R. Seizeur

Retrospective study of 19 patients with intramedullary spinal cord metastasis.

OBJECTnIntramedullary spinal cord metastasis (ISCM) is a rare but devastating complication of cancer. Due to both widespread MRI availability and longer survival of cancer patients, the probability of discovering an ISCM during the course of the disease has increased and raised issues regarding the management of these patients, and particularly the place of surgery. In this study, we assess predictive factors for surgical outcome and survival.nnnPATIENTS AND METHODSnWe retrospectively reviewed a series of 19 patients consecutively admitted in our institution from 1993 to 2006 for ISCM, representing the second largest series published in the literature. MRI was performed on all patients. Thirteen underwent microsurgical excision of ISCM. Functional outcome was evaluated and factors influencing survival were statistically analyzed.nnnRESULTSnMedian survival was statistically longer when surgery was performed (7.4 vs. 2.6 months). Preoperative neurological status, nature of primary cancer, presence of systemic and/or CNS metastases influenced survival, but differences were without statistical significance. Neurological status improved in 58% (11/19) of operated patients.nnnCONCLUSIONSnOptimal management of patients with ISCM is difficult due to the wide variety of clinical situations and the lack of controlled studies on the results of different therapeutic options. Diagnosis should be made as early as possible and surgical resection should be considered as the primary treatment whenever feasible, particularly in the case of rapidly progressive neurological deficits and when a clear cleavage plane exists. Our study shows that surgery could result in both increased survival rate and significant improvement of neurological function.

Spontaneous resolution of arachnoid cysts: review and features of an unusual case

SummaryMost intra-cranial arachnoid cysts are quiescent and remain asymptomatic throughout life. Within the natural course of arachnoid cyst evolution, spontaneous resolution has been known to occur rarely, but its frequency is probably underestimated due to lack of systematic detection and long-term observation.We illustrate the spontaneous regression of arachnoid cysts with a patient which was conjointly diagnosed with an arachnoid cyst and a post-traumatic epidural haematoma. Cyst regression was observed 16 months later, upon examination following a second benign cranial trauma. Mechanisms underlying the resolution of the arachnoid cyst are discussed.

Acute non-traumatic spinal subdural haematoma: An unusual aetiology

We report an unusual case of a spinal subdural haematoma associated with a ruptured spinal aneurysm. The delayed diagnosis or misdiagnosis of this rare entity can have disastrous consequences. We discuss various possible aetiologies and its association with spinal aneurysms.

Management of ACTH-secreting supradiaphragmatic adenomas

Supradiaphragmatic adrenocorticotropic hormone (ACTH) secreting pituitary adenomas are exceptionally encountered (14 cases previously described) and raise issues concerning their nosology and management. If surgery is the treatment of choice, the nature of surgical approach (craniotomy, transsphenoidal approach) remains controversial. To illustrate this issue, we presented two cases of supradiaphragmatic ACTH secreting pituitary adenomas successfully excised via a subfrontal approach. Both patients were female (20 and 41 years) and had a typical Cushings syndrome. MRI revealed, in both cases, a suprasellar mass in contact with the pars tuberalis of the pituitary. In the first case, the patient underwent initially a transsphenoidal approach with negative exploration and subsequent partial hypophysectomy. One year later, the patient was operated on again via a subfrontal approach, allowing excision of a supradiaphragmatic adenoma and a complete cure of Cushings disease. In the second case, the patient underwent initially a subfrontal approach and was definitely cured. In both cases, the diaphragma sellae was found to be intact and the pituitary stalk could be preserved. Postoperative MRI demonstrated a clearly visible intact pituitary stalk in conjunction with normal aspect of the pituitary. Supradiaphragmatic pituitary adenomas are most likely adenomas of the pituitary stalk with extra-axial development. Surgery remains the treatment of choice. Should the superior approach be preferred, the transsphenoidal-transtuberculum sellae approach may represent a viable alternative when performed by a well-trained surgical team. Surgery may be difficult, and drawbacks are non negligible, particularly in elderly patients. In these cases, stereotactic radiosurgery should receive more consideration.

Arthrodèses lombaires par voie antérieure dans le traitement des lombalgies et lomboradiculalgies récidivantes postchirurgicales : étude rétrospective de 46 cas ☆

BACKGROUND AND PURPOSEnAnterior lumbar interbody fusion (ALIF) has gained popularity for the treatment of degenerative disease of the lumbar spine. In this report, we present our experience with the ALIF procedure for treatment of failed back surgery syndrome following lumbar discectomy in a noncontrolled retrospective cohort.nnnMETHODSnFrom 1st January to 31 December 2005, we performed an ALIF in 46 patients presenting with low back pain with or without radiculopathy. All patients had a history of intractable pain resistant to conventional medical treatment and failed posterior lumbar surgery. Clinical and radiological outcomes were recorded. Neurological pain and functional outcomes were measured postoperatively (at 1, 3 and 12 months). Operative data, intraoperative complications, and the fusion rate were recorded.nnnRESULTSnForty-six patients with a preoperative diagnosis of failed back surgery syndrome underwent ALIF. The mean follow-up was 21 months. Back pain and leg pain completely disappeared in 60.9% of patients, decreased but required occasional medication in 28.3%, and 10.8% declared no benefit from ALIF surgery.nnnCONCLUSIONnOn the basis of our results, we found ALIF to be a safe and effective procedure for the treatment of failed back surgery syndrome.

