Publications by authors named "Nicolas Lonjon"

37 Publications

Inhibiting microglia proliferation after spinal cord injury improves recovery in mice and nonhuman primates.

Theranostics 2021 31;11(18):8640-8659. Epub 2021 Jul 31.

MMDN, Univ. Montpellier, EPHE, INSERM, Montpellier, France.

No curative treatment is available for any deficits induced by spinal cord injury (SCI). Following injury, microglia undergo highly diverse activation processes, including proliferation, and play a critical role on functional recovery. In a translational objective, we investigated whether a transient pharmacological reduction of microglia proliferation after injury is beneficial for functional recovery after SCI in mice and nonhuman primates. The colony stimulating factor-1 receptor (CSF1R) regulates proliferation, differentiation, and survival of microglia. We orally administrated GW2580, a CSF1R inhibitor that inhibits microglia proliferation. In mice and nonhuman primates, we then analyzed treatment outcomes on locomotor function and spinal cord pathology. Finally, we used cell-specific transcriptomic analysis to uncover GW2580-induced molecular changes in microglia. First, transient post-injury GW2580 administration in mice improves motor function recovery, promotes tissue preservation and/or reorganization (identified by coherent anti-stokes Raman scattering microscopy), and modulates glial reactivity. Second, post-injury GW2580-treatment in nonhuman primates reduces microglia proliferation, improves motor function recovery, and promotes tissue protection. Finally, GW2580-treatment in mice induced down-regulation of proliferation-associated transcripts and inflammatory associated genes in microglia that may account for reduced neuroinflammation and improved functional recovery following SCI. Thus, a transient oral GW2580 treatment post-injury may provide a promising therapeutic strategy for SCI patients and may also be extended to other central nervous system disorders displaying microglia activation.
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http://dx.doi.org/10.7150/thno.61833DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8419033PMC
July 2021

Injury characteristics, initial clinical status, and severe injuries associated with spinal fractures in a retrospective cohort of 506 trauma patients.

J Trauma Acute Care Surg 2021 09;91(3):527-536

From the Trauma Critical Care Unit (H.W., M.G., X.C., J.C.), Montpellier University Hospital, Montpellier; OcciTRAUMA Network (H.W., M.G., X.C., J.C.), Occitanie; and Radiology Department (A.B., C.C., I.M.), Neurosurgery Department (N.L.), Montpellier University Hospital, Montpellier, France.

Background: Our aim was to describe the characteristics of vertebral fractures, the presence of associated injuries, and clinical status within the first days in a severe trauma population.

Methods: All patients with severe trauma admitted to our level 1 trauma center between January 2015 and December 2018 with a vertebral fracture were analyzed retrospectively. The fractures were determined by the AO Spine classification as stable (A0, A1, and A2 types) or unstable (A3, A4, B, and C types). Clinical status was defined as stable, intermediate, or unstable based on clinicobiological parameters and anatomic injuries. Severe extraspinal injuries and emergent procedures were studied. Three groups were compared: stable fracture, unstable fracture, and spinal cord injury (SCI) group.

Results: A total of 425 patients were included (mean ± SD age, 43.8 ± 19.6 years; median Injury Severity Score, 22 [interquartile range, 17-34]; 72% male); 72 (17%) in the SCI group, 116 (27%) in the unstable fracture group, and 237 (56%) in the stable fracture group; 62% (95% confidence interval [CI], 57-67%) had not a stable clinical status on admission (unstable, 30%; intermediate, 32%), regardless of the group (p = 0.38). This decreased to 31% (95% CI, 27-35%) on day 3 and 23% (95% CI, 19-27%) on day 5, regardless of the group (p = 0.27 and p = 0.25). Progression toward stable clinical status between D1 and D5 was 63% (95% CI, 58-68%) overall but was statistically lower in the SCI group. Severe extraspinal injuries (85% [95% CI, 82-89%]) and extraspinal emergent procedures (56% [95% CI, 52-61%]) were comparable between the three groups. Only abdominal injuries and hemostatic procedures significantly differed significantly (p = 0.003 and p = 0.009).

