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Objective An expert working group was set up at the initiative of the French Ministry of Sports with the objective of harmonising the management of sport related concussion (SRC) in France, starting with its definition and diagnosis criteria. Results Definition: A clinical definition in 4 points have been established as follows: Concussion is a brain injury: 1) caused by a direct or indirect transmission of kinetic energy to the head; 2) resulting in an immediate and transient dysfunction of the brain characterised by at least one of the following disorders: a) Loss of consciousness, b) loss of memory, c) altered mental status, d) neurological signs; 3) possibly followed by one or more functional complaints (concussion syndrome); 4) the signs and symptoms are not explained by another cause. Diagnosis criteria: In the context of the direct or indirect transmission of kinetic energy to the head, the diagnosis of concussion may be asserted if at least one of the following signs or symptoms, observed or reported, is present within the first 24 hours and not explained by another cause: 1) loss of consciousness; 2) convulsions, tonic posturing; 3) ataxia; 4) visual trouble; 5) neurological deficit; 6) confusion; 7) disorientation; 8) unusual behaviour; 9) amnesia; 10) headaches; 11) dizziness; 12) fatigue, low energy; 13) feeling slowed down, drowsiness; 14) nausea; 15) sensitivity to light/noise; 16) not feeling right, in a fog; 17) difficulty concentrating. Conclusion Sharing the same definition and the same clinical diagnostic criteria for concussion is the prerequisite for common rules of management for all sports and should allow the pooling of results to improve our knowledge of this pathology.

Introduction Mild traumatic brain injury (mTBI) and whiplash are two pathologies which appear in the follow-up of a cranio-cervical trauma. The objective of this study is to review their definitions, to discuss each entity. Methods Whiplash and mTBI were defined. Then, a systematic literature review was carried out using the Pubmed database. Relevant studies after 1995 were selected, with 16 articles describing a link between whiplash and mTBI. 8 articles were analyzed after reading their abstracts. Results Whiplash and mTBI have many similarities (symptoms, biomechanics, cognitive disorders, presence of diffuse axonal lesions on functional imaging) and some differences (in posture, more vestibular and balance disorders in whiplash). mTBIs result from linear accelerations between 60- 160 g (gravity), studies on whiplash have shown that they can appear from 4.5 g, which could explain biomechanically the frequent concomitant appearance. Cervical joint dysfunction can appear in persistent concussive syndrome, with upper cervical pain, less endurance of the cervical flexor muscles, and an increase in cervical stiffness leading to tension headache. This could explain neck pain in mTBI and headache in whiplash. An explanation to vestibular and cochlear disorders is given, and the two pathologies concomitantly could increase the symptoms. Conclusion To our knowledge, no studies define distinct boundaries between these two pathologies, which overlap on many points. An explanation is their concomitant onset, due to the biomechanics of the trauma and anatomical reasons. Larger-scale studies of rigorous scientific quality are needed to answer the question of the difference between whiplash and mTBI.

Objective:\ud Sport-related concussion commonly occurs in contact sports such as rugby. To date, diagnosis is based on the realization of clinical tests conducted pitch-side. Yet, the potential effect of prior physical effort on the results of these tests remains poorly understood. The purpose of this study was to determine whether preceding physical effort can influence the outcome of concussion assessments.\ud \ud Design: \ud Prospective observational study.\ud \ud Setting: \ud University Medicine Center\ud \ud Patients: \ud A cohort of 40 subjects (20 rugby players and 20 athletes from a range of sports).\ud \ud Intervention: \ud A concussion assessment was performed immediately following physical activity. Following a period of 6 months and under the same experimental conditions, the same cohort performed the same tests in resting conditions.\ud \ud Main outcome measure: \ud Results of concussion tests.\ud \ud Results: \ud In both cohorts, the comparison for post-exercise and rest assessments demonstrated a most likely moderate-to-very large increase in the number of symptoms, severity of symptoms and BESS score. In the rugby cohort, scores for concentration, delayed memory and SAC, likely-to-most likely decreased following completion of physical activity compared to baseline values. The between-cohort comparison showed a greater impact post-exercise in the rugby players for delayed recall (0.73±0.61, 93/7/1) and SAC score (0.75±0.41, 98/2/0).\ud \ud Conclusion: \ud Physical activity altered the results of concussion diagnostic tests in athletes from a range of sports and notably in rugby players. Therefore, physical efforts prior to the concussion incident should be accounted for during pitch-side assessments and particularly during rugby competition and training.

