 patients.

Methods and materials

Over a period of 6 years, we retrospectively studied 24 files of patients suffering from vertebral compression of metastatic pulmonary origin and treated by balloon kyphoplasty from January 2009 to December 2014 in the neurosurgery department of the North Hospital of Marseille (France).

Results

The mean age was 66.2 years (39–80 years) with a sex ratio of 5. Dorsal location was predominantly 17 cases. Balloon kyphoplasty involved one level in 14 patients. The general condition (Karnofski) was bad in 16 patients. Survival prediction was less than 6 months in 22 patients. The indication was mainly pain with a mean visual analog scale of 7.7. The evolution was marked by the regression of the painful symptomatology in all patients with a mean visual analog scale of 2.2 postoperatively. Postoperative complications were noted in two cases (pulmonary embolism, compression of the left iliac vein).

Conclusion

Our short series shows the efficacy and low morbidity of balloon kyphoplasty in the control of spinal pain secondary to vertebral metastases of bronchopulmonary cancers.

Endovascular treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial

OBJECTIVE

The role of endovascular treatment in the management of patients with brain arteriovenous malformations (AVMs) remains uncertain. AVM embolization can be offered as stand-alone curative therapy or prior to surgery or stereotactic radiosurgery (SRS) (pre-embolization). The Treatment of Brain AVMs Study (TOBAS) is an all-inclusive pragmatic study that comprises two randomized trials and multiple registries.

METHODS

Results from the TOBAS curative and pre-embolization registries are reported. The primary outcome for this report is death or dependency (modified Rankin Scale [mRS] score > 2) at last follow-up. Secondary outcomes include angiographic results, perioperative serious adverse events (SAEs), and permanent treatment-related complications leading to an mRS score > 2.

RESULTS

From June 2014 to May 2021, 1010 patients were recruited in TOBAS. Embolization was chosen as the primary curative treatment for 116 patients and pre-embolization prior to surgery or SRS for 92 patients. Clinical and angiographic outcomes were available in 106 (91%) of 116 and 77 (84%) of 92 patients, respectively. In the curative embolization registry, 70% of AVMs were ruptured, and 62% were low-grade AVMs (Spetzler-Martin grade I or II), while the pre-embolization registry had 70% ruptured AVMs and 58% low-grade AVMs. The primary outcome of death or disability (mRS score > 2) occurred in 15 (14%, 95% CI 8%–22%) of the 106 patients in the curative embolization registry (4 [12%, 95% CI 5%–28%] of 32 unruptured AVMs and 11 [15%, 95% CI 8%–25%] of 74 ruptured AVMs) and 9 (12%, 95% CI 6%–21%) of the 77 patients in the pre-embolization registry (4 [17%, 95% CI 7%–37%] of 23 unruptured AVMs and 5 [9%, 95% CI 4%–20%] of 54 ruptured AVMs) at 2 years. Embolization alone was confirmed to occlude the AVM in 32 (30%, 95% CI 21%–40%) of the 106 curative attempts and in 9 (12%, 95% CI 6%–21%) of 77 patients in the pre-embolization registry. SAEs occurred in 28 of the 106 attempted curative patients (26%, 95% CI 18%–35%, including 21 new symptomatic hemorrhages [20%, 95% CI 13%–29%]). Five of the new hemorrhages were in previously unruptured AVMs (n = 32; 16%, 95% CI 5%–33%). Of the 77 pre-embolization patients, 18 had SAEs (23%, 95% CI 15%–34%), including 12 new symptomatic hemorrhages [16%, 95% CI 9%–26%]). Three of the hemorrhages were in previously unruptured AVMs (3/23; 13%, 95% CI 3%–34%).

CONCLUSIONS

Embolization as a curative treatment for brain AVMs was often incomplete. Hemorrhagic complications were frequent, even when the specified intent was pre-embolization before surgery or SRS. Because the role of endovascular treatment remains uncertain, it should preferably, when possible, be offered in the context of a randomized trial.

Delayed Collet-Sicard syndrome after internal carotid dissection and Jefferson fracture. Case report and Review of Literature

Background:

Lower cranial nerve palsies, or Collet-Sicard syndrome, can be caused by many different etiologies including head trauma, basilar occipital fractures, tumors, and interventions. Few reports describe different presentations of this condition, and we present here a case study to increase awareness of and add to the variable spectrum.

