Neurochirurgie最新文献

Background

Advanced pelvic surgery is associated with potential vascular risks. The aim of this study was to complete the existing classification of the anatomical variations of the internal iliac veins encountered on a series of preoperative angio CT with a view to performing anterior lumbar spine surgery.

Materials and Methods

In this monocentric retrospective study conducted between 2010 and 2020, all preoperative angio CT performed before an anterior lumbar surgery were systematically analyzed. All the abnormalities of the iliac veins were referenced in an updated classification system.

Results

910 patients (431 men and 479 women) with a mean age of 49 years [16–88] were included. Apart from the most common variant in the population (type I), 64 anatomical variations (7.0%) in the iliac veins were reported and classified according to our new classification. The percentage of coverage of the L4-L5 intervertebral disc is 52%, including 32% by the inferior vena cava before the confluence of the common iliac veins. At the level of the L5-S1 intervertebral disc, the coverage is 30% (same distribution between left and right).

Conclusions

Variations of the iliac veins are frequent, and contrary to what one might think, and even if they can represent an anatomical trap during surgery, certain variations do not limit anterior lumbar spine surgery and are not more associated with vascular complications. Nevertheless, these anatomical variations must be known before any advanced pelvic surgery. Depending on their distribution, level L5-S1 is more suitable for ALIF, level L4-L5 for OLIF approaches.

Background

The vertebral artery (VA) is in close proximity to bony structures, nerves and nerve sheaths of the cervical spine and craniovertebral junction (CVJ). These structures can be sources of tumors that are responsible for displacement, encasement and sometimes invasion of the VA. Removing these tumors while minimizing the risk of vascular injury requires thorough knowledge of the vascular anatomy, risk factors of vascular injury, the relationships of each tumor type with the VA, and the different surgical approaches and techniques that result in the best outcomes in terms of vascular control, tumoral exposure and resection.

Objective

To present an overview of preoperative and anatomical considerations, differential diagnoses and various approaches to consider in cases of tumors in close relationship with the VA.

Method

A review of recent literature was conducted to examine the anatomy of the VA, the tumors most frequently affecting it, surgical approaches, and the necessary pre-operative preparations for ensuring safe and maximal tumor resection. This review aims to underscore the principles of treatment.

Conclusion

Tumors located at the CVJ and the cervical spine intimately involved with the VA, pose a surgical challenge and increase the risk of incomplete removal of the lesion. Detailed knowledge of the patient-specific anatomy and a targeted pre-operative work-up enable optimal planning of surgical approach and management of the VA, thereby reducing surgical risks and improving extent of resection.

Background

Ependymal cysts (EC) typically present supra-tentorially near the lateral ventricle, juxta ventricular, or temporoparietal regions. Previous cases have also identified infratentorial EC of the brainstem, cerebellum, and subarachnoid spaces. They are mostly asymptomatic. In this paper, we present the first-ever case of a symptomatic medullary ependymal cyst treated with surgery, along with a comprehensive review of the literature on EC of other parts of the brain stem.

Case description

This 51-year-old female presented with hearing loss, dizziness, diplopia, and ataxia. Radiographic imaging indicated the presence of a non-enhancing lesion in the medulla with a mass effect on the brainstem. Pathological examination confirmed its characterization as an ependymal cyst. The patient underwent a suboccipital craniotomy for the fenestration of the medullary ependymal cyst under neuro-navigation, Intra-op ultrasound and intra-operative neuro-monitoring. Histopathological examination confirmed the diagnosis of an ependymal cyst. At one month follow-up, her KPS is 90, ECOG PS 1, and her ataxia has improved with complete resolution of diplopia.

Conclusion

Due to their rarity and potential similarity to other cystic structures, EC may be overlooked or incorrectly diagnosed resulting in mismanagement and surgical disaster. Therefore, a comprehensive understanding and awareness of their distinct characteristics are essential for accurate diagnosis and appropriate management.

