Mono-segmental percutaneous screw fixation in the management of AoSpine thoracolumbar type B fracture in patients with ankylosing spondylitis: A new treatment

PURPOSE

To assess the viability and effectiveness of mono-segmental percutaneous screw fixation in the treatment of unstable type B thoracolumbar fracture due to ankylosing spondylitis.

METHODS

We report here all 40 patients treated by mono-segmental screw fixation in this indication, between January 2018 and January 2022, with follow-up at 3 and 9 months. Study variables comprised operating time, length of stay, fusion, stabilization quality, and peri-operative morbidity and mortality.

RESULTS

One patient showed early displacement of rods caused by technical error. None of the others showed secondary displacement of rods or screws. Mean age was 73 years (range 18-93), mean hospital stay 4.8 days (range 2-15), mean operative time 52minutes (range 26-95minutes) and mean estimated blood loss 40ml. There were 2 deaths caused by intensive care unit complications. All patients except those in intensive care were verticalized within 24hours after surgery. Parker score was unchanged for each patient before and after surgery and during follow-up.

CONCLUSION

Mono-segmental percutaneous screw fixation in the treatment of unstable type B thoracolumbar fracture due to ankylosing spondylitis was safe and effective. This study showed that this surgery reduced length of hospital stay, operative time, blood loss and complications compared to open or extended percutaneous surgery, and allowed fast rehabilitation in this vulnerable population.

Could conventionally fractionated radiation therapy coupled with stereotactic body radiation therapy improve local control in bone oligometastases?

PURPOSE

To describe clinical outcomes of stereotactic body radiation therapy (SBRT) applied alone or as a boost after a conventionally fractionated radiation therapy (CFRT) for the treatment of bone oligometastases.

MATERIAL AND METHODS

This retrospective cohort study included patients treated with SBRT from January 2007 to December 2015 in the Institut de cancérologie de Lorraine in France. The inclusion criteria involved adults treated with SBRT for one to three bone metastases from a histological proven solid tumor and a primary tumor treated, an Eastern Cooperative Oncology Group (ECOG) score inferior or equal to 2. Local control (LC), overall survival (OS), progression free survival (PFS), bone progression incidence (BPI), skeletal related events free survival (SRE-FS), toxicity and pain response were evaluated.

RESULTS

Forty-six patients and 52 bone metastases were treated. Twenty-three metastases (44.2%) received SBRT alone mainly for non-spine metastases and 29 (55.8%) a combination of CFRT and SBRT mainly for spine metastases. The median follow-up time was 22months (range: 4-89months). Five local failures (9.6%) were observed and the cumulative incidences of local recurrence at 1 and 2years respectively were 4.4% and 8% with a median time of local recurrence of 17months (range: 4-36months). The one- and two-years OS were 90.8% and 87.4%. Visceral metastasis (HR: 3.40, 95% confidence interval [1.10-10.50]) and a time from primary diagnosis (TPD)>30months (HR: 0.22 [0.06-0.82]) were independent prognostic factors of OS. The 1 and 2years PFS were 66.8% and 30.9% with a median PFS time of 18months [13-24]. The one- and two-years BPI were 27.7% and 55.3%. In multivariate analysis, unfavorable histology was associated with worse BPI (HR: 3.19 [1.32-7.76]). The SRE-FS was 93.3% and 78.5% % at 1 and 2years. The overall response rate for pain was 75% in the evaluable patients (9/12). No grade≥3 toxicity nor especially no radiation induced myelopathy (RIM), two patients developed asymptomatic vertebral compression fractures.

CONCLUSION

The sole use of SBRT or its association with CFRT is an efficient and well-tolerated treatment that allows high LC for bone oligometastases.

[Decision-making regarding treatment limitation after severe traumatic brain injury: A survey of French neurosurgeons]

BACKGROUND/INTRODUCTION

In France, the law defines and prohibits "unreasonable obstinacy" and provides a framework for the subsequent decision to limit or to cease treatment. It also gives the person the right to appoint a trusted person and to draft advance directives regarding this issue. There have been few studies of neurosurgeons' involvement in decision-making in regard to treatment limitation after severe traumatic brain injury.

AIM OF THE STUDY

The first aim of the study was to assess French neurosurgeons' adherence to the law on patients' rights and end of life which governs such decision-making. The second aim was to assess the prognostic and decision-making criteria applied by neurosurgeons.

