Céline Salaud

Overall Survival in Spine Myeloma Metastases: Difficulties in Predicting with Prognostic Scores.

Study Design. Fifty-one patients with spinal multiple myeloma (MM) metastases were operated and followed between January 2004 and July 2014. Objective. The aim of this study was to consider the efficiency of surgical prognosis scores in the management of spinal metastases myelomas. Summary of Background Data. The spine is the most common site of bone metastases in MM. Surgery in spine metastases MM is a matter of debate and its impact on the increase of a patients survival time is not clear. Several surgical survival scores have been developed to determine the best treatment in these patients. Methods. We studied 51 patients operated for spinal MM metastases between January 2004 and July 2014. We determined the Tokuhashi and Tomita survival scores and compared them with documented patient survivals. The two scores were also compared with the International Staging System (ISS). Results. Median survival (MS) was 108 months [standard deviation (SD) 62] for ISS I, 132.2 (SD 40) for ISS II, and 45.5 months (SD 16.3) for ISS III (P = 0.09). According to Tokuhashi survival score, 21 patients (41.2%) will survive <6 months, 6 (11.8%) 6 to 12 months, and 24 (47%) >12 months. According to Tomita et al., 50 patients (98%) will survive >49.9 months and 1 patient (2%) <15 months. Regardless of the ISS grade prognosis, Tokuhashi survival score, and to a lesser extent Tomita score, underestimated the actual survival very significantly [P < 0.0001, Log Rank (Mantel-Cox)]. Conclusion. We suggest that spine surgical prognosis scores are not accurate and are not able to predict the survival of patients with spine myeloma metastases. Spine surgeons have to be guided not by the initial ISS stage but rather by spinal instability and neurological status. Level of Evidence: N/A

Entrapment of the posterior femoral cutaneous nerve and its inferior cluneal branches: anatomical basis of surgery for inferior cluneal neuralgia

PurposeThe apparent failure of pudendal nerve surgery in some patients has led us to suggest the possibility of entrapment of other adjacent nerve structures, leading to the concept of inferior cluneal neuralgia. Via its numerous collateral branches, the posterior femoral cutaneous nerve innervates a very extensive territory including the posterior surface of the thigh, the infragluteal fold, the skin over the ischial tuberosity, but also the lateral anal region, scrotum or labium majus via its perineal branch.MethodsWe described the pathophysiological features of cluneal neuralgia, the surgical technique and our preliminary results.ResultsWe performed a transmuscular approach leading to the fat of the deep gluteal region. Exploration was continued cranially underneath the piriformis, looking for potential entrapments affecting the posterior femoral cutaneous nerve and the sciatic nerve. Nerve decompression on the lateral surface of the ischial tuberosity was then performed. A constant anatomical finding must be highlighted: the presence of a lateral fibrous expansion from the ischium passing behind the nerves and vessels, especially the posterior femoral cutaneous nerve and its perineal branches. In our patients, release of this expansion allowed decompression of the nerve trapped by this expansion.ConclusionCluneal neuralgia constitutes a distinct entity of perineal pain, which must be identified and distinguished from pudendal neuralgia. Surgery should be performed via a transgluteal approach. A lateral ischial obstacle must be investigated, in the form of a constant fibrous expansion, which, like a retinaculum, can cause nerve entrapment.

Extrinsic and intrinsic blood supply to the optic chiasm: Blood Supply to the Optic Chiasm

Although there have been many studies of the arterial cerebral blood supply, only seven have described the optic chiasm (OC) blood supply and their results are contradictory. The aim of this study was to analyze the extrinsic and intrinsic OC blood supply on cadaveric specimens using dissections and microcomputer tomography (Micro‐CT). Thirteen human specimens were dissected and the internal or common carotid arteries were injected with red latex, China Ink with gelatin or barium sulfate. Three Micro‐CTs were obtained to reveal the intrinsic blood supply to the OC. The superior hypophyseal arteries (SupHypA) (13/13) and posterior communicating artery (PCoA) (12/13) supplied the pial network on the inferior side of the OC. The first segment of the anterior cerebral artery (ACA) (10/10), SupHypA (7/10), the anterior communicating artery (ACoA) (9/10), and PComA (1/10) supplied the pial network of its superior side. The intrinsic OC blood supply was divided into three networks (two lateral and one central). Capillaries entering the OC originated principally from the inferior pial network. The lateral network capillaries had the same orientation as the visual lateral pathways, but the central network was not correlated with the nasal fibers crossing into the OC. There was no anastomosis in the pial or intrinsic networks. Only SupHypA, PCoA, ACoA, and ACA were involved in the OC blood supply. Because there was no extrinsic or intrinsic anastomosis, all arteries should be preserved. Tumor compression of the inferior intrinsic arterial network could contribute to visual defects. Clin. Anat. 31:432–440, 2018.

Management of aneurysmal subarachnoid haemorrhage with intracerebral hematoma: Is there an indication for coiling first? Study of 44 cases

Background Aneurysmal subarachnoid haemorrhage (ASH) with intracerebral hematoma (ICH) has a poor prognosis. The treatment is to secure the aneurysm and do an ICH evacuation. Objective The aim of the study was to determine if aneurysm coiling followed by ICH evacuation is a viable alternative treatment compared to exclusive surgery, regardless of the clinical or paraclinical presentations. Methods A retrospective study was conducted between 2004 and 2014, which included 44 patients. The patients were divided up in four groups. Two were principal groups: The clipped group (aneurysm clipping with ICH evacuation) and the coiled group (aneurysm coiling, followed by ICH evacuation); and two were subgroups of the latter: Aneurysm coiling with ICH evacuation after 24 hours and ICH evacuation followed by aneurysm coiling. We studied the demographic and radiologic characteristics, and the 3-month outcome. Results We included 17 patients in the coiled group: The outcome was better for the patients with World Federation of Neurosurgery (WFNS) scores of 1, 2 and 3; compared to the patients with WFNS scores 4 and 5. We included 16 patients in the clipped group: The outcome was better, compared the coiled group, for those patients with WFNS scores 4 and 5. Six patients were treated with aneurysm coiling, followed by ICH evacuation after 24 hours: 33% had a good outcome. Five patients were treated by ICH evacuation, followed by aneurysm coiling: None had a good outcome. Conclusions It was necessary to realise a prospective study to compare the outcomes of patients with WFNS scores of 1, 2 or 3; between those with aneurysm coiling followed by ICH evacuation and aneurysm clipping with ICH evacuation, to determine the potential of using the coiling first, for these patients.