Case Description:

A 56-year-old who had been hit while diving was admitted to our department. On examination, he was conscious without any signs of lateralization but presented with severe neck pain. CT brain and cervical spine revealed a C1 fracture with bilateral symmetrical fracture of the anterior and posterior arches (Jefferson’s fracture) and slight bilateral joint dislocation C1-C2 discreetly predominant on the left. One week later, he presented with dysarthria, dysphonia, swallowing disorder, anisocoria, tongue deviation, and palate deviation (XII, IX, and X). CT Angiography showed dissection of the internal carotid artery immediately after the carotid bulb. He has been treated conservatively with curative anticoagulants with stable symptoms. No surgical intervention had been proposed.

Conclusion:

Adding to the literature, delayed Collet-Sicard syndrome and lower cranial affection can be caused by missed carotid wall hematoma following severe craniocervical trauma associated with Jefferson’s fracture.

[Percutaneous kyphoplasty using expandable SpineJack® implant for the treatment of osteoporotic vertebral fractures]

Introduction

L'objectif était d’évaluer le résultat de notre prise en charge chirurgicale des fractures ostéoporotiques vertébrales avec un extenseur vertébral percutané de type SpineJack®.

Méthodes

Il s'agit d'une étude rétrospective analytique et mono centrique de 33 mois (avril 2015 - décembre 2017). Elle avait porté sur les patients ayant été traités par kyphoplastie avec le pour une fracture vertébrale ostéoporotique. Le kit comprenant un extenseur vertébral en titane à type de SpineJack® de Vexim et le ciment acrylique avait été utilisé. Les patients présentant une rachialgie d'intensité croissante malgré le traitement lié à une fracture vertébrale ostéoporotique ont été inclus dans l'étude ainsi que ceux ayant acceptés le principe de la chirurgie et donner leur consentement éclairé. La fracture vertébrale était diagnostiquée à la tomodensitométrie (TDM) et son caractère récent confirmé par l'imagerie par résonnance magnétique (IRM).

Résultats

Entre avril 2015 et décembre 2017, trente-sept patients porteurs de fractures ostéoporotiques vertébrales ont été traités par kyphoplastie avec un extenseur vertébral en titane. L'âge moyen était de 73,4 ans avec un sexe ratio à 0,6. L'échelle visuelle analogique moyenne était de 7,3. Le score d'Osvestry était en moyenne de 81,6. Les fractures étaient prédominantes au niveau de la charnière thoraco-lombaire. L'angle de cyphose vertébrale mesurait en moyenne 18,45°. La kyphoplastie avait concerné 44 vertèbres. Quatre cas de complications opératoires avaient été enregistrés. La durée moyenne d'hospitalisation était de 5,4 jours. A 6 mois de suivi, 9 patients étaient encore sous traitement antalgique. A un an, aucun cas de fracture de vertèbre adjacente n'avait été trouvé.

Conclusion

La kyphoplastie percutanée avec un extenseur en titane est un moyen thérapeutique sûr et efficace des fractures vertébrales ostéoporotiques. Avec son effet quasi immédiat, il permet au patient, un retour rapide à la vie active.

Decompressive craniectomy for severe traumatic brain injury: Evaluation of the effects at one year*

OBJECTIVE

To assess the effect on outcome (1 yr) of decompressive craniectomy performed within or after the first 24 hrs post-trauma in severely head-injured trauma patients with intractable cerebral hypertension.

DESIGN

Retrospective cohort study.

SETTINGS

Intensive care unit of a university hospital.

PATIENTS

Among 816 patients with severe head trauma (Glasgow Coma Scale < or =8), 40 underwent decompressive craniectomy. After data collection, patients were divided into two groups: early and late decompressive craniectomy. An early decompressive craniectomy was performed within the first 24 hrs in patients according to the following criteria: a Glasgow Coma Scale score <6 and the existence of clinical signs of cerebral herniation (absence of pupillary reflexes), correlated with abnormalities in computed tomography scan including hematoma, appearance of diffuse or unilateral brain swelling, and/or cerebral herniation. The intracranial pressure in these patients was not measured before the decompressive craniectomy was performed. A late decompressive craniectomy (>24 hrs) was performed according to following criteria: an intractable intracranial hypertension with intracranial pressure >35 mm Hg, a unilateral or bilateral absence of pupillary reflexes, and the same abnormalities in computed tomography scan as previously described.

