Abstract BACKGROUND The role of surgery for the treatment of malignant gliomas in patients 70 years of age or older is unsettled. We conducted a randomized trial that compared surgical resection of the tumor and biopsy only, both followed by standard therapy, in such patients. MATERIAL AND METHODS Patients aged 70 years and older, with a KPS of at least 50, presenting with a radiological suspicion of an operable glioblastoma (GBM) were randomly assigned between tumor resection and biopsy. Subsequently, they underwent standard radiotherapy during the first years of the trial (2008–2017), with the adjunction of concomitant and adjuvant temozolomide when this regimen became standard (2017–2019). The primary end point was survival; secondary endpoints were progression free survival (PFS), cognitive status (MMS), autonomy (KPS), quality of life (EORTC QLQ C30 and BN20), and perioperative morbidity/ mortality. RESULTS From 2008 to 2019, 107 patients from 9 centers were enrolled in the study, of whom 101 were evaluable for analysis because the diagnosis of GBM was histologically confirmed (50 patients in the “surgery” arm and 51 patients in the “biopsy” arm). There was no statistically significant difference of median survival between the “surgery” arm (9.37 mo) and the “biopsy” arms (8.96 mo, p=0.36). However, the surgery group had increased PFS (5.06 mo vs 4.02 mo; p=0.034; p=0.002 on multivariate analysis) and better QOL (e.g. physical and cognitive functioning, motor dysfunction, fatigue) and KPS score evolution as compared to the “biopsy” group. Surgery was not associated with increased mortality or morbidity. CONCLUSION This study suggests that optimal debulking surgery does not provide a significant survival benefit in elderly patients suffering from newly diagnosed malignant glioma, but resection improves QOL and autonomy with a significant though modest improvement of PFS.

BACKGROUND:Repairing bone defects generated by craniectomy is a major therapeutic challenge in terms of bone consolidation as well as functional and cognitive recovery. Furthermore, these surgical procedures are often grafted with complications such as infections, breaches, displacements and rejections leading to failure and thus explantation of the prosthesis. OBJECTIVE:To evaluate cumulative explantation and infection rates following the implantation of a tailored cranioplasty CUSTOMBONE prosthesis made of porous hydroxyapatite. One hundred and ten consecutive patients requiring cranial reconstruction for a bone defect were prospectively included in a multicenter study constituted of 21 centres between December 2012 and July 2014. Follow-up lasted 2 years. RESULTS:Mean age of patients included in the study was 42±15 years old (y.o), composed mainly by men (57.27%). Explantations of the CUSTOMBONE prosthesis were performed in 13/110 (11.8%) patients, significantly due to infections: 9/13 (69.2%) (p<0.0001), with 2 (15.4%) implant fracture, 1 (7.7%) skin defect and 1 (7.7%) following the mobilization of the implant. Cumulative explantation rates were successively 4.6% (SD 2.0), 7.4% (SD 2.5), 9.4% (SD 2.8) and 11.8% (SD 2.9%) at 2, 6, 12 and 24 months. Infections were identified in 16/110 (14.5%): 8/16 (50%) superficial and 8/16 (50%) deep. None of the following elements, whether demographic characteristics, indications, size, location of the implant, redo surgery, co-morbidities or medical history, were statistically identified as risk factors for prosthesis explantation or infection. CONCLUSION:Our study provides relevant clinical evidence on the performance and safety of CUSTOMBONE prosthesis in cranial procedures. Complications that are difficulty incompressible mainly occur during the first 6 months, but can appear at a later stage (>1 year). Thus assiduous, regular and long-term surveillances are necessary.

Objective. - The aim of this review was to evaluate the complications of spinal cord stimulation (SCS) for chronic pain.Methods. - This was a retrospective case series of 212 patients treated with SCS for chronic lower-limb neuropathic pain between March 2002 and February 2015 in a Reims academic hospital. All patients received a surgically implanted paddle-type electrode. Complications with this technique are here described and analyzed, and other treatment and preventative methods proposed.Results. - The major indication was 'failed back surgery syndrome', and 74 (35%) patients experienced complications, of which 57% were benign, while 42% required invasive treatment. Most frequent complications (n = 22, 10%) were hardware malfunctions. There were two cases (0.9%) of postoperative neurological deficit and nine (4.2%) with postoperative infections. All patients received the appropriate treatment for their complication.Conclusion. - Despite the presence of complications, SCS is still a safe technique, although careful patient selection and proper surgical technique can help to avoid major complications. (C) 2016 Elsevier Masson SAS. All rights reserved.

