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The development of new percutaneous treatment techniques using a balloon for the reduction and cement for the stabilization for tibial plateau fractures (TPF) are promising. The biomechanical changes brought by the cement in the periarticular fracture are unknown. The objective of this study was to provide elements of understanding of the bone behavior in an epiphyseal fracture treated with cementoplasty and to define the modifications brought about by the presence of this cement in the bone from both an architectural and biomechanical point of view. In vitro animal experimentation was conducted. Bones samples were prepared with a cavity created with or without cancellous compaction, aided by balloon expansion following the same protocol as in the treatment of TPF. A uniaxial compression test was performed with various speeds and by using Heaviside Digital Image Correlation to measure mechanical fields. Preliminary finite element models were constructed with various boundary conditions to be compared to our experimental results. The analysis of the images permits us to obtain a representative load vs. time response, the displacement fields, and the strain distribution for crack initiation for each sample. Microcracks and discontinuity began very early at the interface bone/cement. Even when the global behavior was linear, microcracks already happened. There was no strain inside the cement. The finite element model that matched our experiments had no link between the two materials. In this work, the use of a novel correlation process highlighted the biomechanical role of the cement inside the bone. This demonstrated that there is no load transfer between bone and cement. After the surgery, the cement behaves like a rigid body inside the cancellous bone (same as a screw or plate). The cement provides good reduction and primary stabilization (mini-invasive approach and good stress distribution), permitting the patient to undergo rehabilitation with active and passive mobilization, but no weight-bearing should be authorized while the cortical bone is not consolidated or stabilized.
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INTRODUCTION: Discogenic lumbosciatica is a common disorder in patients between 30 and 40 years old. Because of the frequency and socio-professional impact of this entity, it represents a real public health problem. DiscoGel® is a class III medical device used for nucleolysis to avoid discectomy. The goal of this study was to evaluate the effectiveness of this treatment in patients with discogenic lumbosciatica following unsuccessful conservative medical treatment. MATERIALS AND METHODS: This is a retrospective, single-center study including 25 patients who were treated with DiscoGel® between 2010 and 2011 at Niort Hospital, France. The severity of lumbar and radicular pain was assessed by a verbal numeric scale (VNS) and patient satisfaction. Patients were classified as successes or failures. RESULTS: Treatment was found to reduce the severity of lumbar pain in 73% and of radicular pain in 80% of patients in the success group. Treatment was a failure in 64% of patients. A comparison of the two groups showed that a preoperative MODIC 2 MRI signal of the adjacent vertebral end plate was significantly associated with treatment failure (Chi(2)=8572, P < 0.01). DISCUSSION: The VNS for lumbar pain and radicular pain decreased in 42% and 50% of patients respectively after the use of DiscoGel®. In our series, DiscoGel® treatment was unsuccessful for discogenic lumbosciatica in 16 patients. These results do not support others in the literature. A lack of statistical power could partly explain these results. The most important result of this study is found in the subgroup analysis which suggests that indications for DiscoGel® treatment could be modified in the future in relation to preoperative imaging data. LEVEL OF EVIDENCE: 4.
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Geles , Quimiólisis del Disco Intervertebral/instrumentación , Dolor de la Región Lumbar/terapia , Vértebras Lumbares , Ciática/terapia , Adulto , Etanol/administración & dosificación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Satisfacción del Paciente , Estudios Retrospectivos , Tungsteno , Adulto JovenRESUMEN
Sarcoidosis is a multisystemic disease which involves the nervous system in 5 to 15 p.cent. Neurosarcoidosis without signs of systemic disease is rare and may be difficult to diagnose. We report a case of a 61 year-old patient with a pseudotumoral neurosarcoidosis and along evolution of 25 years without systemic signs. In such cases, histological analysis is rewarding.
