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UNLABELLED: The frequency of intramedullary tumors is 0.5 cases per year for 100,000 inhabitants. The study reported herein was a retrospective study conducted from January 1985 to September 2007. MATERIAL: Seventy-nine cases were distributed in the following manner: ependymomas, 38; astrocytomas, 22; oligodendrogliomas, four; gangliogliomas, two; hemangioblastomas, 10 (nine sporadic cases and one case of Von Hippel-Lindau disease); primitive melanoma, one; and intramedullary neurinomas, two. Three patients were lost to follow-up and 10 patients died. METHOD: All patients were explored using MRI and were operated using a microsurgical technique. Tumor removal was complete in the cases of ependymoma and hemangioblastoma and subtotal in the cases of astrocytoma. RESULTS: Ependymoma: 38 cases with three cases of ependymoblastoma. Mean age: 47 years (range, 17-74 years); 17 males and 21 females. Diagnostic delay: less than one year, 11; one year, 15 cases; two years, nine cases; three years, three cases. Seven recurrences with one 35 years after a prior removal. Localizations: cervical and cervicodorsal, 19; dorsal, ten; dorsolumbar, seven; holomedullary, one. Number of levels concerned: 5-12 (with the cysts associated). Mean follow-up was 10 years (range, two months to 35 years). Patients stabilized, 19; worse, six; improved, nine. Patients deceased: four, one by suicide, three cases of ependymoblastoma (survival, seven months). Astrocytomas: 22 cases, with 14 cases of astrocytoma, two pilocytic astrocytoma, four malignant astrocytoma, and two glioblastoma. Mean age: 44 years (range, 22-73 years); 14 males and eight females. Diagnostic delay: malignant tumors, one to nine months; low grades; three to six years (range, eight months to 25 years). Number of levels concerned: two to eight. Mean follow-up: seven years (range, six months to 10 years). Stabilized patients: 13; worse, five; deaths, four. Oligodendroglioma: four cases. Mean age: 58 years; two males and two females. Diagnostic delay: 10months. Localization: cervical, three; dorsal, one. Oligodendroglioma A, two; B, two. Results: two cases stabilized, one case with recurrence, and one patient deceased. Ganglioglioma: two. Both cases were associated with scoliosis. Recurrence in the eighth month and two years for the second case. One patient died. Hemangioblastoma: 10 cases, nine sporadic and one case of Von Hippel-Lindau disease. Nine cervical localizations, one on the medulla cone. Mean age: 45 years (range, 11-54 years); eight males and two females. Total removal in nine cases. One case of recurrence seven years after a prior surgery and operated a second time with no recurrence after 10 years of follow-up. Intramedullary neurinomas: two cases with a total removal and 15 years of follow-up. Primitive melanoma: one case with mediothoracic location. Treatment with surgery plus radiotherapy. Follow-up, seven years without recurrence. CONCLUSION: Total removal of the intramedullary tumors is a challenge. In cases of removal, the risk of worsening status is 18-19.5%. Subtotal or incomplete removal 27-40% risk of recurrence.

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The rupture of gravid uterus is a rare complication concerning less than one percent of the pregnant women involved in a motor vehicle accident. The authors report the case of a 39-year woman, gravida 4, referred for an uterine rupture with intrauterine fetal death at 24 weeks gestation, following a car crash. The surgical laparotomic exploration in emergency showed a wide fundal uterine tear with placental abruption. The placenta and the fetus were found in the abdominal cavity. A conservative surgical treatment could be realized. Principles of management, which must be quick and co-ordinated, are reminded.

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HIV-1 infects resting peripheral blood mononuclear cells (PBMCs) but remains inactive state until subsequent cell activation. We have demonstrated that the cross-linking of cell surface CD4 by gp120-anti-gp120 immune complexes or heat-inactivated HIV-1 (iHIV-1) is sufficient to trigger activation signals leading to virus reactivation (9). In this study, we demonstrate that NF-kappaB nuclear translocation and stimulation of virus production by iHIV-1 were strictly linked to the concentrations of viral proteins used as exogenous stimuli. Moreover, we further investigated the physiologic relevance of these observations. When submitted to an in vitro CD4 cross-linking by iHIV-1, PBMCs from HIV-1-infected patients were found to produce virus. This viral reactivation was associated with increased NF-kappaB nuclear translocation in patients' PBMCs. Additionally, virus reactivation in resting PBMCs infected in vitro with HIV-1 was found to be specifically induced by ligands of the CDR2-loop in domain 1 (D1) of CD4 (virus envelope and anti-CD4 monoclonal antibodies). In contrast, virus reactivation was not observed following CD4 oligomerization by antibodies that bind other epitopes in D1, including the D1/CDR3-loop. Finally, soluble CD4 (sCD4) prevented virus reactivation by D1/CDR2-loop ligands. Our results indicate that the signaling events initiated in PBMCs by oligomerization of CD4 at the D1/CDR2-loop can trigger HIV-1 upregulation in infected individuals.