entre 50 % et 100 % (65 %). Aucune difference entre les hommes et les femmes. Les douleurs peripheriques sont plus rapidement equilibrees (6 mois), avec une amelioration superieure (70 %) et surtout une stabilite dans le temps qui ameliore nettement la qualite de vie. Concernant les etiologies cerebrales, AIC restent l’indication preferentielle, les lesions tumorales semblent moins satisfaisantes (50 %, n = 2). L’intensite de stimulation est plus faible (2,0 V). Pour les atteintes medullaires, les resultats sont plus decevants (55 % en moyenne). L’equilibre est plus long (2 ans) et la douleur fluctue (en fonction des conditions atmospheriques). L’intensite est plus forte (3,5 V). Le traitement medicamenteux reste inchange. Conclusion.– La stimulation corticale est theoriquement un traitement strictement symptomatique peu importe la cause. Les membres fantomes et algodystrophie ont la reputation d’etre de mauvaises indications. Dans cette etude, les resultats sont satisfaisants et surtout stables dans le temps. Enfin, les atteintes medullaires sont souvent decevantes, mais restent le seul traitement efficace lors des echecs medicamenteux.

Results.– Amnesic effect on pain may occur during mobilization. Flexion: 958 active. Pain: 0/10 at rest and walking. Improving the quality of walking with a smooth and not increase walking speed without technical assistance. Resumption of his previous 26 months work after the diagnosis of CRPS-I. Scintigraphy: net regression process CRPS-I detected in his right knee in 2010. Regularization of all households hyperactive. Discussion and conclusion.–This would be for the benefit of nitrous oxide in the mobilization of a stiff joint including CRPS-I through a permitting algofunctional improvement and joints that enabled our patient to return to his previous work. References [1] Collado V, Nicolas E, Faullks D, Hennequin M. A revue of the safety of 50 % nitrous oxyde/oxygen on conscious sedation. Expert Opin Drug Saf 2007;6(5):559–71. [2] http://www.cnrd.fr/IMG/pdf/RCP_KALI.pdf.

Introduction. - Atypical and malignant meningiomas are a rare disease whose histological definition is still recent. Their management is not consensual. The aim of this study was to review the outcome, prognostic factors and the role of complementary therapies.Patients and methods. - Between 1999 and 2007,36 patients with atypical or malignant meningiomas were managed in our hospital. All surgical specimens were reviewed according to the 2007 WHO classification system. The sex ratio was 1.25 male, the median age was 59 years. The median follow-up was 55 months. Thirty meningiomas were atypical and six were malignant.Results. - Five and 10 years overall survival rate are respectively 72 and 41%, whereas 5 and 10 years progression free survival rate are 61 and 23%. We only identify female sex, age over 70 years and Karnofsky status under 70% as negative prognostic factors.Conclusion. - Atypical and malignant meningiomas are difficult to manage and have high recurrence and poor survival rates. The prognostic of OMS II meningiomas is heterogeneous. Adjuvant radiation therapy is recommended in case of malignant menigioma or in case of atypical meningioma if incomplete surgical excision is performed. (C) 2012 Published by Elsevier Masson SAS.

Growing incidence of postoperative cognitive dysfunction (POCD) in the elderly populations after major surgery challenges us to provide stable and effective treatments. Mitochondria dysfunction is essential in the pathogenesis of aging and neurodegenerative diseases. It is hypothesized that varenicline improves cognitive impairment through restoring mitophagy and tau phosphorylation. Wild type C57BL/6 mice (male, 18-month-old) were subjected to laparotomy with or without chronic varenicline administration. Postoperative cognition and anxiety were determined by Morris water maze and elevated plus maze tests. Meanwhile, oxidative stress, mitochondria function, mitophagy and tau phosphorylation, as well as the correlation of PKR and STAT3 were characterized. In aged mice following laparotomy, persistent cognitive dysfunction in spatial learning and memory were indicated by longer escape latency and less crossing frequency in the target quadrant. Laparotomy also induced anxiety responses deficits. After postoperative 14 days, significant ROS accumulation and smaller mitochondria with impaired function were presented in the hippocampus. Simultaneously, there were abundant of neuronal apoptosis and translocation of tau phosphorylation in the mitochondria. Enhanced mitophagy and down regulated ChAT activity were distributed in the mice subjected to laparotomy. PKR signaling was activated and required for subcellular activation of STAT3 in the brain. After chronic varenicline administration (1 mg/kg/day), cognitive dysfunction, hippocampal oxidative stress, as well as fragile mitophagy were improved. Our results highlight that laparotomy caused cognitive impairment with persistent oxidative stress, mitochondria dysfunction and autophagy dysregulation. PKR/STAT3 maybe the potential mechanism, and perioperative varenicline treatment could be an efficient therapeutic strategy for POCD.