Conclusion: More than the half of the patients with severe trauma had altered initial clinical status or severe extraspinal injuries that were not compatible with safe early surgical management for the vertebral fracture. These observations were independent of the stability of the fracture or the presence of an SCI.

Level Of Evidence: Prognostic and epidemiological, level III.
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http://dx.doi.org/10.1097/TA.0000000000003249DOI Listing
September 2021

Combined video-assisted thoracoscopy surgery and posterior midline incision for en bloc resection of non-small-cell lung cancer invading the spine.

Interact Cardiovasc Thorac Surg 2021 Jul 30. Epub 2021 Jul 30.

Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

Objectives: This article aims to evaluate the feasibility and safety of a hybrid video-assisted thoracic surgery (VATS) approach to achieve en bloc lobectomy and spinal resection for non-small-cell lung cancer (NSCLC).

Methods: Between October 2015 and November 2020, 10 patients underwent VATS anatomical lobectomy and en bloc chest wall and spinal resection through a limited posterior midline incision as a single operation for T4 (vertebral involvement) lung cancer. Nine patients had Pancoast syndrome without vascular involvement and 1 patient had NSCLC of the right lower lobe with invasion of T9 and T10.

Results: There were 5 men and 5 women. The mean age was 61 years (range: 47-74 years). Induction treatment was administered to 9 patients (90%). The average operative time was 315.5 min (range: 250-375 min). The average blood loss was 665 ml (range: 100-2500 ml). Spinal resection was hemivertebrectomy in 6 patients and wedge corpectomy in 4 patients. Complete resection (R0) was achieved in all patients. The average hospitalization stay was 14 days (range: 6-50 days). There was no in-hospital mortality. The mean follow-up was 32.3 months (range: 6-66 months). Six patients (60%) are alive without recurrence.

Conclusions: VATS is feasible and safe to achieve en bloc resection of NSCLC inviding the spine without compromising oncological efficacy. Further experience and longer follow-up are needed to determine if this approach provides any advantages over thoracotomy.
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http://dx.doi.org/10.1093/icvts/ivab215DOI Listing
July 2021

Corticosteroids as an Adjuvant Treatment to Surgery in Chronic Subdural Hematomas: A Multi-Center Double-Blind Randomized Placebo-Controlled Trial.

J Neurotrauma 2021 Jun 28;38(11):1484-1494. Epub 2021 Apr 28.

Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.

Chronic subdural hematoma (CSDH) is a common condition necessitating surgery; however, recurrence occurs in 15-25% of cases despite surgical management. The HEMACORT trial was a prospective randomized, double-blind, placebo-controlled, multi-centric study (NCT01380028). The aim of this trial was to determine the effect of corticosteroids as an adjuvant treatment to surgery on CSDH recurrence at 6 months. After surgery, participants were assigned by block-randomization to receive either placebo or oral prednisone at a dose of 1 mg/kg/day followed by weekly stepwise tapering in steps of 10 mg/day. The primary outcome was CSDH recurrence, defined by the need for reoperation and/or radiological progression of CSDH. Secondary outcomes were one-year death, radiological changes, safety, neurological status, and quality of life. The trial was discontinued at midpoint of expected inclusions: 78 participants received prednisone and 77 received placebo controls. In an intention-to-treat analysis, CSDH clinicoradiological recurrence was not different between prednisone and placebo groups (21.8% vs. 35.1%, respectively; hazard ratio 0.56; 95% confidence interval 0.30-1.02;  = 0.06), although analyses concluded to statistical significance ( = 0.02). Earlier radiological resolution was observed after prednisone administration, but reoperation rates (reaching 5.8% overall) and functional outcomes were not different at 6 months. Among adverse events, sleep disorders occurred more often in the prednisone group (26.1% vs. 9.1%,  = 0.02). The HEMACORT trial data suggest that prednisone, as an adjuvant treatment to surgery, may reduce early radiological recurrence of CSDH, although clinical benefits are unclear. In view of these findings, the authors suggest that shorter treatment duration should be assessed for safety and efficacy in future trials.
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http://dx.doi.org/10.1089/neu.2020.7560DOI Listing
June 2021

Litigations following spinal neurosurgery in France: "out-of-court system," therapeutic hazard, and welfare state.