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The present course on the anterior and antero-lateral surgical approach of the lower cervical spine was organized for the neurosurgery trainees by the French Speaking Neurosurgical Society, and was held during the winter meeting in December 1995. The aim of this course was to recall the basic technical principles of the microsurgical anterior cervical approach, and to discuss the main indications of this surgical treatment. Many theoretical points were strengthened by the author's personal experience and comments. In Part I, the technical bases of the different anterior or antero-lateral approaches were presented (1996, 42 : 105-122). In the present Part II, the main indications of the anterior surgical approach to the cervical disk or the vertebral body are detailed, and the requirement of a bone graft and/or an osteosynthesis are discussed with their consequences on the final results. Secondly, variants of the surgical technics in use in case of cervical spinal instability are commented. Then various approaches to the cervical spinal tumors and to the vertebral artery are detailed and commented. Lastly, general and specific complications of the anterior cervical approach are listed with their rate of occurrence, and their prevention and management are discussed.

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The anterior approach to the cervical spine is currently a worldwide traditional surgical technique used by neurosurgeons or orthopedists in the treatment of traumatic, degenerative or tumoral cervical spinal lesions. Many original rules of these techniques were raised by pioneers as R. Cloward and H. Verbiest, and are still valid. Advances in the surgical armentarium and in bio-materials markedly improved the original technique and subsequently improved the clinical results. The present course was organized for the neurosurgery trainees by the French Speaking Neurosurgical Society, and was helded during the winter meeting in December 1995. The aim of this course is to recall the basic technical principles of the microsurgical anterior cervical approach, and to discuss the main indications of this surgical treatment. Many theoretical points are strengthened by the author's personal experience and comments. Part I presents the different anterior or antero-lateral approaches which any surgeon involved in cervical spine surgery actually needs to know. Secondly, the materials and technical basis needed to achieve an interbody graft or fusion or fixation are described. Lastly, some practical applications are detailed as a microdiscectomy, a medial or lateral cervical spine decompression, and the use of acrylic plastic or prothesis for a cervical vertebral replacement.

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Intraoperative facial nerve monitoring has become an indispensable tool during cerebellopontine angle surgery. Ninety-seven patients underwent surgical removal of an acoustic neurinoma with the use of a pneumatic sensor monitoring between January 1, 1986, and December 31, 1990. In the early postoperative period, a normal or near-normal facial function (grades I and II) was achieved in 86% of the patients, a moderate dysfunction (grade III) was present in 7%, and a total or severe dysfunction (grades V or VI) was present in 6%. Normal function at 1 year was achieved in 90.5% of the patients, 4% were grade II, a moderate dysfunction (grade III) was present in 2%, and 3% showed a total or severe dysfunction (grade V and VI). The incidence of normal function decreased with tumor size, with an occurrence rate of 100%, 94%, and 91% in small, medium, and large tumors, respectively. In eight consecutive patients, all responses detected by the monitoring during the operation were collected and analyzed according to intraoperative events. Analysis of the results indicate that 95% of the 316 mechanically induced stimulations were of small or extremely small amplitude, and only 5% were of moderate amplitude. A medial-to-lateral strategy of dissection, preservation of the arachnoid veil over the facial nerve, a control by the monitoring of the amount of traction, and a more widespread use of sharp dissection were the major approaches to reduce surgical trauma during dissection.

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This report concerns 15 adults (nine men and six women) who experienced lumbar and sciatic pain associated with an unusual defect of the edges of the vertebral bodies together with a small bony ridge protruding into the spinal canal. This lesion was well demonstrated by computed tomography and easily differentiated from the posterior longitudinal ligament or herniated disc calcifications, as well as from posterior degenerative ridge osteophytes. This lesion looked like the so-called lumbar posterior marginal node. First described in adolescents, this entity was considered as a traumatic fracture of the posterior ring apophysis. Recently, identical cases were noted in young adults in the absence of previous trauma, which were a particular type of marginal cartilaginous node. In the cases reported here, the computed tomographic scans suggested several mechanisms of formation of the vertebral lesion: a variant of marginal cartilaginous nodes; traumatic avulsion; avulsion related to disc herniation; and fusion of the avulsed bony fragment with the vertebral body.