Growing incidence of postoperative cognitive dysfunction (POCD) in the elderly populations after major surgery challenges us to provide stable and effective treatments. Mitochondria dysfunction is essential in the pathogenesis of aging and neurodegenerative diseases. It is hypothesized that varenicline improves cognitive impairment through restoring mitophagy and tau phosphorylation. Wild type C57BL/6 mice (male, 18-month-old) were subjected to laparotomy with or without chronic varenicline administration. Postoperative cognition and anxiety were determined by Morris water maze and elevated plus maze tests. Meanwhile, oxidative stress, mitochondria function, mitophagy and tau phosphorylation, as well as the correlation of PKR and STAT3 were characterized. In aged mice following laparotomy, persistent cognitive dysfunction in spatial learning and memory were indicated by longer escape latency and less crossing frequency in the target quadrant. Laparotomy also induced anxiety responses deficits. After postoperative 14 days, significant ROS accumulation and smaller mitochondria with impaired function were presented in the hippocampus. Simultaneously, there were abundant of neuronal apoptosis and translocation of tau phosphorylation in the mitochondria. Enhanced mitophagy and down regulated ChAT activity were distributed in the mice subjected to laparotomy. PKR signaling was activated and required for subcellular activation of STAT3 in the brain. After chronic varenicline administration (1 mg/kg/day), cognitive dysfunction, hippocampal oxidative stress, as well as fragile mitophagy were improved. Our results highlight that laparotomy caused cognitive impairment with persistent oxidative stress, mitochondria dysfunction and autophagy dysregulation. PKR/STAT3 maybe the potential mechanism, and perioperative varenicline treatment could be an efficient therapeutic strategy for POCD.

L’arthrodèse C1–C2 représente un défi sur le plan chirurgical du fait de la proximité d’éléments neuro-vasculaires nobles (artères vertébrales et moelle épinière) ainsi que du haut degré de mobilité de cette articulation rendant l’obtention d’une fusion osseuse difficile. De nombreuses techniques ont été proposées successivement dans la littérature, visant à diminuer les risques anatomiques de cette chirurgie et à obtenir de meilleurs résultats sur le plan de la stabilité biomécanique et du taux de fusion. Récemment, Harms a proposé une nouvelle technique reposant sur la mise en place de vis poly-axiales dans les masses latérales de C1 et dans les pédicules de C2.Le but de ce travail est de rapporter notre expérience à propos de 26 patients consécutifs opérés d’une arthrodèse C1–C2 selon la technique de Goel et Harms et de décrire de façon détaillée, étape par étape, les aspects techniques de cette intervention. Un scanner postopératoire immédiat et à 6 mois a été systématiquement réalisé pour contrôler le positionnement des vis, d’une part, et évaluer la qualité de la fusion, d’autre part. Le recul est de 1 an minimum pour tous les patients sauf deux (10 mois).Vingt-six patients d’âge moyen de 57 ans ont été inclus dans cette étude. Les indications étaient : une pseudarthrose de C2 (n = 11), une fracture et/ou luxation du complexe C1–C2 (n = 11), une pathologie inflammatoire (n = 2) et une pathologie tumorale (n = 2). Nos résultats mettent en évidence une bonne fiabilité de la technique (aucune complication neuro-vasculaire et 85 % de vis parfaitement positionnées) et un excellent taux de fusion (100 % à 6 mois).Compte tenu des considérations anatomiques et biomécaniques, ainsi que des résultats cliniques et radiologiques observés à travers cette série, nous concluons que l’arthrodèse selon la technique de Goel et Harms constitue désormais la technique de première intention pour les arthrodèses C1–C2 par voie postérieure.Niveau IV, étude prospective.

