O. Hamel

Continuous controlled-infusion of hypertonic saline solution in traumatic brain-injured patients: a 9-year retrospective study

IntroductionDescription of a continuous hypertonic saline solution (HSS) infusion using a dose-adaptation of natremia in traumatic brain injured (TBI) patients with refractory intracranial hypertension (ICH).MethodsWe performed a single-center retrospective study in a surgical intensive care unit of a tertiary hospital. Fifty consecutive TBI patients with refractory ICH treated with continuous HSS infusion adapted to a target of natremia. In brief, a physician set a target of natremia adapted to the evolution of intracranial pressure (ICP). Flow of NaCl 20% was a priori calculated according to natriuresis, and the current and target natremia that were assessed every 4 hours.ResultsThe HSS infusion was initiated for a duration of 7 (5 to 10) (8 ± 4) days. ICP decreased from 29 (26 to 34) (31 ± 9) mm Hg at H0 to 20 (15 to 26) (21 ± 8) mm Hg at H1 (P < 0.05). Cerebral perfusion pressure increased from 61 (50 to 70) (61 ± 13) mm Hg at H0 up to 67 (60 to 79) (69 ± 12) mm Hg at H1 (P < 0.05). No rebound of ICH was reported after stopping continuous HSS infusion. Natremia increased from 140 (138 to 143) (140 ± 4) at H0 up to 144 (141 to 148) (144 ± 4) mmol/L at H4 (P < 0.05). Plasma osmolarity increased from 275 (268 to 281) (279 ± 17) mmol/L at H0 up to 290 (284 to 307) (297 ± 17) mmol/L at H24 (P < 0.05). The main side effect observed was an increase in chloremia from 111 (107 to 119) (113 ± 8) mmol/L at H0 up to 121 (117 to 124) (121 ± 6) mmol/L at H24 (P < 0.05). Neither acute kidney injury nor pontine myelinolysis was recorded.ConclusionsContinuous HSS infusion adapted to close biologic monitoring enables long-lasting control of natremia in TBI patients along with a decreased ICP without any rebound on infusion discontinuation.

Perineal pain and inferior cluneal nerves: anatomy and surgery

Neuropathic perineal pains are generally linked to suffering of the pudendal nerve. But some patients present pains described as a type of burning sensation located more laterally on the anal margin and on areas including the scrotum or the labiae majorae, the caudal and medial parts of the buttock and the upper part of the thigh. These pains extend beyond the territory of the pudendal nerve. It is interesting to note that the inferior cluneal nerves are responsible for the cutaneous sensitivity in the inferior part of the buttock. We wanted to check if these nerves, or some of their branches, could be responsible for such pains. An anatomic study, containing six dissections on corpse, has been conducted. The inferior cluneal nerves, emerging from the posterior femoral cutaneous nerve have some branches joining the perineum, especially by a perineal ramus. However, two conflict areas have been identified on the path of these nerves and on the perineal ramus: one at the level of the sacrotuberal ligament, and the other being the passage under the ischium. Two surgical approaches have been established from these observations with the aim of suppressing the conflicts.

The intervertebral disc: From pathophysiology to tissue engineering

Lowbackpainhasalifetimeprevalenceof80%inthegeneralpopulation and causes a huge public health burden in industri-alized countries. The most common cause of low back pain isdegenerativediseaseoftheintervertebraldiscs(IVDs).Theeco-nomic impact of low back pain is tremendous, with estimateddirect and indirect costs of 20 to 100billion dollars per year inthe US [1]. Symptomatic treatment is rarely sufficient and newtherapeutic approaches are therefore needed, most notably tocounteractthedegenerativeprocess.Formanyyears,researchershave been working on methods to regenerate the Nucleus pulpo-sus (NP), the central component of the IVD. Among the severalapproaches suggested to date, tissue engineering is consideredpromising by clinicians. Tissue engineering involves replac-ing the damaged tissue by a biomaterial and appropriate cells.Preclinical studies are under way, and the place for tissue engi-neeringinthetherapeuticmanagementforlowbackpainisbeingdefined.

La chirurgie du nerf pudendal dans la prise en charge thérapeutique des douleurs pelvipérinéales chroniques

OBJECTIVE To define the place of pudendal nerve surgery in pudendal nerve entrapment syndromes. MATERIALS AND METHODS Description of the various surgical techniques and published results. RESULTS The original surgical technique, which remains the reference technique, consists of performing surgical release of the pudendal nerve from the infrapiriformis foramen to Alcocks canal via a transgluteal approach. This surgical procedure is safe and gives encouraging results validated by a prospective, randomized protocol: 66 to 80% of patients are improved. Other transvaginal or transperineal approaches have also been proposed. CONCLUSION Pudendal nerve surgery is a reasonable treatment option when all other treatments have failed. However, the various techniques proposed and their respective criticisms must be carefully evaluated.

The arterial supply of the coracoid process

ObjectiveThe aim of this study was to describe the arterial supply of the coracoid process and to define its possible involvement in complications of Latarjet procedure.MethodFive shoulder dissections were performed to highlight the extraosseous blood supply of the coracoid process. Postmortem arteriographies of the upper limb were performed. Diaphanization of a scapula enabled to view its intraosseous blood supply.ResultsThe vertical part of coracoid process was supplied by supra-scapular artery, and the horizontal part by branches of the axillary artery.Discussion and conclusionThis anatomical study has shown that the coracoid process had its own blood supply. During the Latarjet procedure, vascular sacrifices are mandatory to allow coracoid process transfer to the scapular neck. Such sacrifices could explain lysis or non-union of the coracoid process after Latarjet procedure. Preservation of axillary artery branches supplying horizontal part of the coracoid process could be a possible solution to prevent non-union and lysis of the bone transfer.

