Indications, perspectives et limites de la stimulation électrique épidurale en cas d'artériopathie périphérique ou coronarienne [Indications, limits and future of epidural spinal cord electrical stimulation for coronary and peripheral artery disease]

The electrical stimulation of the dorsal columns of the spinal cord exerts a dual analgesic and vasodilatory effect on ischemic tissues. It is increasingly considered a valuable method to treat severe and otherwise intractable coronary and peripheral artery disease. The quality of the results depends from both a strict selection of the patients by vascular specialists and the frequency and quality of the follow-up controls. However the indications, limits, mode of action and results of spinal cord stimulation are still poorly understood. This article, based on a personal experience of 164 implantations for peripheral and coronary artery disease, aims to draw attention to this technique and to provide information on recent and future developments.

A pilot study on ocular safety and efficacy of infliximab as an antifibrotic agent after experimental filtration surgery

Purpose To evaluate the safety and efficacy of infliximab as an antifibrotic agent after experimental glaucoma filtration surgery in rabbits. Methods In a randomized, prospective, masked-observer study, 30 New Zealand Albino rabbits underwent glaucoma filtration surgery. The animals were allocated to receive either intraoperative application of infliximab (group A) or mitomycin C (MMC) at a concentration of 0.2mg/ml (group B) or balanced salt solution (BSS, control)(group C). Different infliximab doses, namely 1.0mg, 2.0mg, 3.0mg, 4.0mg, 5.0mg in 0.1ml were applied. Bleb survival and characteristics were evaluated over a 30day period. The animals were killed on postoperative day 15 and 30. Histology of the operated eyes was performed to evaluate and grade the amount of scarring in each group.Cellular density was evaluated in each case. Results Infliximab did not appear to improve the outcome of filtration surgery in this model of glaucoma filtration surgery.There was a significant decrease in cellular density in the MMC group compared to the control group (p=0.0352). There was neither a significant decrease in cellular density between the infliximab group and the control group nor between the infliximab group and the MMC group. Overall there was no difference in terms of fibrosis between the three different groups. There was slightly less inflammation in the infliximab group, but not significant. Conclusions In this study intraoperative application of infliximab does not appear to be superior to the application of MMC or a control with regard to bleb survival and fibrosis. This study however demonstrates that intraoperative application of MMC significantly reduces the cellular density of the filtration bleb.

Distribution of arm velocity and frequency of arm usage during daily activity: objective outcome evaluation after shoulder surgery.

In clinical settings, functional evaluation of shoulder movement is primarily based on what the patient thinks he/she is able to do rather than what he/she is actually performing. We proposed a new approach for shoulder assessment based on inertial sensors to monitor arm movement in the daily routine. The detection of movement of the humerus relative to the trunk was first validated in a laboratory setting (sensitivity>95%, specificity>97%). Then, 41 control subjects and 21 patients suffering from a rotator cuff tear were evaluated (before and after surgery) using clinical questionnaires and a one-day measurement of arm movement. The quantity of movement was estimated with the movement frequency and its symmetry index (SIFr). The quality of movement was assessed using the Kolmogorov-Smirnov distance (KS) between the cumulative distribution of the arm velocity for controls and the same distribution for each patient. SIFr presented differences between patients and controls at 3 month follow-up (p<0.05) while KS showed differences also after 6 months (p<0.01). SIFr illustrated a change in dominance due to the disorder whereas KS, which appeared independent of the dominance and occupation, showed a change in movement velocity. Both parameters were correlated to clinical scores (R(2) reaching 0.5). This approach provides clinicians with new objective parameters for evaluating the functional ability of the shoulder in daily conditions, which could be useful for outcome assessment after surgery.

Neurophysiological changes during shortening osteotomies of the spine.

