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Introduction/But Presentation des resultats d’une serie homogene et prospective d’enfants atteints de diplegie spastique traites par une technique de radicotomie dorsale permettant de cibler chacune des racines lombo-sacrees et de respecter l’architecture rachidienne posterieure. Materiel et methodes Les patients ont ete selectionnes par une meme equipe multidisciplinaire, avec etablissement d’un planning chirurgical propre a chaque enfant. Les 22 enfants inclus ont beneficie d’une radicotomie dorsale selon les memes modalites techniques. Ces abords interlamaires elargis respectent partiellement les lames et les epineuses ainsi que la totalite du ligament interepineux. Ces abords interlamaires sont a 3 niveaux : L1-L2 pour acces aux racines L2 et L3, L3-L4 pour les racines L4 et L5 et L5-S1 pour les racines S1 et S2. Les racines sont visualisees et identifiees en intradural lors de leur sortie au foramen a chaque niveau. Chaque racine ventrale est stimulee pour en verifier le territoire d’innervation motrice et chaque racine dorsale est stimulee pour evaluer son degre d’excitabilite. Les reponses motrices de chaque groupe musculaire des membres inferieurs (et le sphincter anal) sont observees cliniquement par le kinesitherapeute et enregistrees par EMG. Les sections radiculaires posterieures sont realisees selon la charte preoperatoire mais avec ajustements issus du monitorage peroperatoire. Resultats Les objectifs vises en preoperatoire ont ete atteints chez 21 des 22 patients. Le degre d’amelioration a ete evalue par le GMFM Score. Le programme reeducatif a pu etre debute des le 10eme jour post-operatoire. Il n’a pas ete constate d’aggravation neurologique hormis chez un patient (deficit quadricipital gauche), de perte de la fonction urinaire, d’hypoesthesie, paresthesies ou douleurs sequellaires. Conclusion Ces resultats montrent que la technique utilisee a permis une amelioration fonctionnelle chez les enfants diplegiques marchants et une amelioration des possibilites de soins et de la qualite de vie chez les enfants quadriplegiques. Aucune destabilisation du rachis n’est survenue.

Introduction La Radicotomie Dorsale, intervention ancienne indiquee essentiellement chez l’enfant diplegique spastique, peut-etre realisee selon des abords interlamaires segmentaires de type KIDr (Keyhole Interlaminar Dorsal rhizotomy)permettant un monitoring EMG per-operatoire precis. Nous rapportons les resultats des 7 premiers cas de la serie nanceienne realises selon ses modalites. Materiel et methodes Chez chaque enfant, une charte pre-operatoire a ete etablie de facon multidisciplinaire avec les objectifs attendus et la quantification de la section de chacune des racines selectionnees. Les 7 interventions on ete realisees selon les memes modalites avec abords interlamaires type KIDr et monitoring EMG per-operatoire par stimulation des racines ventrale et dorsale de toutes les racines lombo-sacrees de L2 a S2 de chaque cote realise avec le stimulateur Icare d’Innopsys. Un controle par observationclinique des reponses motrices etait egalement realise en parallele par un kinesitherapeute. La duree d’hospitalisation fut de 9 jours en moyenne. Tous les patients ont ensuite ete transfere en centre de reeducation specialisee pour une duree de 6 semaines. Resultats La duree moyenne de l’intervention etait de 5h30. Aucune complication per- ou post-operatoire hormis un pseudo meningocele n’a ete observe. La spasticite a diminue chez tout les enfants a 1 mois (Ashworth de 3,3 a 1,7). Trois patients sur 7 ont eu une aggravation fonctionnelle pour le 1er mois (marche), en relation avec l’hypotonie, cette derniere a toujours recupere a 6 mois laissant une spasticite amelioree. 5 patients ont decrits des le 1er mois une diminution des douleurs des membres inferieurs presentes avant l’intervention. Six familles sur 7 se declaraient satisfaites. Conclusion La radicotomie dorsale realisee avec l’abord de type KIDr et monitoring EMG per-operatoire donne des resultats satisfaisants chez l’enfant en permettant une diminution de la spasticite et une amelioration fonctionnelle.