Item does not contain fulltext We present an overview of the history, development, technological advancements, current application, and future trends of cranial endoscopy. Neuroendoscopy provides a safe and effective management modality for the treatment of a variety of intracranial disorders, either tumoral or non-tumoral, congenital, developmental, and degenerative, and its knowledge, indications, and limits are fundamental for the armamentarium of the modern neurosurgeon.

Intracranial dural arteriovenous fistulae with perimedullary venous drainage are unusual type of vascular brain malformations. Patients may present with a rapidly progressive ascending myelopathy associated with autonomic dysfunction, which can cause a misdiagnosis and delay the therapeutic management. These clinical signs must be quickly recognized to avoid a poor outcome. The authors report the case of a 60-year-old woman presenting with a progressive myelopathy due to a dural arteriovenous fistula with perimedullary venous drainage. The diagnosis was suspected on brain-spinal MRI and confirmed by brain arteriography visualizing the arteriovenous shunt in the middle segment of the superior petrous sinus. MRI showed edema in the medulla oblongata. The treatment was performed early by endovascular glue embolization of the arteriovenous shunt and of the origin of the vein. Brain arteriography and clinical follow-up, one month later, showed complete disappearance of the dural fistula and regression of clinical symptoms. MRI control showed the reduction of the brain stem edema. Because of the early pejorative prognosis of these kinds of fistulae, early diagnosis and treatment are needed.

L’objet de cet article est de presenter le projet MIRAS : Robot avec interaction multimodale pour l’assistance a la deambulation. Les objectifs de ce projet sont exposes dans un premier temps ; puis chaque axe de travail est detaille : description des scenarii et fonctions multimodales associees, presentation du travail de conception et de realisation du robot, synthese de l’etude de securite et, enfin, presentation des travaux menes pour la validation clinique. Les resultats des premiers essais pilotes sont egalement analyses pour souligner les points d’amelioration. Enfin, une discussion sur l’interet de l’etude et ses problematiques est menee avant de conclure l’article.

Resume Objectif Etablir des regles de prise en charge des commotions cerebrales au cours de la pratique du rugby professionnel et haut niveau en France. Materiel et methodes A partir des donnees de la litterature, des recommandations de l’IRB et des conferences de consensus successives sur les commotions cerebrales au cours de la pratique sportive, les recommandations ont ete etablies par un groupe d’experts et adaptees a la pratique du rugby professionnel en France. Resultats Les recommandations comportent la description des signes cliniques necessaires au diagnostic sur le terrain justifiant la sortie definitive du joueur, les consignes de prise en charge immediate, la necessite d’une consultation specialisee au-dela de 48 h de repos strict, l’etablissement d’une classification pronostique sur les donnees cliniques et anamnestiques (en particulier les antecedents de commotions anterieures) etablissant les delais et les conditions de retour au jeu qui ne peut se faire qu’apres une nouvelle consultation specialisee. Conclusion Ces recommandations sont destinees a etre appliquees d’ores et deja et sont susceptibles d’evoluer en fonction des donnees scientifiques qui seront suivies annuellement par le groupe d’experts.

Normal pressure hydrocephalus must be considered when gait disturbance, cognitive impairment and sphincter disorders are associated. Symptoms of normal pressure hydrocephalus, especially gait disturbance, are potentially curable by surgery. Our paper provides a summary review of gait disorders associated with normal pressure hydrocephalus detailing their characteristics and the best assessment methods. Although the pathogenic mechanisms underlying normal pressure hydrocephalus remain poorly understood, advances in imaging have enabled considerable progress in our fundamental knowledge of the condition. Tapping the cerebrospinal fluid by lumbar puncture or external lumbar drainage remains the diagnostic test and is predictive of a favorable response to surgical treatment. Clinical severity scores validated for walking and for sphincter dysfunction and cognitive disorders provide the best means of assessing each patient's response to treatment.