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This paper reports our experience about intraoperative facial nerve monitoring carried out in 97 patients operated on by a retrosigmoid approach. Intra-operative facial nerve monitoring was performed using a pneumatic sensor which transforms into acoustic signals contractions of facial muscles elicited by mechanical, electrical or thermal stimulations of facial nerve. Long term results showed that a normal facial function (grade I) was achieved in 90.5% of patients, 4 patients were grade II, 2 patients grade III, a total paralysis (grades V and VI) was persistent in 3 patients. Our experience with facial nerve monitoring suggests a modification of the strategy of dissection based upon a preservation of the arachnoid veil and a medial to lateral direction of dissection.

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The authors present three cases of paraganglioma located in the cauda equina. In all cases pre-operative diagnosis was neurinoma of the cauda equina and only the histology permitted correct identification. All were intradural extramedullary tumors and in two cases the presenting and dominant symptom was low back pain and sciatica. The remaining third case experimented a paraparesis with urinary and fecal incontinence. The follow-up (range of 4 months-4 years) after total excision was uneventful in two cases and showed in the third case with preoperative paraparesis, some persistent urinary incontinence (follow-up: 3 years) with good motor recovery. The light microscopic features were a Zellballen pattern of cells containing argyrophil granules. Electron microscopy was not performed. The most likely theory regarding the embryogenesis of cauda equina paragangliomas is that they arise from pre-existing paraganglia, possibly of the visceral-autonomic group. The prognosis after complete excision appears to be good. The literature is thoroughly reviewed.

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The surgical treatment of the primary spinal tumors is started after the analysis of the following data: --location of the tumor, --pathological identification after the biopsy examination, --staging of the lesion according to Enneking. In case of benign tumors it is possible to realize: a total resection by morcellement until healthy margins in case of chondroma or osteochondroma, intralesional excision until healthy borders in case of osteoid osteoma, total excision by partial anterior or posterior vertebrectomy (with previously embolization) according to the location (body or neural arch resection) in case of giant cells tumour or aneurysmal bone cyst. In case of malignant tumors, the total resection is an absolute goal when the feasability occurs (total vertebrectomy), in case of chordoma, chondrosarcoma and malignant giant cells tumours; the stabilization surgery is indicated without attempt of total tumor removal because others means are availables and/or accurates (radio and/or chemotherapy) in cases of Ewing's sarcoma, plasmocytoma and lymphoma.

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Tumors of the cranio-cervical junction can be surgically approached either anteriorly or posteriorly. The main anterior (transoral, transcervical or lateral) and posterior routes are described. Posterior approach is used for localization on the posterior arch and for anthrodesis. Anterior approach is proposed for extra-dural lesions of the anterior part of C1 and the foramen magnum.

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Three main techniques can be discussed for surgery of spinal tumor at the thoraco-lumbar level: posterior stabilization, partial vertebrectomy (lamina or body) and total vertebrectomy. Surgical principles to realize these 3 techniques are described according to the tumoral level: upper thoracic (C7-T3), midthoracic (T4-T10), thoraco-lumbar (T11-L2), upper lumbar (L2-L4) and lower lumber (L5-S1).

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This chapter incorporates 206 observations from the different neurosurgery units which replied to the questionnaires on primary tumours of the vertebral column. A homogeneous data bank, analysed and processed using the Excel database, was established by retranscribing each observation into 32 sections. The majority of the sample population (fig. 1) was male and included 42 observations of subjects under the age of 18 years, thereby constituting one of the largest series in this age range. The global histological distribution demonstrates a predominance of malignant tumors in the adult (65%) with no sexual bias. In children, malignant (19 cases) and benign (23 cases) tumours are more homogeneously distributed (fig. 3 and 4). The different histological types encountered are listed in table I in order of frequency. In order to make it easier to read the following tables, the numerical code given to each histological type is indicated in table II. Chordomas (code 14), which most authors classified among the malignant tumours, are situated in a transitional zone between benign tumours (from 1 to 13) and malignant tumours (from 15 to 37) on the various graphs. Histological distribution in adults (fig. 5) demonstrates the existence of two peaks in the malignant tumor zone: the highest peak correspond to the chordomas, the other to solitary myelomas. In children (fig. 6), distribution is different: the benign osteoblastoma and the aneurysmal bone cyst are the most common benign tumors, and the most common malignant tumor observed is Ewing's sarcoma. The different tumor sites along the spinal axis are reported in figures 7, 8, 9, 10 and 11.(ABSTRACT TRUNCATED AT 250 WORDS)