In nearly all cases, primary hemifacial spasm is related to arterial compression of the facial nerve in the root exit zone at the brainstem. The offending arterial loops originate from the posterior inferior cerebellar, anterior inferior cerebellar, or vertebrobasilar artery. In as many as 40% of the patients, neurovascular conflicts are multiple. The cross-compression at the brainstem is almost always seen on magnetic resonance imaging combined with magnetic resonance angiography. Botulinum toxin can be useful by alleviating the symptoms, but the effects are inconstant and only transient. The definitive conservative treatment is microvascular decompression (MVD), which cures the disease in 85 to 95% of patients. In expert hands, the MVD procedure can be done with relatively low morbidity. Because cure of spasms is frequently delayed – by several months to even a few years –, we do not recommend early reoperation in patients with failure or until at least 1 year of follow-up. Delayed cure could well be explained by the slow reversal of the plastic changes in the facial nucleus that may have caused the symptoms.

Percutaneous radiofrequency (RF) thermorhizotomy of the trigeminal nerve is an effective treatment for trigeminal neuralgia. Long-term efficacy is proportional to the degree of postoperative hypoesthesia. The advantage is the topographic selectivity of the thermolesion, provided the electrode tip is placed accurately. This requires precise x-ray guidance and neurophysiological testing. In addition to the indication in idiopathic trigeminal neuralgia, especially for elderly patients with precarious conditions, thermorhizotomy is particularly useful for treating patients with trigeminal neuralgia due to multiple sclerosis. It can also be applied to symptomatic neuralgias, but only when the main components are of the paroxysmal and/or the allodynic types ; the thermorhizotomy method could aggravate permanent components, especially when burning pain predominates; it could also increase preexisting trophic disturbances, particularly keratitis.

Glossopharyngeal neuralgia, more accurately called vago-glossopharyngeal neuralgia (VGPN) because of the frequent association with pain irradiation in the sensory territory of the vagus nerve, is not always recognized because its incidence is much lower than the incidence of trigeminal neuralgia (100 times more frequent). As in trigeminal neuralgia, when pain becomes resistant to anticonvulsants – its specific medical treatment – VGPN can almost always be cured by surgery. The first option is microvascular decompression, since vascular compression is the main cause of the neuralgia. Percutaneous thermorhizotomy at the foramen jugularis (pars nervosa) is only indicated as a second option, because of unavoidable sensorimotor deficits in the ninth and tenth nerves. Tractonucleotomies at the medullary level should be reserved essentially for pain of malignant origin.

Resume La neurochirurgie moderne permet de controler dans presque tous les cas la nevralgie trigeminale essentielle pharmacoresistante. L’on peut avoir recours a deux grands types de methodes. Les premieres correspondent a l’interruption des voies nociceptives. Elles sont, soit percutanees : il en est ainsi de la thermocoagulation retrogasserienne, de la compression par ballonnet gonflable et de la neurolyse par injection de glycerol dans le cavum de Meckel, soit par radiochirurgie au moyen du gamma-knife qui est tres precis. Le second type de methodes est la decompression vasculaire microchirurgicale qui leve le conflit vasculonerveux de la racine trigeminale. Cette methode qui est conservatrice et curative necessite un abord direct et une anesthesie generale ; elle s’adresse aux patients de moins de 70 - 75 ans, en bon etat general. Lorsque les patients sont tres âges et/ou en etat general precaire, les methodes percutanees ou la radiochirurgie sont preferables, mais la duree de leur efficacite est proportionnelle au degre d’hypoesthesie sequellaire, avec ses consequences.