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Encefalopatías/diagnóstico , Sarcoidosis/diagnóstico , Corticoesteroides/uso terapéutico , Antiinflamatorios/uso terapéutico , Encefalopatías/líquido cefalorraquídeo , Encefalopatías/complicaciones , Encefalopatías/patología , Neoplasias Encefálicas/diagnóstico , Medios de Contraste , Diagnóstico Diferencial , Femenino , Gadolinio , Cefalea/etiología , Humanos , Imagen por Resonancia Magnética , Meningitis/diagnóstico , Persona de Mediana Edad , Papiledema/etiología , Recurrencia , Sarcoidosis/líquido cefalorraquídeo , Sarcoidosis/complicaciones , Sarcoidosis/patología , Esteroides , Tuberculosis del Sistema Nervioso Central/diagnósticoRESUMEN
Two cases of massive erosive skull base sphenoid mucocele are reported. Even if intra-sphenoid mucoceles are an ENT pathology, when extensive they become of neurosurgical interest. An endoscopic minimally invasive procedure was performed in both cases with an excellent outcome. Patient 1 presented with several years of retro-orbital bilateral pain and several months of purulent pharyngeal leak. CT scan and MRI imaging showed an extensive erosive intra-sphenoid mass, with peripheral contrast enhancement. Patient 2 was referred because of several months of frontal headache and decreased left visual acuity. A wide intra-sphenoid mass was evident at CT scan and MRI. This mass included an anterior compartment, hyperintense on both T (1)- and T (2)-weighted images, and a posterior part, hypointense on T (1)- and hyperintense on T (2)-weighted images. A pure endoscopic endonasal one nostril pure procedure was performed in both cases. Endoscopic technique has been shown to be an easy and minimally invasive procedure. It should be the treatment of choice in case of invasive skull base mucocele in order to avoid blind damage of vasculo-nervous structures which are not protected by the bone, extensively eroded by the lesion.
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Mucocele/cirugía , Cavidad Nasal/cirugía , Neuroendoscopía , Neoplasias de la Base del Cráneo/cirugía , Hueso Esfenoides/cirugía , Adulto , Anciano , Humanos , Masculino , Mucocele/patología , Invasividad Neoplásica , Neoplasias de la Base del Cráneo/patología , Hueso Esfenoides/patologíaRESUMEN
BACKGROUND AND PURPOSE: The direct transnasal approach is a less invasive approach to the sella turcica and represents an alternative to the sublabial transsphenoidal approach with minor oro-nasal complications. In this study, we describe this approach with emphasis on post-operative course. METHODS: We studied retrospectively 60 patients operated on consecutively by a transnasal approach between January 1996 and December 2000. RESULTS: There were 47 macroadenomas, 9 microadenomas and 4 non-adenomatous pathologies. Despite its narrowness, the transnasal approach was possible in all cases and allowed tumor removal as satisfactory as with the sublabial approach. Eight patients had complications not directly related to the approach: 1 death (meningitis with brain stem ischemia), 3 pituitary fossa hematomas, 4 rhinorrheas and 2 meningitis. Seven patients had complications related to the approach: 2 nasal obstructions, 1 nasal dryness, 2 sinusitises and 2 hyposmias. All these local complications were transitory and disappeared within 3 months. CONCLUSIONS: In our experience, the direct transnasal approach is safe, quick and less invasive than the sublabial approach.
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Adenoma/cirugía , Cavidad Nasal/cirugía , Procedimientos Neuroquirúrgicos/métodos , Neoplasias Hipofisarias/cirugía , Silla Turca/cirugía , Adenoma/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Cavidad Nasal/anatomía & histología , Procedimientos Neuroquirúrgicos/efectos adversos , Neoplasias Hipofisarias/patología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/patología , Estudios Retrospectivos , Instrumentos QuirúrgicosRESUMEN
BACKGROUND AND PURPOSE: By definition, image-guided neuroendoscopy is a connection between a neuroendoscope and a neuronavigational system creating a computer-guided instrument. Our objective was to adapt our rigid endoscope with our neuronavigation system to perform computer-guided endoscopy. METHODS AND RESULTS: The rigid neuroendoscope, equipped with light emitting diodes, was connected to the work station. We report our early results with this device in 17 patients: 8 ventriculocisternostomies, 5 ventriculocisternostomies with biopsies of tumors of the posterior part of the third ventricule, 4 biopsies or tumor removal like colloid cysts. No technical complications were encountered. CONCLUSIONS: The development of image-guided neuroendoscopy has modified our approach to neuroendoscopy because the surgical procedure is facilitated. The use of fluoroscopy becomes unnecessary. The surgeon can choose, independent of the preestablish surgical technique, the entry point, the target and, of course, the optimal trajectory. The technique is adaptable to the individual anatomy of each patient, the location and the nature of the target. It is an undeniably useful teaching tool and represents a real progress in minimally invasive neurosurgery.
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Encéfalo/patología , Endoscopía/métodos , Procedimientos Neuroquirúrgicos/métodos , Adulto , Anciano , Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/patología , Neoplasias Encefálicas/cirugía , Quistes/cirugía , Endoscopios , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador , Masculino , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos/instrumentación , Estudios RetrospectivosRESUMEN
Most ruptured cervical discs are operated on by an anterolateral approach. The posterior approach is an older procedure, nowadays underused because it was associated with a high morbidity, especially in terms of medullary complications. However, posterior approach has evolved in posterolateral route, which is not so devastating and has a very low morbidity rate. It gives excellent functional results when surgery is dedicated to monoradiculopathy from soft posterolateral cervical hernias. It seems appropriate to consider this surgical route as an alternative to anterolateral surgery in these very selected cases. The authors describe and comment the technique.