METHODS

A declarative practice and opinion survey, using a self-administered questionnaire emailed to all practising neurosurgeons members of the French Society of Neurosurgery, was conducted from April to June 2016.

RESULTS

Of the 197 neurosurgeons contacted, 62 filled in the questionnaire. Discussions regarding treatment limitation were in all cases collegial, as required under the law, and the patient's neurosurgeon was always involved. The trusted person and/or family were always informed and consulted, but their opinions were not consistently taken into account. Advance directives were most often lacking (68%) [56; 80] or inappropriate (27%) [16; 38]. The most frequently used prognostic criteria were clinical parameters, intracranial pressure, cerebral perfusion pressure, and imaging, with significant interindividual variation in their use. The main decision-making criteria were foreseeable disability, expected future quality of life, and age.

CONCLUSIONS

Neurosurgeons showed good compliance with legal requirements, except in the matter of calling for the opinion of an external consultant. Furthermore, this survey confirmed variability in the use of prognosis predictors, and the need for further clinical research so as to achieve more-standardized practices to minimise the subjectivity in decision-making.

[Intracranial hemorrhage and oral anticoagulants of patients treated between 2011 and 2013 at the Nancy Regional University Hospital]

OBJECTIVE

To perform a descriptive analysis of intracranial hemorrhages of patients treated with an antivitamin K (fluindione, acenocoumarol or warfarin) or a direct oral anticoagulant (dabigatran, rivaroxaban or apixaban) at the Nancy Regional University Hospital.

MATERIAL AND METHOD

The study period was from January 2011 to December 2013 and the computerized data (Programme de Médicalisation des Systèmes d'Information) of our hospital was accessed to identify the patients. Clinical data were obtained from the patients' files. Regional healthcare system was queried for reimbursement data.

RESULTS

Among the 157 identified cases of intracranial hemorrhage, 153 were related to antivitamin K, primarily fluindione (n=127), and only 4 to a direct oral anticoagulant (3 dabigatran and 1 rivaroxaban). During the same period, regional data indicated that 65,345 patients had had at least one reimbursement of antivitamin K and 20,983 patients one reimbursement of an oral direct anticoagulant. In our series, the most frequent intracranial hemorrhages were subdural hematoma (chronic in 65 cases, acute in 50 cases) and intraparenchymal hemorrhage (20 cases). The global mortality rate was 20.2% but varied with the site of hemorrhage. In multivariate analysis, the two risk factors of fatal outcome were coma on admission (OR 6.2; 95%CI: 2.6-15.0) and a history of previous intracranial hemorrhage (OR 13,4; 95% CI: 1,6-114,9).

CONCLUSION

During the 2011-2013 period, antivitamin K, especially fluindione, was the most frequently involved anticoagulants in intracranial hemorrhages with hospitalization at our Regional University Hospital. Coma on admission and a history of previous intracranial hemorrhage were the two main risk factors for fatal outcome.

Focal electrical intracerebral stimulation of a face-sensitive area causes transient prosopagnosia

Face perception is subtended by a large set of areas in the human ventral occipito-temporal cortex. However, the role of these areas and their importance for face recognition remain largely unclear. Here we report a case of transient selective impairment in face recognition (prosopagnosia) induced by focal electrical intracerebral stimulation of the right inferior occipital gyrus. This area presents with typical face-sensitivity as evidenced by functional neuroimaging right occipital face area (OFA). A face-sensitive intracerebral N170 was also recorded in this area, supporting its contribution as a source of the well-known N170 component typically recorded on the scalp. Altogether, these observations indicate that face recognition can be selectively impaired by local disruption of a single face-sensitive area of the network subtending this function, the right OFA.

Drug-resistant temporal lobe epilepsy is associated with postural control abnormalities

Epilepsy is responsible for falls that are not systematically associated with seizures and that therefore suggest postural impairment. There are very few studies of postural control in patients with epilepsy and none of them focus on temporal lobe epilepsy (TLE), although part of the vestibular cortex is located in the temporal cortex. The aim of this study was to evaluate the characteristics of postural control in a homogeneous population of patients with complex partial TLE. Twenty-six patients with epilepsy and 26 age-matched healthy controls underwent a sensory organization test combining six conditions, with and without sensory conflicting situations. Patients with epilepsy displayed poorer postural control, especially in situations where vestibular information is necessary to control balance. In addition to potential antiepileptic drug side effects, vestibular dysfunction could be related to the temporal pathology. Our study allows for a better understanding of the mechanism underlying falls in this population of patients.