Neurosurg Focus 2020 11;49(5):E11

6Department of Neurosurgery, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France.

Objective: Spinal surgeries carry risks of malpractice litigation due to the random nature of their functional results, which may not meet patient expectations, and the hazards associated with these complex procedures. Claims are frequent and costly. In France, since 2002, a new law, the Patients' Rights Law of March 4, 2002, has created an alternative, out-of-court scheme, which established a simplified, rapid, free-of-charge procedure (Commission for Conciliation and Compensation [CCI]). Moreover, this law has optimized the compensation provided to patients for therapeutic hazards by use of a national solidarity fund. The authors analyzed the consequences of this alternative route in the case of claims against private neurosurgeons in France.

Methods: From the data bank of the insurer Mutuelle d'Assurances du Corps de Santé Français (MACSF), the main insurance company for private neurosurgeons in France, the authors retrospectively analyzed 193 files covering the period 2015-2019. These computerized files comprised the anonymized medical records of the patients, the reports of the independent experts, and the final judgments of the CCI and the entities supporting the compensation, if any.

Results: During the 5-year study period (2015-2019), the insurance company recorded 494 complaints involving private neurosurgeons for spinal surgery procedures, of which 126 (25.5%) were in civil court, 123 (24.9%) were under amicable procedure, and 245 (49.6%) were in the out-of-court scheme administered by the CCI. Out of these 245 cases, only 193 were closed due to delays. The conclusions of the commission were rejection/incompetence decisions in 47.2% of the cases, therapeutic hazards in 21.2%, nosocomial infections in 17.6%, and practitioner fault in 13.5%. National solidarity compensated for 48 complaints (24.8%). The final decision of the CCI is not always consistent with the conclusions of the experts mandated by it, illustrating the difficulty in defining the concept of hazards. The authors found that the therapeutic hazards retained and compensated by the national solidarity included decompensated spondylotic myelopathies (15% of the 40 cases) and cauda equina syndromes (30%). As allowed by law, 11.5% of the patients who were not satisfied triggered a classical procedure in a court.

Conclusions: In the French out-of-court system, trial decisions resulting in rulings of proven medical malpractice are rare, but patients can start a new procedure in the classical courts. The therapeutic hazard remains a subtle definition, which may be problematic and require further discussion between experts and magistrates. In spite of the imperfections, this out-of-court system proposes a major evolution to move patients and medical providers from legal battles to reconciliations.
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http://dx.doi.org/10.3171/2020.8.FOCUS20582DOI Listing
November 2020

Management of Incidental Durotomy: Results from a Nationwide Survey Conducted by the French Society of Spine Surgery.

World Neurosurg 2020 11 22;143:e188-e192. Epub 2020 Jul 22.

Service de Neurochirurgie, Clinique de l'Union, Saint-Jean, France.

Objective: To obtain real-life data on the most common practices used for management of incidental durotomy (ID) in France.

Methods: Data were collected from spinal surgeons using a practice-based online questionnaire. The survey comprised 31 questions on the current management of ID in France. The primary outcome was the identification of areas of consensus and uncertainty on ID follow-up.

Results: A total of 217 surgeons (mainly orthopaedic surgeons and neurosurgeons) completed the questionnaire and were included in the analysis. There was a consensus on ID repair with 94.5% of the surgeons considering that an ID should always be repaired, if repairable, and 97.2% performing a repair if an ID occurred. The most popular techniques were simple suture or locked continuous suture (48.3% vs. 57.8% of surgeons). Nonrepairable IDs were more likely to be treated with surgical sealants than with an endogenous graft (84.9% vs. 75.5%). Almost two thirds of surgeons (71.6%) who adapted their standard postoperative protocol after an ID recommended bed rest in the supine position. Among these, 48.8% recommended 24 hours of bed rest, while 53.5% recommended 48 hours of bed rest. The surgeons considered that the main risk factors for ID were revision surgery (98.6%), patient's age (46.8%), surgeon's exhaustion (46.3%), and patient's weight (21.3%).