Purpose To assess whether conformal radiotherapy (CRT) after incomplete surgery or biopsy for pure oligodendrogliomas and mixed gliomas results in decreased long-term sequelae without impairing local control and while reducing irradiated volume. Materials and methods Twenty-six consecutive patients who presented with pure (21) or mixed (5) oligodendrogliomas and who were given incomplete resections were treated according 3 different strategies: CRT alone (12), chemotherapy followed by CRT (4), and chemotherapy and delayed CRT at the time of tumor progression (10). CRT consisted of multiple noncoplanar fields. Median dose was 60 Gy. Quality of CRT was assessed using tumor and normal tissue conformal indexes. The location of recurrences was assessed with MRI and dosimetric data. Late sequelae were assessed by a questionnaire exploring professional outcome, and also by a Mini Mental State Examination test. Results The mean overall survival was 5.2 years. Fifteen patients experienced a local relapse. All but 1 occurred in the 95% isodose. Among 11 nonevolutive patients, 6 have a full-time or part-time job. Conclusion Despite CRT, infield recurrence was a common feature in patients with oligodendrogliomas and mixed tumors. Further research, including molecular biology typing of tumors and type of treatment, is warranted to improve survival and quality of life.

Introduction La valeur diagnostique de l’IRM pour etablir la responsabilite d’un conflit neurovasculaire (CNV) dans une nevralgie trigeminale (NT) reste contestee en particulier du fait que des relations vasculaires avec le trijumeau existent chez nombre d’individus n’ayant pas de NT ou du cote asymptomatique d’un porteur de nevralgie. Patients et methode L’etude a porte sur 100 IRM faites en preoperatoire, IRM a haute resolution, associant : un T2-DRIVE, un TOF-Angio et un T1-Gado. Les images ont ete evaluees par un examinateur (chirurgien senior) masque des donnees operatoires et cliniques, y compris le cote de la nevralgie. L’examinateur a decrit toutes les relations neurovasculaires avec le trijumeau, et cela des deux cotes, puis en fonction de celles-ci, en particulier de leur degre de compression a estime quel devrait etre le cote de la nevralgie. Dans un second temps apres demasquage, les estimations de l’examinateur ont ete confrontees aux donnees cliniques, en particulier le cote de la NT, ainsi qu’aux donnees anatomiques operatoires. Resultats L’erreur de prediction du cote globale a ete de 25/100. Elle a ete de 58,3 % lorsque les images de relation neurovasculaire etaient relativement symetriques (18/31) et de 10,1 % lorsqu’elles etaient relativement asymetriques (7/69) (p = 0,003). Dans les 69 cas qualifies « d’asymetriques », il n’y avait aucune image de CVN y compris de simple contact du cote asymptomatique chez 60 patients. Chez les 9 autres patients, le degre de compression du cote asymptomatique etait nettement plus faible. Dans les 31 cas qualifies de « relativement symetriques », le degre de compression etait un peu plus eleve du cote de la nevralgie (+0,35 degres), mais de facon non-significative. Par ailleurs, le vaisseau conflictuel a ete correctement identifie dans 89 % des cas, tous patients confondus, avec une concordance de degre dans 60 % des cas. Conclusion Dans la majorite des patients avec une NT, un CVN unilateral est identifie avec le cote de la nevralgie evident seul sur l’imagerie. Dans un tiers des patients, une configuration symetrique des deux cotes ne permet pas l’identification sans correlation clinique du cote nevralgique, ces patients presentant des conflits bilateraux symetriques. L’IRM correctement effectuee reste fiable pour identifier les CVN dans les deux types de configuration.

Surgery should be considered only after anticonvulsant medications have failed or if medical treatment is not well-tolerated, including in cases of asthenia or drowsiness. In most reference centers, consensus is that MVD is the first option when patients are in good health. Percutaneous lesioning operations or radiosurgery are preferable in patients with adverse co-morbidity or those who are not willing to undergo open surgery.