[Chronic or subacute orbital inflammation (inflammatory pseudotumors)]

Subacute or chronic orbital inflammation can cause proptosis or painful myositis. It is either primitive or secondary to systemic diseases such as polyarteritis nodosa or Wegener's granulomatosis. Corticosteroids are the basic treatment, allowing biopsy and thus anatomopathological diagnosis. Some authors advocate surgery.

[Orbital metastasis]

Orbital metastases are uncommon, accounting for 4% of all adult orbital tumors. The mean age at time of presentation is 60 years. The primary tumor is most often a carcinoma involving the breast (40%), lung (11%), or prostate (8%). Proptosis is the main clinical sign at diagnosis and is often associated with visual impairment, pain or ptosis. Imaging features are not specific; nevertheless, an enhanced extraconal tumor with osteolysis suggests the diagnosis. From a pathological point of view, there are no differences between the metastasis and the primary tumor. Regarding the average survival, the gold standard treatment remains radiotherapy.

[Hematopoietic orbital tumors]

Non Hodgkin B cell lymphomas account for most hematopoietic orbital tumors and 10 % of all orbital tumors. Typically, orbital lymphomas present as salmon-pink, painless, and slow growing conjunctival tumors affecting patients over 50 years of age. Therapeutic orientation is guided by biopsy.

[Histiocytic disorders with orbital involvement]

The eosinophilic granuloma of bone is the most common type of histiocytic disorder involving the orbital area. Imaging data typically show bony defects with an intra-orbital soft-tissue extension. Surgical debulking is most often required. Rosai-Dorfman disease is commonly associated with uni- or bilateral orbital locations. The other histiocytic disorders are very rare, but some have a poor prognosis such as Erdheim-Chester disease.

Thalamic ependymal cyst presenting with tremor

CASE REPORT

We report the case of a 6-year-old boy presenting with intention tremor. CT and MR scanning showed a large thalamic cyst.

TREATMENT

Stereotactic tapping of this cyst was carried out as the first step in surgical management. Following drainage of the cyst the tremor disappeared, but recurred 18 months later. Repeat MRI showed that the thalamic cyst had refilled. As the initial tapping of the cyst had resulted in effective but only transient clinical improvement a cysto-peritoneal shunting procedure was performed.

OUTCOME

The clinical symptoms again disappeared and the child has now remained tremor free for 3 years.

Bilateral subthalamic nucleus stimulation improves balance control in Parkinson's disease

BACKGROUND

Parkinson's disease (PD), the most common basal ganglia degenerative disease, affects balance control, especially when patients change balance strategy during postural tasks. Bilateral chronic stimulation of the subthalamic nucleus (STN) is therapeutically useful in advanced PD, and reduces the motor signs of patients. Nevertheless, the effects of STN stimulation on postural control are still debatable.

AIMS

To assess the impact of bilateral STN stimulation on balance control in PD and to determine how basal ganglia related sensorimotor modifications act on neurosensorial organisation of balance and motor postural programming.

METHODS

Twelve subjects aged 45-70 years underwent unified Parkinson's disease rating scale motor (part III) clinical tests, static and dynamic posturography, including sensory organisation and adaptation tests, shortly before and six months after bilateral implantation of electrodes into the STN.

RESULTS

The postoperative static test showed an improvement in postural control precision both in eyes open and eyes closed conditions. The dynamic test highlighted the decreased number of falls and the ability of the patients to develop more appropriate sensorimotor strategies when stimulated. The sensory organisation test showed an improvement of equilibrium score and, thus, a better resolution of sensorial conflicts.

CONCLUSIONS

STN stimulation allowed a reduction in rigidity and therefore an improvement in the ability to use muscular proprioception as reliable information, resulting in vestibulo-proprioceptive conflict suppression. STN stimulation has a synergistic effect with levodopa for postural control. Accordingly, non-dopaminergic pathways could be involved in postural regulation and STN stimulation may influence the functioning of these pathways.