Background and objective

Metal arrows are medieval weapons typically used for hunting and war. The incidence of metal arrow wounds has declined considerably since the 16th century. Different metal arrowheads exist, and the traditional Sahelian arrowhead is barbed. Extraction of this type of metal arrow is challenging because of the risk of extensive damage to surrounding structures. To the best of our knowledge, there are no guidelines in the literature for intracranial and spinal penetrating Sahelian arrow injuries and their surgical extraction. Most authors referred to the principles of common trauma injury.

In this study, we aimed to share our experience with the surgical extraction of intracranial and spinal artisanal Sahelian arrows leading to penetrating injuries, and to propose some guidelines for such lesions.

Methods

We present a consecutive case series of 8 patients admitted to the Department of Neurosurgery of the National Hospital of Zinder for metal arrow injuries of the head and spine between November 2015 and June 2023.

Results

Eight patients with penetrating head and spine barbed-arrow injuries were admitted to our department. Mean age was 19.37 years (range, 15 to 25 years). Patients were all male, from a rural area. Trauma circumstances involved fighting between farmers and herders. All patients received antibiotics, analgesics and tetanus prophylaxis at admission before undergoing surgical extraction under general anesthesia. Successful extraction was achieved in all cases.

Conclusion

Extraction of intracranial or spinal artisanal Sahelian arrows is a challenge, particularly in limited facility structures. The proposed guidelines may lead to good extraction outcomes.

Syringomyelia associated with extensive spinal adhesive arachnoiditis (SAA) can be defined as a rare but progressive disease with potentially devastating clinical consequences. Diagnosis can be challenging due to the absence of specific clinical findings, confusion with other pathologies, and late imaging modalities. The treatment strategy for syringomyelia associated with extensive SAA should include direct drainage of the syringomyelia, and dissection of the adhesive arachnoid with expansive duraplasty. Hence, several approaches have been reported for arachnoid dissection and decompression of the subarachnoid space. The high risk of recurrence after the operation is one of the most challenging situations. First two cases were operated previously, and the cyst walls were removed and anastomosed to the intact subarachnoid space at the upper and lower ends by each other. However, in both cases, the cyst recurred after a short time and they were anastomosed again in our clinic. A subarachnoid-subarachnoid shunt was placed with a multi-hole silicone tube extending to the proximal and distal intact subarachnoid spaces and passing through the cyst removal area. In our third case, the shunt system we described was applied directly, and satisfactory results were obtained in the clinical follow-up of the patient. It has been demonstrated that subarachnoido-subarachnoid shunt is a very satisfactory treatment option for this type of pathology, which is difficult to follow and treat.

Primary ectopic extradural and extraspinal meningiomas are rare. We present a unique case of this type of meningioma in the brachial plexus.

A 25-year-old man consulted us because of neuropathic supraclavicular pain and the appearance of a supraclavicular mass whose volume had increased. Clinical examination found paresis of the deltoid, biceps brachii and brachialis muscles rated as M4 (MRC) and a strong Tinel sign at the supraclavicular fossa, over the palpable mass. There was no sign pointing towards central nervous system involvement or altered general condition. MRI revealed a mass measuring 53 × 24 mm invading the C5-C6 plexus roots and the primary upper trunk, but not the bone or spinal area. This lesion was hyperintense on DWI/ADC, hyperintense on T2 with hypointense spots, and hypointense on T1 with intense heterogeneous gadolinium enhancement.

Excisional biopsy was done 6 months after symptoms started. The tumor had developed at the C5 root, which was fibrous and at the C6 root, which was grossly normal.

Anatomical pathology confirmed the WHO grade 1 meningioma, meningothelial and psammomatous histological subtypes.

At 6 months, a follow-up MRI found no postoperative tumor remnants or recurrence. During the postoperative course, persistent paralysis of the deltoid muscle at 5 months justified a nerve transfer.

This is a rare case of ectopic extraspinal and extradural meningioma of the brachial plexus. The diagnosis of an ectopic meningioma must be considered when a patient presents with a brachial plexus tumor causing neurological deficits. The extradural nature is not sufficient to rule out this diagnosis.