Resume Ce travail presente une revue generale des interventions neurochirurgicales qui peuvent etre realisees au niveau du pied paretique et spastique. Ces interventions portent soit sur la spasticite (les neurotomies tibiales), soit sur la paresie (stimulation peripherique implantee des nerfs des releveurs du pied).

This prospective study was designed to evaluate the clinical and gait parameter changes induced by two types of hyperselective motor blocks of the triceps surae nerves (superior soleus and gastrocnemius nerves) and their ability to predict the results of selective tibial neurotomy.Seven adult patients (four males and three females, mean age of 41 yrs old) with spastic foot were included in this study. Clinical (equinus foot score, ankle range of motion, spasticity, pain, and comfort wearing shoes), and gait analysis (kinematic and electromyographic parameters) assessment were performed before and after each motor block (superior soleus nerve and gastrocnemius nerve) and 1 mo after selective tibial neurotomy.The superior soleus nerve block was effective on clinical parameters (triceps surae stretch reflex scores decreased from 2.57 to 0.9, and mean walking time decreased from 44 to 32.1 secs) and on kinematics parameters (the total duration of the gait cycle was decreased because of a reduction of the R3 and swing phases). The same results are observed after soleus neurotomy.This work confirms the practical value of selective superior soleus nerve motor block and that this block provides a useful prediction of the effect of selective soleus neurotomy. It constitutes an additional argument in favor of the predominant role of the soleus in spastic foot.

OBJECTIVE:Tibial neurotomy is a surgical technique widely used for the treatment of spastic equinus foot, but it has rarely been evaluated. The primary objective of this prospective study was to provide an objective quantification of the long-term results of tibial neurotomy.METHODS:This multicenter prospective study was conducted from 1999 to 2003. Fifty-five patients with spastic equinus foot were treated in five neurosurgical centers. Preoperative and postoperative clinical evaluation comprised description of the foot deformity, study of stretch reflexes, evaluation of the repercussions of the deformity, and gait analysis. Selective neurotomy was performed in all patients.RESULTS:No postoperative complications were observed. The mean postoperative follow-up was 10 months. Tibial neurotomy improved the appearance of the foot (equinus and varus deformities, claw toes); the equinus score decreased from 1.54 to 0.273 after the operation. Stretch reflex scores were decreased significantly and for a long term after surgery; the mean triceps surae stretch reflex score decreased from 2.46 to 0.47. The angle of passive dorsiflexion of the ankle increased significantly (from −0.56 degrees to +6.85 degrees). Gait analysis demonstrated a statistically significant increase in the speed of the patient's gait after surgical treatment; the time taken by the patient to walk 10 m at a normal speed in shoes decreased from a mean of 55 seconds to 35.16 seconds. Postoperatively, 92.7% of preoperative objectives had been achieved.CONCLUSION:Tibial neurotomy ensures long-term functional improvement of patients with spastic equinus foot. It provides a lasting response for these patients compared with other, more transient treatments.

Spasticity is one component of the upper motor neuron syndrome, which also includes motor deficits and loss of fine movement. Of these three components of the upper motor neuron syndrome, only spasticity is amenable to treatment, hence, the interest in this symptom. Evaluation of spasticity must therefore consider the patient as a whole. The patient presents a disorder of somatic motility that must be described precisely. Clinical examination must identify signs suggestive of spasticity such as alteration of passive mobilization of the limb segment, and abnormal deep tendon reflexes. Electrophysiology may help to define and quantify the altered reflexes. The most important step then consists of demonstrating that the spasticity, its consequences, or both, interfere with the patient’s natural movement (or with the patient’s remaining functional possibilities when voluntary movement is totally abolished), an essential prerequisite to determining a treatment program. Reversible tests (motor blocks, intrathecal baclofen test injections) provide a major contribution to the determination of functional impairment caused by spasticity and allow the objectives of treatment to be clearly defined.