BACKGROUND CONTEXT: Kyphotic deformities with sagittal imbalance of the spine can be treated with spinal osteotomies. Those procedures are known to have a high incidence of neurological complications, in particular at the thoracic level. Motor evoked potentials (MEPs) have been widely used in helping to avoid major neurological deficits postoperatively. Previous reports have shown that a significant proportion of such cases present with important transcranial MEP (Tc-MEP) changes during surgery with some of them being predictive of postoperative deficits. PURPOSE: Our aim was to study Tc-MEP changes in a consecutive series of patients and correlate them with clinical parameters and radiological changes. STUDY DESIGN/SETTING: Retrospective case notes study from a prospective patient register. PATIENT SAMPLE: Eighteen patients undergoing posterior shortening osteotomies (nine at thoracic and nine at lumbar levels) for kyphosis of congenital, degenerative, inflammatory, or post-traumatic origin were included. OUTCOME MEASURES: Loss of at least 80% of Tc-MEP signal expressed as the area under the curve percentual change, of at least one muscle. METHODS: We studied the relation between outcome measure (80% Tc-MEP loss in at least one muscle group) and amount of posterior vertebral body shortening as well as angular correction measured on computed tomography scans, occurrence of postoperative deficits, intraoperative blood pressure at the time of the osteotomy, and hemoglobin (Hb) change. RESULTS: All patients showed significant Tc-MEP changes. In particular, greater than 80% MEP loss in at least one muscle group was observed in five of nine patients in the thoracic group and four of nine patients in the lumbar group. No surgical maneuver was undertaken as a result of this loss in an effort to improve motor responses other than verifying the stability of the construct and the extent of the decompression. Four patients developed postoperative deficits of radicular origin, three of them recovering fully at 3 months. No relation was found between intraoperative blood pressure, Hb changes, and Tc-MEP changes. Severity of Tc-MEP loss did not correlate with postoperative deficits. Shortening of more than 10 mm was linked to more severe Tc-MEP changes in the thoracic group. CONCLUSIONS: Transcranial MEP changes during spinal shortening procedures are common and do not appear to predict severe postoperative deficits. Total loss of Tc-MEP (not witnessed in our series) might require a more drastic approach with possible reversal of the correction and wake-up test.

Congenital joint dislocations caused by carbohydrate sulfotransferase 3 deficiency in recessive Larsen syndrome and humero-spinal dysostosis

Deficiency of carbohydrate sulfotransferase 3 (CHST3; also known as chondroitin-6-sulfotransferase) has been reported in a single kindred so far and in association with a phenotype of severe chondrodysplasia with progressive spinal involvement. We report eight CHST3 mutations in six unrelated individuals who presented at birth with congenital joint dislocations. These patients had been given a diagnosis of either Larsen syndrome (three individuals) or humero-spinal dysostosis (three individuals), and their clinical features included congenital dislocation of the knees, elbow joint dysplasia with subluxation and limited extension, hip dysplasia or dislocation, clubfoot, short stature, and kyphoscoliosis developing in late childhood. Analysis of chondroitin sulfate proteoglycans in dermal fibroblasts showed markedly decreased 6-O-sulfation but enhanced 4-O-sulfation, confirming functional impairment of CHST3 and distinguishing them from diastrophic dysplasia sulphate transporter (DTDST)-deficient cells. These observations provide a molecular basis for recessive Larsen syndrome and indicate that recessive Larsen syndrome, humero-spinal dysostosis, and spondyloepiphyseal dysplasia Omani type form a phenotypic spectrum.

The value of intraoperative ultrasound in oblique corpectomy for cervical spondylotic myelopathy and ossified posterior longitudinal ligament.