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Intraoperative Doppler exploration during neurosurgery was used during treatment of intracranial aneurysms, arteriovenous malformations (AVM) and cerebral revascularization by extra-intra cranial anastomosis (EICA). It was also employed to study behavior of cortical arteries under different conditions. During treatment of aneurysms, Doppler can show, prior to clipping, whether blood flow through. The flow is regular--spasm of supply artery provokes acceleration of blood rate. After clipping it is possible to evaluate whether artery is still permeable without stenosis or torsion. In AVM, Doppler detects direction of blood. Flow and, in case of intraoperative embolization, confirms good exclusion of angiomatous nidus. Flow rate in cortical arteries was determined to verify reality of operative trauma under automatic retractors used in standard surgery. In EICA, Doppler provides precise data on exact localization of cutaneous incision centered on superficial temporal artery (STA) (longitudinal incision) and identifies its parietal branch. The artery in the cortical vessels with the lowest flow rate can be selected. After EICA it is possible to identify whether the donor artery is under spasm from the proximal clamp and whether or not the anastomosis is patent. When functioning is correct it can be defined whether there exists a preferential direction or a regular laminar distribution in T. In tumoral pathology, Doppler serves to identify arteries enclosed in lesion and therefore whether conservation is essential.

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A case of aneurysmal bone cyst of the fifth cervical vertebra was unusual in that it occurred in a 35 year old man treated initially by radiotherapy (3,800 rads), within 3 years, worsening of clinical and radiologic signs led to a complete two-stage exeresis because of extension of lesion to body and posterior arch of C5. This male patient was 35 years old at diagnosis and 38 at time of surgery (respectively 1.2 and 2.5% of cases in the Hay series and 1.9% in the Ruiter series), this lesion affecting mainly age groups under 20 years. Aneurysmal bone cyst (ABC) constitutes 1.4% of primary bone tumors (Dahlin), and spinal localizations 3% (Biesecker), 14% (Reiter) or 20% (Tillman) of total ABC. The cervical lesion represents 13% (Reiter) or 22% (Hay) of spinal localizations, C5 being affected twice in the 17 cases reported by Ameli, and fills, according to Hay, 3.3% of all spinal column lesions and 15% of cervical lesions. Initial treatment applied in another center was by radiotherapy alone at the dose of 3,800 rads (the recommended dose-level in the literature being 20 to 30 Grays). Neither clinical nor radiologic improvement was reported. The recurrence rate after all types of treatment for ABC was 12.6%, and after radiotherapy alone was 11% in the Hay series, MacCarty reporting only one recurrence among 9 patients treated with irradiation alone.(ABSTRACT TRUNCATED AT 250 WORDS)

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Between 1981 and 1984, 44 patients underwent acoustic neurinoma removal by a posterior cranial fossa approach with an attempt to preserve hearing. Seven tumors were small (less than 20 mm), 28 were medium (20 to 40 mm), and 9 were large (greater than 40 mm). Preoperatively, 4 patients had normal hearing, 15 had serviceable hearing, 10 had poor hearing, and 15 had no hearing. Postoperative hearing was preserved in 11 cases. Of the 19 patients with normal or serviceable hearing, 8 (42%) had serviceable hearing preserved postoperatively. Hearing preservation was achieved in 43% of the patients with small tumors, 25% of those with medium tumors, and 11% of those with large tumors. This study confirms the value of the suboccipital approach, which can be used in an attempt to preserve hearing whenever the patient has serviceable hearing preoperatively and whenever the tumor size makes it feasible.

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Between 1981 and 1984, 44 patients underwent acoustic neuroma removal by a posterior cranial fossa approach in an attempt to preserve hearing. 7 tumors were small (less than 20 mm), 28 were medium (20 to 40 mm) and 9 large (greater than 40 mm). Of these 44 patients, 4 had normal hearing preoperatively, 15 had serviceable hearing, 10 poor hearing and 15 no hearing. Postoperative hearing was preserved in 11 cases. Of the 19 patients with normal or serviceable hearing, 8 (42%) had serviceable hearing preserved postoperatively. Hearing preservation was achieved in 43% of the cases of small tumors, 25% of those medium tumors and 11% with large tumors. This study confirms the value of the suboccipital approach, which can be used in an attempt to preserve hearing whenever the patient has serviceable hearing preoperatively and whenever the tumor size makes in feasible.

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A 50-year-old patient developed a left temporal fibrochondrosarcoma 27 years after radiation therapy for a suspected pituitary adenoma. The long latency between the irradiation and the development of the sarcoma and the histological nature of the tumour are unusual features for a malignant radiation-induced intracranial tumour. The histogenesis of fibrochondrosarcoma of the brain is discussed.

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The authors have seen 13 cases of fracture-separation of the articular processes in the lower cervical spine with horizontal facets. This type of lesion was caused by trauma in hyperextension, compression and rotation. The mechanism appears to be similar to that of dislocations in hyperextension. Four types are defined according to the displacement and the association of disc and ligamentous lesions. Most of the cases were unstable and had to be fixed surgically. Eleven cases were treated in this way, twice by a posterior approach, 6 times by an anterior approach and 3 times by a combined anterior and posterior approach.

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