Objectives: This study was conducted to evaluate the long term clinical and electrophysiological outcome by recording the H reflex in a consecutive series of six patients treated by selective tibial neurotomy for spastic equinus foot. Method: The amplitudes of Hmax reflexes, Mmax responses, and Hmax:Mmax ratio were recorded in six patients with chronic lower limb spasticity, before and after surgery, at day 1 and 8 months and 24 months after selective tibial neurotomy. The passive range of movement, the stretch reflex score according to the Tardieu scale, the osteoarticular and tendon repercussions, and the quality of motor control of dorsiflexion were evaluated preoperatively and postoperatively. Results: At the end of the study, all patients presented a reduction of equines. Gait and Tardieu's score of spasticity had improved in all patients. Active dorsiflexion of the ankle was unchanged in four patients, but two improved by 5° to 12°. In five cases, fascicular resection of the superior nerve to soleus was, alone, sufficient to reduce spastic equinus foot, without recurrence, for a mean follow up of 28 months. Two patients were reoperated on, one for remaining spasticity related to an underestimated spasticity of the gastrocnemius muscles, and the other for painful claw toes. Hmax, Mmax, and Hmax:Mmax ratios were significantly lower the day after surgery. The reduction of Hmax and Hmax/Mmax ratio remained stable over time and was still statistically significant two years after the operation. However, the value of Mmax eight months postoperatively was no longer significantly different from the preoperative value. Conclusion: This study shows the long term efficacy of the selective tibial neurotomy as treatment of spastic equinus foot. Neurotomy confined to fibres supplying the soleus muscle is sufficient in most cases and acts by decreasing sensory afferents without significant long term motor denervation.

Background Depression of spinal cord motoneuron excitability has been proposed to contribute to surgical immobility. The H-reflex, which measures alpha-motoneuron excitability, is depressed by volatile anesthetics, whereas the action of propofol is unknown. The objective of this study was to determine the effects of propofol anesthesia on the H-reflex. Methods In 13 patients (group 1), H-reflex was measured before (T0), 3 min after (T1), and 10 min after (T2) a 2-mg/kg bolus dose of propofol, followed by an infusion of 10 mg x kg(-1) x h(-1). Ten patients (group 2) were studied when propofol was given via a programmable pump set to a propofol blood concentration of 6 microg/ml, and 10 patients (group 3) were studied with the pump set to 9 microg/ml. Latencies and amplitudes of H-reflexes (H0, H1, H2) and M-responses (M0, M1, M2) of the soleus muscle were recorded, and H/M ratios (H0/M0, H1/M1, H2/M2) were calculated. Results In group 1, H-reflex amplitudes and the H/M ratio were diminished after induction with propofol (H0 vs. H1, P = 0.033; H0/M0 vs. H1/M1, P = 0.042). After 10 min of propofol infusion, the H2/M2 ratio was still decreased versus H0/M0 (P = 0.031). In group 2, no difference was detected. In group 3, propofol depressed H-reflex amplitudes at T2 (H0 vs. H2, P < 0.01), and amplitudes were also lower at T2 than at T1 (H1 vs. H2, P < 0.01). In this group, the H/M ratio decreased from T0 to T2 (H0/M0 vs. H2/M2, P < 0.002). Conclusions During steady state conditions using propofol as the sole agent, a depression of the H-reflex is observed only at a high blood concentration of 9 microg/ml. The authors suggest that immobility during propofol anesthesia is not caused by a depression of spinal motoneuron circuit excitability.

OBJECTIVE This prospective, nonrandomized, noncontrolled study was performed to evaluate the results of a new type of neurotomy, namely the soleus neurotomy, for treatment of the spastic equinus foot. METHODS Between May 1996 and March 1998, 46 patients were treated for a spastic equinus foot. Clinical status, spasticity (Ashworth Scale score), and kinematic parameters of the gait were determined before and after surgery. The neurotomy was performed on the upper nerve of the soleus in all cases and was associated with other neurotomies (lower nerve of the soleus, 21 patients; gastrocnemius, 9 patients, tibialis posterior, 18 patients; flexor hallucis longus, 16 patients; and flexor digitorum longus, 17 patients). RESULTS The mean follow-up period was 15 months (range, 8–28 mo). The equinus deformity disappeared clinically in all patients. Before the operation, all patients had an Ashworth Scale score of 2, with an inexhaustible clonus present on knee extension and persisting with knee flexion (Tardieu Scale score, 4), which was abolished in 95% of the patients after surgery. Two patients still had some clonus on knee extension; this did not interfere with their clinical improvement. Knee recurvatum disappeared in eight patients. Analysis of kinematic parameters demonstrated a statistically significant increase in joint motion of the second rocker (P = 0.0026) of the ankle during stance. The duration of the stance or swing phase, length of the walking cycle, and velocity or rate of spontaneous walking were not significantly modified. CONCLUSION The study demonstrated that soleus neurotomy is effective for the treatment of spastic equinus foot, leading to abolition of spasticity and improvement in the range of ankle motion during the stance phase of gait.