Intraoperative ultrasound (IOUS) has been described to be useful during central corpectomy for compressive cervical myelopathy. This study aimed at documenting the utility of IOUS in oblique cervical corpectomy (OCC). Prospective data from 24 patients undergoing OCC for cervical spondylotic myelopathy and ossified posterior longitudinal ligament (OPLL) were collected. Patients had a preoperative cervical spine magnetic resonance (MR) image, IOUS and a postoperative cervical CT scan. Retrospective data from 16 historical controls that underwent OCC without IOUS were analysed to compare the incidence of residual compression between the two groups. IOUS identified the vertebral artery in all cases, detected residual cord compression in six (27%) and missed compression in two cases (9%). In another two cases with OPLL, IOUS was sub-optimal due to shadowing. IOUS measurement of the corpectomy width correlated well with these measurements on the postoperative CT. The extent of cord expansion noted on IOUS after decompression showed no correlation with immediate or 6-month postoperative neurological recovery. No significant difference in residual compression was noted in the retrospective and prospective groups of the study. Craniocaudal spinal cord motion was noted after the completion of the corpectomy. IOUS is an inexpensive and simple real-time imaging modality that may be used during OCC for cervical spondylotic myelopathy. It is helpful in identifying the vertebral artery and determining the trajectory of approach, however, it has limited utility in patients with OPLL due to artifacts from residual ossification.

Cost-effectiveness of surgery in low- and middle-income countries: a systematic review.

BACKGROUND: There is increasing interest in provision of essential surgical care as part of public health policy in low- and middle-income countries (LMIC). Relatively simple interventions have been shown to prevent death and disability. We reviewed the published literature to examine the cost-effectiveness of simple surgical interventions which could be made available at any district hospital, and compared these to standard public health interventions. METHODS: PubMed and EMBASE were searched using single and combinations of the search terms "disability adjusted life year" (DALY), "quality adjusted life year," "cost-effectiveness," and "surgery." Articles were included if they detailed the cost-effectiveness of a surgical intervention of relevance to a LMIC, which could be made available at any district hospital. Suitable articles with both cost and effectiveness data were identified and, where possible, data were extrapolated to enable comparison across studies. RESULTS: Twenty-seven articles met our inclusion criteria, representing 64 LMIC over 16 years of study. Interventions that were found to be cost-effective included cataract surgery (cost/DALY averted range US$5.06-$106.00), elective inguinal hernia repair (cost/DALY averted range US$12.88-$78.18), male circumcision (cost/DALY averted range US$7.38-$319.29), emergency cesarean section (cost/DALY averted range US$18-$3,462.00), and cleft lip and palate repair (cost/DALY averted range US$15.44-$96.04). A small district hospital with basic surgical services was also found to be highly cost-effective (cost/DALY averted 1 US$0.93), as were larger hospitals offering emergency and trauma surgery (cost/DALY averted US$32.78-$223.00). This compares favorably with other standard public health interventions, such as oral rehydration therapy (US$1,062.00), vitamin A supplementation (US$6.00-$12.00), breast feeding promotion (US$930.00), and highly active anti-retroviral therapy for HIV (US$922.00). CONCLUSIONS: Simple surgical interventions that are life-saving and disability-preventing should be considered as part of public health policy in LMIC. We recommend an investment in surgical care and its integration with other public health measures at the district hospital level, rather than investment in single disease strategies.

Anterior Segment Angiography in Strabismus Surgery

Background: Anterior ciliary arteries travelling along recti muscles provide anterior segment vascularization, which can be compromised by surgery involving more than 2 muscles.Patients and Methods: We studied retrospectively the files of 10 patients in whom a fluorescein angiography of the iris had been performed as a pre-operative assessment prior to a second or third oculomotor surgery.Results: The median age of the patients was 47.5 years (range 15 to 73 years). Relative iris ischemia was present in 4 patients following multiple surgeries, none of them presenting any general cardiovascular risk. The initial surgical protocol was modified according to angiographic results in these 4 patients.Conclusion: When further surgery has to be performed on previously multi-operated patients, anterior segment angiography can be useful in the planning of surgery in order to minimize the risks of anterior segment ischemia.

Disc degeneration: current surgical options.