Anatomical basis of digital rectal examination

PurposeRectal examination is difficult to carry out by students because of their lack of knowledge and fear. It is therefore necessary to search for methods in order to facilitate its practice. This work mainly focuses on the palpation of the posterior lateral area of the rectum.MethodsThis work bases itself on the study of the average length of indexes and on the anatomical study of the dissection and prints of two pelvises. In the lithotomy position, we can identify three successive levels of exploration of the posterior and lateral area of the rectum. These three levels are defined by the extremity of the index, and the distal and proximal interphalangeal articulations placed successively on the tip of the coccyx. A 180° rotation of the hand enables at each level to identify the parietal structures that the pad of the index comes across, but excludes the palpation of genital organs and rectum.ResultsThe first level corresponds to the higher part of the anal canal, the ischioanal fossa and the ischium. The second level corresponds to the levator ani muscle, the ischioanal fossa and the pudendal canal. The third level corresponds to the sacrospinous ligament, the ischiatic spine and the internal obturator muscle.ConclusionsIn spite of the significant differences between the lengths of the indexes, the use of these landmarks will facilitate the identification of parietal anatomical structures. The internal organs’ palpation will depend on the patient’s position, his efforts in pushing, the length of the index, and the way the examiner presses on the perineum.

Hernies internes : anatomie chirurgicale

A la suite de la presentation « les fossettes duodenales : etude anatomique et applications cliniques » lors du dernier congres des morphologistes, nous rapportons notre experience a propos de 14 cas de hernies internes. Il s’agit de veritables hernies intra abdominales, a travers un orifice intra peritoneal. Restant a l’interieur de l’abdomen, et excluant les hernies iatrogeniques (post chirurgicales). En fonction de la nature de l’orifice, plusieurs types et mecanismes peuvent etre decrits. 1/ Orifice para normal, realisant une fossette peritoneale, due a un defaut d’accolement des feuillets peritoneaux (Toldt ou Treitz) : retrocaecal (4/14), paraduodenal (4 dont 2 droites et 2 gauches) ; ou exageration d’un repli peritoneal : ileocaecal (1), retroduodenal (1 cas), paravasculaire : artere iliaque droite (1). D’autres localisations ont ete decrites : paracolique, inter sigmoidienne, supra vesicale ou dans les replis du ligament large. 2/ A travers un orifice pathologique anormal, dont le mecanisme reste discute : petit ou grand omentum, ligament falciforme du foie (1/14), trans mesenterique ou mesocolique. 3/ Enfin a travers un orifice normal : le foramen epiploique (Hiatus de Winslow) : 2 cas. Le plus souvent symptomatiques (13 fois), traduites par un syndrome occlusif (9/13), une peritonite (3/13) ou des douleurs abdominales (1 fois) ; elles necessitent un traitement chirurgical urgent. Le diagnostic preoperatoire n’est que rarement evoque (3 fois). Le geste est simple : reduction du viscere hernie, resection si necessaire, fermeture de la fossette peritoneale ou de l’orifice anormal. Le seul probleme resulte de l’attitude a avoir lors d’une hernie interne a travers le foramen epiploique. Les suites sont simples (en fonction de la peritonite et de l’etat general du patient), sans recidive.

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.

The echographic “butterfly wing” aspect of the sphenoid bone is a critical landmark to insonate the middle cerebral artery

Dear Editor, Cerebral blood flow evaluation in the middle cerebral artery (MCA) is mandatory in the neurointensive care setting [1]. There is currently no standardized technique to perform transcranial Doppler (TCD) with echography, although this technique is now widespread. We validated a simple protocol to localize the MCA with echography. The local ethics committee approved the protocol. A postmortem analysis was performed in two corpses to evaluate the exact MCA location and identify bone structures that could be accessible with echography. This analysis demonstrated that the temporal window above the zygomatic arch allows the best MCA exploration with a horizontal position of the echographic probe. This standardized TCD protocol was then validated in a monocentric observational cohort. We included 250 patients undergoing mechanical ventilation in a surgical ICU. Localization of the sphenoid bone with a ‘‘butterfly wing’’ aspect leads to a successful MCA localization in all patients, with a constant depth of 59 ± 3 mm. Figure 1a shows a brain CT scan and the anatomical relationship between the MCA and sphenoid bone. The sphenoid bone is marked with white arrowheads and the petrous pyramid with black arrowheads. In Fig. 1b, the echographic butterfly wing shape is marked with the same black and white arrowheads, with the temporal bone apex in the middle (black arrow). The MCA lies on this ‘‘butterfly wing’’. The time to achieve a proper echographic image of both MCA was 50 ± 20 s. With our protocol, identification of the ‘‘butterfly wing’’ with echography allows a fast localization of the MCA in 100 % of the cases.

Arterial supply to the tibial tuberosity: involvement in patellar ligament transfer in children

PurposeThe aims were to study arterial blood supply of the tibial tuberosity, and to evaluate its remaining blood supply after patellar ligament transposition in children.MethodsThe anatomic study was carried out on 15 lower limbs after latex injection, and on two fetuses after diaphanization.ResultsTibial tuberosity was vascularized by an arterial network mainly supplied by anterior tibial recurrent artery. Other arteries from the popliteal artery or its branches were also involved in the tibial tuberosity blood supply.ConclusionsOur findings confirm the safety of transposition of patellar ligament in children due to dense arterial network supplying tibial tuberosity.