✓ Since its description by Dandy in 1922, several techniques have been used to perform third ventriculostomy under endoscopic control. Except for the blunt technique, in which the endoscope is used by itself to create the opening in the floor of the third ventricle, the other techniques require more than one instrument to perforate the floor of the ventricle and enlarge the ventriculostomy. The new device described is a sterilizable modified forceps that allows both the opening of the floor and the enlargement of the ventriculostomy in a simple and effective way.The new device has the following characteristics: 1) the tip of the forceps is thin enough to allow the easy perforation of the floor of the ventricle; 2) the inner surface of the jaws is smooth to avoid catching vessels of the basal cistern; and 3) the outer surface of the jaws has indentations that catch the edges of the opening to prevent them from slipping along the instrument's jaws. The ventricle floor is opened by gentle pressure of the forceps, which is slowly opened so that the edges of the aperture are caught by the distal outer indentation of the jaws, leading to an approximately 4-mm opening of the floor. This device has been used successfully in 10 consecutive patients.This new device allows surgeons to perform third ventriculostomy under endoscopic control in a very simple, quick, and effective way, avoiding the need for additional single-use instruments.

Thirty-two patients with refractory central and neuropathic pain of peripheral origin were treated by chronic stimulation of the motor cortex between May 1993 and January 1997. The mean follow-up was 27.3 months. The first 24 patients were operated according to the technique described by Tsubokawa. The last 13 cases (eight new patients and five reinterventions) were operated by a technique including localisation by superficial CT reconstruction of the central region and neuronavigator guidance. The position of the central sulcus was confirmed by the use of intraoperative somatosensory evoked potentials. The somatotopic organisation of the motor cortex was established peroperatively by studying the motor responses at stimulation of the motor cortex through the dura. Ten of the 13 patients with central pain (77%) and ten of the 12 patients with neuropathic facial pain had experienced substantial pain relief (75%). One of the three patients with post-paraplegia pain was clearly improved. A satisfactory result was obtained in one patient with pain related to plexus avulsion and in one patient with pain related to intercostal herpes zooster. None of the patients developed epileptic seizures. The position of the stimulating poles effective on pain corresponded to the somatotopic representation of the motor cortex. The neuronavigator localisation and guidance technique proved to be most useful identifying the appropriate portion of the motor gyrus. It also allowed the establishment of reliable correlations between electrophysiological-clinical and anatomical data which may be used to improve the clinical results and possibly to extend the indications of this technique.

Resume L'analyse retrospective de 202 blocs anesthesiques realises dans une unite d'evaluation et de traitement de la spasticite et de la dystonie a permis de preciser l'interet de cette technique dans l'approche des troubles du comportement moteur et l'ajustement des protocoles de traitement. Cent-un patients selectionnes, sur une periode de 2 ans, a partir d'une consultation specialisee ont fait l'objet d'une hospitalisation de jour pour la realisation d'un ou de plusieurs blocs anesthesiques: il s'agissait de patients ages de 4 a 70 ans (moyenne d'âge de 28 ans), presentant les affections suivantes: traumatisme crânien (38 %), accident vasculaire cerebral (18 %), traumatisme ou accident vasculaire medullaire (10 %), infirmite motrice cerebrale (28 %), maladie degenerative ou leucodystrophie (5 %) et un myelomeningocele (1 %). Tous les blocs ont ete realises avec de la lidocaine non adrenalinee a 1,5 %, choisie pour son index puissance-toxicite equilibre, avec un reperage du tronc nerveux peripherique par une nouvelle generation de neurostimulateurs maniables et surs. Le bloc moteur permet l'analyse objective de la composante passive du mouvement, de la raideur musculaire et du potentiel moteur residuel. Les ≪moteurs≫ transferables sont testes avec plus de precision dans leur force, leur course et leur pattern syncinetique. Les blocs volontiers simultanes et selectifs et l'analyse de l'eventuel effet supraou infrasegmentaire ont permis d'affiner nos interpretations et un ajustement optimal du geste therapeutique propose, sans prendre le risque de modifier un equilibre deja installe.