Chronic low back pain attributed to lumbar disc degeneration poses a serious challenge to physicians. Surgery may be indicated in selected cases following failure of appropriate conservative treatment. For decades, the only surgical option has been spinal fusion, but its results have been inconsistent. Some prospective trials show superiority over usual conservative measures while others fail to demonstrate its advantages. In an effort to improve results of fusion and to decrease the incidence of adjacent segment degeneration, total disc replacement techniques have been introduced and studied extensively. Short-term results have shown superiority over some fusion techniques. Mid-term results however tend to show that this approach yields results equivalent to those of spinal fusion. Nucleus replacement has gained some popularity initially, but evidence on its efficacy is scarce. Dynamic stabilisation, a technique involving less rigid implants than in spinal fusion and performed without the need for bone grafting, represents another surgical option. Evidence again is lacking on its superiority over other surgical strategies and conservative measures. Insertion of interspinous devices posteriorly, aiming at redistributing loads and relieving pain, has been used as an adjunct to disc removal surgery for disc herniation. To date however, there is no clear evidence on their efficacy. Minimally invasive intradiscal thermocoagulation techniques have also been tried, but evidence of their effectiveness is questioned. Surgery using novel biological solutions may be the future of discogenic pain treatment. Collaboration between clinicians and basic scientists in this multidisciplinary field will undoubtedly shape the future of treating symptomatic disc degeneration.

Chirurgie du cancer du sein [Breast cancer surgery].

Breast conserving surgery followed by radiation therapy is the treatment of choice for early breast cancer. For patients who choice or need a mastectomy, breast reconstruction provides an acceptable alternative. Breast cancer surgery has been evolving through minimally invasive approaches. Sentinel node biopsy has already remplaced axillary lymph node dissection in the evaluation of the axilla. Local ablation of the tumor may be a valuable alternative to surgery in the future.

Ultrastructural changes of the internal limiting membrane removed during indocyanine green assisted peeling versus conventional surgery for an idiopathic epimacular membrane

Purpose:To evaluate the histological features of cellular retinal fragments on the internal limiting membrane (ILM) removed during epiretinal membrane peeling surgery with and without the aid of ICG diluted in 5% glucose Methods:ILM specimens removed from 88 eyes undergoing vitrectomy and membrane peeling surgery for idiopathic epiretinal membrane between 1995 and 2003 were reviewed retrospectively. Surgery was performed in all cases by the same surgeon using the same technique. ICG was diluted with 5% glucose. Histological analysis focused on the presence and characteristics of retinal structures on the retinal surface of the ILM. Statistical analysis compared the results between group I (conventional surgery without ICG) and group II (ICG-assisted peeling) Results:Seventy-one eyes underwent EMM surgery without the aid of ICG (group I) and seventeen underwent EMM ICG-assisted surgery assisted using ICG (group II). The amount of Muller cell debris on the retinal surface of the ILM was more significant in the group I (no ICG) than in the group II (ICG) (40.8 versus 11.8; p = 0.024). Large fragments of Muller cells were more frequently observed in the group I (no ICG) than in the group II (ICG) (63.4% versus 23.5%; p= 0.003).The presence of larger retinal elements such as neural axons and vessels were observed attached to retinal face of the ILM in 5 (7%) cases of the no-ICG group. No such retinal elements were detected in any of the histological ILM specimens of the ICG-assisted group Conclusions:The use of ICG diluted with 5% glucose in the aid of ILM removal during epiretinal membrane surgery was associated with less retinal debris attached to retinal face of the ILM compared to surgery in which ICG was not used. Our findings contradict previous reports in the literature, in which use of ICG diluted with balanced salt solution (BSS) was associated with more retinal fragments attached to the retinal face of the ILM. According to our results, we hypothesize that diluting ICG with 5% glucose may decrease the adhesion of the ILM to the underlying retinal layers such that less retinal debris is removed with peeling of the ILM.