UNLABELLED:Tinnitus is a public health issue in France. Around 1 % of the population is affected and 30,000 people are handicapped in their daily life. The treatments available for disabling tinnitus have until now been disappointing. We report our experience on the treatment of these patients in neurosurgery. PATIENT AND METHODS:Between 2006 and 2008, transcranial magnetic stimulation (rTMS) was performed following several supraliminal and subliminal protocols in 16 patients whose mean age was 47 years (range, 35-71). All patients underwent anatomical and functional MRI of the auditory cortex before and 18 h after rTMS, to straddle the primary and secondary auditory cortices. All patients underwent audiometric testing by an ENT physician. RESULTS:Nine patients responded with rTMS. After these investigations, two quadrapolar electrodes (Resume), connected to a stimulating device implanted under the skin (Synergy, from Medtronic), were extradurally implanted in three patients. The electrodes were placed between the primary and secondary auditory cortices. The mean follow-up was 25 months and significant improvement was found in these patients. CONCLUSION:The feasibility of cortical stimulation in symptomatic treatment of tinnitus was demonstrated by this preparatory work. The intermediate- and long-term therapeutic effects remain to be evaluated.

Tinnitus is a public health issue in France. Around 1% of the population is affected and 30,000people are handicapped in their daily life. The treatments available for disabling tinnitus have until now been

L’empyème intracrânien est une complication fréquente des affections ORL (oto-rhino-laryngologie). Les empyèmes intracrâniens, n’ont fait l’objet que de peu de travaux ces dernières années au Sénégal. Malgré les nouvelles techniques d’imagerie, cette affection pose encore des problèmes diagnostiques, thérapeutiques et de suivi dans nos régions. Cet article rapporte notre expérience confrontée à une revue de la littérature, en mettant l’accent sur les aspects épidémiologiques, les difficultés diagnostique et thérapeutique, et le pronostic.Il s’agit d’une étude rétrospective, réalisée de janvier 2008 à décembre 2011 portant sur 100 observations cliniques. Le diagnostic était posé grâce au scanner cérébral. Le traitement était à 21 % médical exclusif et à 79 % combiné à la chirurgie. La durée du traitement était de 4 à 8 semaines. La surveillance clinique et scannographique était de 12 mois.L’empyème représentait 44,4 % des suppurations collectées intracrâniennes. L’âge moyen était de 21 ans. La porte d’entrée était 35 % ORL, 10 % méningitique et 25 % inconnue. Le siège était 57 % sous-dural, 22 % extra-dural et 10 % inter-hémisphérique. L’empyème était associé à un abcès dans 7 cas. Un cas était situé dans la fosse cérébrale postérieure. L’évolution était favorable dans 78 %, 12,5 % ont présenté des séquelles neurologiques, 11 % sont décédés et 3 % ont présenté une récidive.La fréquence des empyèmes intracrâniens reste encore très élevée au Sénégal. Les difficultés de prise en charge du point de vue diagnostique, thérapeutique et économique font toute la gravité de cette affection. Malgré ces aléas, un schéma thérapeutique bien conduit et précoce est la seule garantie d’une réduction de la morbi-mortalité de cette affection qui touche particulièrement le sujet jeune.Intracranial empyema is a frequent complication of ear-nose-throat (ENT)infections. Limited studies have been carried-out on cerebral empyema during recent years in Senegal. Despite new imaging techniques, diagnostic and therapeutic problems as well as outcome still remain in our regions. We report our experience compared to that of the literature. The study focused on epidemiological aspects, difficulties in diagnosis and treatment as well as prognosis of this condition.This was a retrospective study conducted from January 2008 to December 2011 of 100 clinical cases. Diagnosis was made based on contrast CT-scan. Twenty-one percent of patients received medical treatment alone, while 79% underwent surgery. The duration of the treatment varied from 4 to 8 weeks. The follow-up was clinical and radiological with a mean follow-up time of 12 months.Cerebral empyema represented 44.4 % of all intracranial suppuration cases and the mean age was 21 years. The etiology was ENT in 35%, meningitis 10%, unknown 25%. Localization was sub-dural in 57%, extra-dural in 22%, inter-hemispheric in 10% of the cases. Empyema was associated with an abscess in 7 cases. One case was located in the posterior fossa. The evolution was favorable in 78% of the cases and in 12.5% some neurologic sequelae were observed. Eleven patients died and 3% of the patients had recurrences.The frequency of intracranial empyema is still high in Senegal. Difficulties in diagnosis, therapeutics and low economic incomes account for the gravity of intracranial empyema. In spite of these risks, early stage and effective treatment is necessary to reduce the morbi-mortality, especially in young aged children.