MVD of the left rostral ventrolateral medulla oblongata may be an effective treatment for patients suffering from intractable severe systemic blood hypertension. This article presents a literature review. Further clinical controlled studies have to be conducted to define precise indications.

Resume Le but de notre travail etait d'objectiver les effets de la radicotomie posterieure fonctionnelle chez l'enfant infirme moteur cerebral (IMC) quadriplegique dans les domaines orthopedique et fonctionnel. Nous avons etudie 18 enfants IMC de 5 a 16 ans, en preoperatoire et a 1 an postoperatoire, en ce qui concerne la spasticite, l'etat orthopedique et la fonction. Nous avons mis en evidence une diminution franche de la spasticite. Cette diminution ne permet pas de prevention orthopedique. En revanche, on observe une amelioration fonctionnelle qualitative que les echelles actuelles sont insuffisantes a mesurer.

The authors report a series of 30 adults with medulloblastoma treated after surgery between 1975 and 1990, Half the patients presented a classical medulloblastoma and the other half presented desmoplastic medulloblastoma. Brainstem infiltration was noted in 3 patients, cerebellar peduncle infiltration in 6 cases and 4 patients had cerebrospinal fluid (CSF) involvement. Tumor resection was achieved in all patients except 1, and in 5 surgery was incomplete. All patients but 2 received postoperative cerebral radiotherapy. Six patients did not receive chemotherapy before radiotherapy, 7 patients received CCNU-Vincristine concomitantly with and after irradiation, 1 patient was given a CHOP regimen, and the remaining 16 patients received the 8 drugs in a 1-day (8/1) regimen before irradiation. The median follow-up time was 104 months. The 5- and 10-year overall survival rates were 58.5% and 41%, respectively. Two toxic deaths occurred under the 8/1 regimen, and no better survival was observed for this group of patients in comparison with those receiving other regimens. Persistance of malignant cells in the CSF, brainstem involvement, cerebellar peduncle infiltration, non-radical surgery and a postoperative performance status (PS) of more than 2 were significantly correlated with an adverse outcome for overall survival in adult patients with medulloblastoma.

The authors report a series of 19 patients with one (17 cases) or two (2 cases) pericallosal aneurysms referred during the past 10 years. Of the 19 patients, 18 had a ruptured pericallosal aneurysm and one was asymptomatic. On admission two were graded I, four graded II, six graded III, and six graded IV. Of the latter group two patients died from rebleeding, and the asymptomatic patient would not undergo surgery. The 16 operated patients underwent surgery after a delay ranging from 6 to 90 days after hemorrhage (25 days on average). The delayed surgery allowed the patients to be operated on in better neurological status: seven were graded I or Ia, six graded II, three graded III, and none graded IV. The results were excellent (with resumption of their previous activity) in 11 cases (69%), good (autonomous but with a slight deficit) in 4 cases (25%), and bad in 1 case (6%). There was no operative mortality or morbidity.

Summary In the context of the intraoperative study of spinal cord surface evoked potentials in patients operated upon for chronic pain and spasticity, we have undertaken an analysis of the dipolar dorso-ventral organization of surface spinal cord evoked potentials in man. Averaged evoked potentials to peripheral nerve electrical stimulations were obtained from the dorsal and ventral pial surface of the cervical and lumbo-sacral spinal cord (7 pairs from 5 patients), using a small silver ball macroelectrode, positioned during open neurosurgical approaches. We found that the dorsally recorded N13 and N24 waves reversed into ventral P13 and P24 waves respectively. A second negative potential, N2, and a late prolonged positivity, P, similarly reversed into a P2 and an N wave respectively. Our data add up to a collection of skin, oesophageal, epidural, pial and intramedullary recordings in man and animals to provide the evidence for a transverse dipolar organization of the human postsynaptic N13, N24 and N2 potentials, originating from deep layers of the cord dorsal horn, and for a similar organization of the P wave, which has been shown to correlate with presynaptic inhibition on primary afferent fibres.