Déficits dans les apports nutritionnels chez les candidats a la chirurgie bariatrique [Nutritional deficiencies in candidates for bariatric surgery]

98% of patients who have undergone a gastric bypass for treating severe obesity develop multiple micronutrient deficits. However, prior to surgery, it isn't rare to find nutrient deficiencies. Indeed, the dietary intakes of surgery candidates are often unbalanced, lacking in variety especially in high vitamin and mineral nutrients. We present the preliminary results concerning the qualitative and quantitative analysis in a group of patients waiting for a gastric bypass. The recommended daily amounts in vitamin B9, vitamin D and iron are insufficient in the majority of the patients. The correction of nutritional intakes is advisable, even before the surgery, in order to reduce the risks of developing biological deficiencies.

Anatomical landmarks for transnasal endoscopic skull base surgery

La résection par voie endoscopique transnasale de tumeurs envahissant la base du crâne antérieure a été récemment décrite. Cette chirurgie requiert une connaissance précise des repères anatomiques endoscopiques afin réduire le risque de complications vasculaires et neurologiques.¦Nous avons réalisé une étude anatomique endoscopique sur 6 têtes dont 3 injectées avec du silicone coloré. Les repères anatomiques pour les abords de 3 régions d'importance clinique ont été étudiés. Les repères pour l'abord de l'apex orbitaire sont le recessus carotidien latéral, l'empreinte du nerf optique, « l'optic strut » et le V2. Leurs rapports avec le canal optique, l'artère carotide interne et les fentes orbitaires supérieures et inférieures sont décrits. Les repères pour l'abord de l'apex pétreux sont le V2 et le nerf vidien qui permettent repérer la portion intrapétreuse de l'artère carotide interne. Les repères pour l'abord de la fosse ptérygomaxillaire sont le V2 et le foramen rotundum, l'artère et le trou sphénopalatins et l'artère maxillaire interne.¦Cette nouvelle approche permettant d'aborder des lésions médianes et paramédianes ouvre de nouvelles perspectives pour des équipes de neurochirurgiens et d'ORL. Ces voies d'abords s'appliquent aussi bien à des résections décompressives à but palliatif qu'à l'exérèse de tumeurs benignes et malignes, bien que les résultats à long terme doivent encore être validés pour cette dernière indication.

The effect of n-3 enriched nutrition therapy on post-operative cognitive dysfunction after cardiac surgery

Background: Postoperative cognitive dysfunction (POCD) occurs frequently after cardiac surgery. Some data suggest that inflammation plays a key role in the development of POCD. N-3 fatty acids have been shown to have a beneficial effect on inflammation. We hypothesised that perioperative n-3 enriched nutrition therapy would reduce the incidence of POCD in this group of patients. Methods: Randomized, double blind placebo controlled trial in patients aged 65 or older undergoing elective cardiac surgery with cardiopulmonary bypass. 2x 250 mL placebo (Ensure Plus™, Abbott Nutrition) or n-3 enriched nutrition therapy (ProSure™ Abbott Nutrition) were administered for ten days starting 5 days prior to surgery. Cognition was assessed preoperatively and 7 days after surgery with the Consortium to Establish a Registry for Alzheimer's Disease - Neuropsychological Assessment Battery (CERAD-NAB) [1]. Results: 16 patients were included. Mean age was 72 } 5.3 for placebo and 75 } 4.8 for ProSure™ respectively. CRP and IL-6 did not differ significantly between groups preoperatively and on postoperative days 1, 3, and 7. Preoperative CERAD total scores were 86 } 10 and 81 } 9 (p = n.s.) for Placebo and ProSure™, respectively. Postoperative scores were 88 } 12, and 77 } 19 (p = n.s.) The change in score was not different between the two groups (Placebo: +3 } 5; ProSure: -5 } 11). Conclusion: In this very small sample no effect of preoperatively started n-3 enriched nutritional supplements on inflammation or cognitive functions were detected. However, there is a large likelihood of a type II error and more patients need to be included to assess possible beneficial effects of this intervention in elderly patients undergoing elective cardiac surgery. 1 Chandler MJ, et al. Neurology. 2005;65:102-6.