Hémangioblastome « en sablier » de la huitième racine cervicale

Resume Les hemangioblastomes radiculaires cervicaux « en sablier » avec une composante a la fois extra- et intra-durale sont exceptionnellement rencontres puisqu’un seul cas a ete decrit dans la litterature. Nous rapportons une seconde observation d’un patient de 33 ans ayant une tumeur cervicale inferieure « en sablier », responsable d’une nevralgie cervico-brachiale depuis 6 mois. L’aspect en IRM evoquait un schwannome et l’angiographie du tronc thyro-bicervico-scapulaire montrait une hyper-vascularisation non specifique, si bien que le diagnostic d’hemangioblastome n’a ete precise que par l’examen histologique.L’exerese complete de cette lesion tres vascularisee peut necessiter un abord chirurgical combine (anterieur et posterieur), ainsi qu’une embolisation pre-operatoire.

Intérêt de l’approche sous frontale controlatérale pour l’exérèse des méningiomes du tubercule de la selle

tion visuelle a été subtotale dans 4 cas et partielle dans le dernier cas où le degré d’atrophie était avancé. La voie nasale et l’endoscopie donnent un accès aisé au canal optique et au compartiment médial orbitaire autorisant des décompressions efficaces pour les méningiomes de cette région. La décompression du canal optique nous semble une option à discuter dans les cas de baisse d’acuité visuelle progressive en l’absence d’atrophie pour tenter de mieux préserver la fonction visuelle avant discussion de radiothérapie ou en préalable à une chirurgie d’exérèse tumorale.

Traitement des chondrosarcomes de la base du crâne

BACKGROUND AND PURPOSEnSkull base chondrosarcomas are rare. Gross total removal is the treatment of choice, but can be difficult depending on the closeness of noble structures. Proton beam therapy can be associated in most cases.nnnMETHODSnRetrospective study of five cases treated in 13 years and study of the literature.nnnRESULTSnMedian age of patients was 34 years [28-46]. Cranial nerve palsy was the common clinical presentation. Tumor location was variable but always off midline. Treatment was surgical in all patients with a maximal resection and proton beam therapy associated for two cases. Surgical complications were rare with cranial nerve palsy as the main side effect. Outcomes were good with a median follow-up of 12.4 years [4.3-16.2].nnnDISCUSSIONnThe review of the literature showed that chondrosarcomas of skull base are rare. The best outcome is achieved with total surgical resection. Medical imaging can only give clues to the diagnosis. Pathology is required to obtain a precise immunohistochemistry diagnosis. Multidisciplinary treatment using proton beam therapy and surgical removal enables a good local control (90-100%) at 5 years with good quality-of-life. It is difficult to determine how many cases have been published (around 220 cases in the literature) since many surgical or radiotherapy series included the same patients.

Aplasia cutis congenita du vertex avec atteinte osseuse : synthèse sur la prise en charge et revue de la littérature

Aplasia cutis congenita (ACC) of the vertex is a rare and potentially severe malformation. We report the case of a newborn boy presenting ACC of the vertex with a skull defect. Surgical closure of the skin was performed 5xa0days following birth, which allowed skin healing. The skull spontaneously remodelled perfectly 6xa0months later. When associated with skull defect, this rare malformation characterized by the absence of skin carries the risk of severe complications such as rupture of the superior sagittal sinus or infections. Based on a review of the literature, we purpose an overview of the medical and surgical management of vertex ACC, which depends on the size of the skin defect and the presence of a skull defect.

Hémangiome capillaire ethmoïdal : Cas clinique et revue de la littérature

Resume Nous rapportons l’observation exceptionnelle d’un homme de 38 ans ayant un hemangiome capillaire de siege exclusivement ethmoidal, dont l’exerese complete a pu etre realisee par une double voie d’abord, haute et basse.Les hemangiomes capillaires sont des tumeurs vasculaires, benignes et rares, qui interessent surtout la peau de la tete et du cou, ainsi que les muqueuses orale et nasale. Aucune atteinte ethmoidale pure n’a ete rapportee dans la litterature. Le traitement de choix est chirurgical et doit assurer l’exerese complete de la lesion. Le pronostic est alors bon et le risque de recidive est faible.