INTERVENTION

Twenty-seven patients with signs of cerebral herniation required the procedure at the time of initial evacuation of a mass lesion. In 13 patients, decompressive craniectomy was performed because of elevated intracranial pressure refractory to medical treatment consisting of cerebrospinal fluid derivation, deep sedation, osmotherapy, hyperventilation, and nesdonal or propofol.

MEASUREMENTS AND MAIN RESULTS

Five patients (19%) in whom an early decompressive craniectomy was performed had good recoveries (social rehabilitation), eight patients (30%) remained in a persistent vegetative state or with a severe disability, and 14 died (52%). On the other hand, the performance of late decompressive craniectomy in case of medical treatment failure was followed by social rehabilitation in five patients (38%) and death in three patients (23%). A persistent vegetative state or a severe disability was observed in five patients (38%). Meningitis or cerebral abscess occurred in six patients after decompressive craniectomy and were easily cured by antibiotic treatment.

CONCLUSIONS

In 40 patients with intractable intracranial hypertension and at very high risk of brain death, decompressive craniectomy allowed 25% of patients to attain social rehabilitation at 1 yr.

[Subperiosteal hematoma of the orbit. Three cases]

Orbital subdural hematoma should be considered in victims of head and face trauma with signs of exophthalmia. Early diagnosis and treatment, consisting of decompression, is mandatory to avoid long-term functional complications.

[Tuberculous abscess of the cerebellum. Apropos of a case]

A 22-year-old Asian man developed intracranial hypertension with a 38 degrees C fever. Two months earlier, he had undergone surgery and medical treatment for tuberculous otomastoiditis and pulmonary tuberculosis. The CT scan revealed multiple tuberculous abscesses of the cerebellum. Histological, microbiological and biological proof of diagnosis was obtained. We advocate surgical treatment of intracranial tuberculous abscesses associated with antituberculosis chemotherapy for 18 months. The earlier the treatment, the better the prognosis. This pathology must be kept in mind when treating patients from countries with a high endemic rate of tuberculosis and suffering from immunodeficiency syndrome.

[Extradural hematoma of the posterior fossa]

Extradural hematoma of the posterior fossa (EDHPF) is considered to be a rare complication of head injuries. In early reports, diagnosis was made only at the time of autopsy. Today, CT scanning prompts early diagnosis leading to better outcome. We report 20 consecutive patients observed over the last ten years who underwent surgery for EDHPF. This localization was found in 14,3% of all trauma patients operated for extradural hematoma. In our experience, EDHPF occurs in young adults with a clear male predominance. Vehicle accidents are the most frequent mechanism of injury. The main clinical presentation is subacute onset of signs (50% of our cases). Postoperative outcome was favorable in 19 of our patients (95%). We propose mandatory CT scanning that may have to be repeated as needed, to prevent delay in diagnosis and decision for surgery. Surgical removal of the EDHPF must be carried out as soon as possible as this is the only way to reduce morbidity and mortality.

[Results of an open fixation treatment of 131 fractures of the femoral diaphyses in a Congolese hospital setting]

From 1987 to 1991, 196 fractures of the femoral diaphysis were treated at the University Hospital Center of Brazzaville. A retrospective perusal of the files of these patients produced 131 analyzable cases, all treated by open osteosynthesis using either screw-attached plates (n = 84) or nails (n = 47). The overall infection rate was 5.4% (7/131). This rate was 5.9% (5/84) using screw-attached plates and 4.2% (2/47) using nails, i.e. only slightly higher than in the literature. Bone fixation was successful in 90% of cases. Mechanical complications (11.4%) were due mainly to technical errors during the initial fixation. With a follow-up of 3 years, analysis according to the criteria of GENESTE showed that open osteosynthesis of fractures of the femoral diaphysis in an African orthopedic department led to 90% of good (32%) and excellent (58%) results. In this African series, the main problem was the initial fixation.