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Vértebras Cervicales/cirugía , Discectomía/métodos , Desplazamiento del Disco Intervertebral/cirugía , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Rotura EspontáneaRESUMEN
This paper reports on a series of 101 pituitary region operations performed using image guidance technology in the Department of Neurosurgery, Frenchay hospital, Bristol, UK between 1992-1997. The cases form part of an overall series of image guided surgery of 1,112 cases performed during that time. The systems used were the ISG/Elekta Viewing Wand and the Sofamor Danek StealthStation. Thirty-five tumors had a diameter of > 2.5 cm and 12 > 5 cm. The clinical indications for surgery were: visual failure (n = 47), acromegaly (n = 22). Cushing syndrome (n = 6), hyperprolactinemia (n = 1), hyposecretion syndromes (n = 8), raised intracranial pressure/CSF leak (n = 13). Three cases were operated on because of radiological evidence of tumor progression without symptoms. Eighty-five patients had skull base procedures (56 transnasal routes, 16 transsphenoidal approaches, 13 sphenoid fenestrations), 16 underwent craniotomy. Operating times and postoperative bed stay were shortest the more minimally invasive the procedure. Sixty-eight percent of patients presenting with visual failure improved postoperatively. Surgery produced biochemical "cure" in 41% of patients with hypersecretion syndromes. Fifty percent of patients with hypopituitary syndromes improved endocrinologically postoperatively. Twenty-five complications were noted: 9 rhinorrheas, 5 diabetes insipidus, 3 postoperative epilepsies, 3 induced visual deteriorations and pituitary insufficiency. There were 2 deaths. Image guidance technology is applicable to pituitary surgery, particularly in four situations: i) orientation in difficult skull base approaches e.g. reoperations, paediatric cases, non pneumatised sphenoid, microadenomas, carotid arteries medially placed, ii) in craniotomies to customize the surgical approach, locate different parts of a tumor and identify critical anatomy related to the tumor, iii) in the planning and execution of minimally invasive approaches to the pituitary fossa (sphenoid fenestration, transnasal approach), iii) endoscopy.
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Procesamiento de Imagen Asistido por Computador , Procedimientos Neuroquirúrgicos/métodos , Enfermedades de la Hipófisis/cirugía , Hipófisis/cirugía , Adenoma/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Craneotomía , Femenino , Humanos , Tiempo de Internación , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/instrumentación , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Procedimientos Neuroquirúrgicos/instrumentación , Enfermedades de la Hipófisis/diagnóstico por imagen , Enfermedades de la Hipófisis/patología , Hipófisis/diagnóstico por imagen , Hipófisis/patología , Neoplasias Hipofisarias/cirugía , Complicaciones Posoperatorias , Cráneo/cirugía , Tomografía Computarizada por Rayos XRESUMEN
A retrospective oncological study was performed in 25 woodworkers, in whom an adenocarcinoma of the ethmoid sinuses was discovered between March 1985 and December 1993. All patients were males with a mean age of 57 years, and a mean duration of wood dust exposure of 24 years. Signs of nasal obstruction, drainage, and discomfort were present in all cases. Ophthalmological findings were a poor prognosis indicator. It was possible to precisely evaluate treatment and outcome in 23 cases. The majority of tumors were classified as T3 or T4 (72%), with extension beyond the ethmoid sinuses; all were in contact with the roof of the ethmoidal sinuses. Extension was predominantly into the orbital and intracranial cavities as compared with extension posteriorly or into the maxillary sinuses. Treatment was identical in the 25 patients: a) combined surgery including a paranasal and a neurosurgical approach, b) postoperative radiotherapy. Results were expressed in terms of morbidity related to surgery and the oncologic outcome. Operative morbidity and mortality were substantially reduced with reconstruction of the roof of the ethmoidal sinuses. Meticulous excision, in addition to postoperative radiotherapy, resulted in a decreased rate of local recurrence (26%). On the other hand, metastasis were encountered more frequently (30%). Radiotherapy was insufficient when macroscopic excision was incomplete. Chemotherapy was used as palliative treatment in the event of a recurrence and/or metastases. Survival rate was 68% at 3 years, and 48% at 5 years. Most complications and recurrences arose within the first two years. Exophthalmos, intracranial extension, incompleteremoval, and extensive class T4 tumors were associated with a poor prognosis. Optimal therapy for malignant tumors of the ethmoid sinuses requires combined transfacial and neurosurgical approaches that allow precise assessment of tumor extension and adequate excision, yielding an improved oncologic outcome. Followed by radiotherapy, this association can result in a remission. Patient prognosis depends essentially on management of the initial lesion.