OBJECTIVES To assess by electrophysiology the effect of tibial selective neurotomy on muscle imbalance of the spastic ankle. METHOD The amplitudes of the H reflexes, M responses (muscle contractions recorded after stimulation of the tibial nerve), and Hmax:Mmax ratio were recorded in 12 patients with chronic lower limb spasticity, before and one month after tibial selective neurotomy. Recordings were done on medial and lateral gastrocnemius and soleus muscles. Clinical evaluation was done with both global (Held’s score) and analytical tests (step measurements, gait velocity, and ankle angulation during active and passive movements). RESULTS After neurotomy, gait improved in all patients. Held ’s score of spasticity was better in all patients. Active dorsiflexion of the ankle was unchanged in three patients, but the others improved by 5° to 12°. Hmax, Mmax, and Hmax:Mmax ratios were lower. The Hmax on the gastrocnemius muscle, clinical strength, Mmax of all the muscles, and Hmax:Mmax ratio for the soleus and lateral gastrocnemius muscle were significantly lower after surgery. CONCLUSION There was an improvement of clinical and electrophysiological spastic indices after selective tibial neurotomy. Neurotomy acted not only on motor neurons by decreasing strength, but also the reflex enlargement by decreasing sensory afferents.

alpha 2-Adrenergic agonists induce cerebral vasoconstriction, reduce intracranial pressure (ICP) in experimental animals and may be useful in the hemodynamic management of head-injured patients. We studied the effects of the alpha 2 agonist clonidine on the cerebral circulation in 12 head-injured patients (Glasgow Coma Scale score8). Middle cerebral artery flow velocity (MCAV), ICP, mean arterial pressure (MAP), and cerebral perfusion pressure (CPP), were continuously recorded before (T0), at the end (T1), and 30 min after (T2) a 10-min intravenous (i.v.) infusion of 2.5 micrograms/kg clonidine. The cerebral arteriovenous oxygen content difference (AVDO2) and Paco2 were sequentially obtained. ICP, Paco2, AVDO2, and MCAV did not change after clonidine administration. In contrast, MAP and CPP decreased (P0.05 and P0.05, respectively, at T1 and T2). Three subjects displayed a transient increase in ICP (10 mm Hg) at T1; this increase was concomitant with the decrease in MAP. Clonidine administered as an i.v. infusion may induce a critical but transient increase in ICP in some severely head-injured patients. This effect may result from cerebral autoregulatory vasodilation and increased cerebral blood volume as a response to the hypotensive effects of clonidine.

✓ The use of an endoscope in the treatment of suprasellar arachnoid cysts provides an opening of the upper and lower cyst walls, thereby allowing the surgeon to perform a ventriculocystostomy (VC) or a ventriculocystocysternostomy (VCC). To discover which procedure is appropriate, magnetic resonance (MR)—imaged cerebrospinal fluid (CSF) flow dynamics in two patients were analyzed, one having undergone a VC and the other a VCC using a rigid endoscope. Magnetic resonance imaging studies were performed before and after treatment, with long-term follow-up periods (18 months and 2 years). The two patients were reoperated on during the follow-up period because of slight headache recurrence in one case and MR—imaged CSF flow dynamics modifications in the other. In each case surgery confirmed the CSF flow dynamics modifications appearing on MR imaging. In both cases, long-term MR imaging follow-up studies showed a secondary closing of the upper wall orifice. After VCC, however, the lower communication between the cyst and the cisterns remained functional. The secondary closure of the upper orifice may be explained as follows: when opened, the upper wall becomes unnecessary and tends to return to a normal shape, leading to a secondary closure. The patent sylvian aqueduct aids this phenomenon, as observed after ventriculostomy when the aqueduct is secondarily functional. The simplicity of the VCC performed using endoscopic control, which is the only procedure to allow the opening in the cyst's lower wall to remain patent, leads the authors to advocate this technique in the treatment of suprasellar arachnoid cysts.