Conclusions: This nationwide survey reflects the lack of a standardized management protocol for ID. Practices among surgeons remain very heterogeneous. Further consensus studies are required to develop a standard management protocol for ID.
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http://dx.doi.org/10.1016/j.wneu.2020.07.121DOI Listing
November 2020

French Spine Surgery Society guidelines for management of spinal surgeries during COVID-19 pandemic.

World J Clin Cases 2020 May;8(10):1756-1762

Aix-Marseille Université, APHM, CNRS, ISM, CHU Timone, Unité de Chirurgie Rachidienne, Marseille 13005, France.

Since the outbreak of coronavirus disease 2019 (COVID-19) in December 2019 in China, various measures have been adopted in order to attenuate the impact of the virus on the population. With regard to spine surgery, French physicians are devoted to take place in the national plan against COVID-19, the French Spine Surgery Society therefore decided to elaborate specific guidelines for management of spinal disorders during COVID-19 pandemic in order to prioritize management of patients. A three levels stratification was elaborated with Level I: Urgent surgical indications, Level II: Surgical indications associated to a potential loss of chance for the patient and Level III: Non-urgent surgical indications. We also report French experience in a COVID-19 cluster region illustrated by two clinical cases. We hope that the guidelines formulated by the French Spine Surgery Society and the experience of spine surgeons from a cluster region will be helpful in order optimizing the management of patients with urgent spinal conditions during the pandemic.
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http://dx.doi.org/10.12998/wjcc.v8.i10.1756DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7262704PMC
May 2020

Middle meningeal artery embolization as an adjuvant treatment to surgery for symptomatic chronic subdural hematoma: a pilot study assessing hematoma volume resorption.

J Neurointerv Surg 2020 Jul 20;12(7):695-699. Epub 2019 Dec 20.

Department of Neuroradiology, Montpellier University Medical Center, Montpellier, Occitanie, France.

Background: Chronic subdural hematoma (CSDH) is a common condition requiring surgical treatment; however, recurrence occurs in 15% of cases at 1 year. Middle meningeal artery (MMA) embolization has recently emerged as a promising treatment to prevent CSDH recurrence.

Objective: To investigate the effect of MMA embolization on hematoma volume resorption (HVR) after surgery in symptomatic patients.

Methods: From April 2018 to October 2018, participants with CSDH requiring surgery were prospectively randomized in a pilot study, and received either surgical treatment alone (ST group) or surgery and adjuvant MMA embolization (ST+MMAE group). The primary outcome was HVR measured on the 3 month CT scan compared with the immediate pre-embolization CT scan. Secondary outcomes were clinical recurrence of CSDH and safety measures.

Results: 46 patients were randomized and 41 of these achieved a 3 month follow-up . Twenty-one patients received MMA embolization. At 3 months, the HVR from postsurgical level was higher in the ST+MMAE group (mean difference 17.5 mL, 95% CI 3.87 to 31.16 mL; p=0.015). Two participants presented a CSDH recurrence (one in each group). One patient died (ST group). No MMA embolization-related adverse events were reported.

Conclusion: The addition of MMA embolization to surgery led to an increase in CSDH resorption at 3 months. One recurrence of CSDH was reported in each group, and there were no treatment-related complications.
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http://dx.doi.org/10.1136/neurintsurg-2019-015421DOI Listing
July 2020

Hangman's fracture: Management strategy and healing rate in a prospective multi-centre observational study of 34 patients.

Orthop Traumatol Surg Res 2019 06 17;105(4):703-707. Epub 2019 Apr 17.

Société Française de Chirurgie Rachidienne, 56, rue Boisonnade, 75014 Paris, France.

Background: Hangman's fractures account for 15% to 20% of all cervical spine fractures. The grading system developed by Effendi and modified by Levine and Edwards is generally used as the basis for management decisions. Nonetheless, the optimal management remains controversial. The objective of this study was to describe the treatments used in France in patients with hangman's fractures. The complications and healing rates were analysed according to the fracture type and treatment used.

Hypothesis: Among patients with hangman's fracture, those with disc damage must be treated surgically.

Material And Methods: A prospective, multi-centre, observational study was conducted under the aegis of the French Society for Spine Surgery (SociétéFrançaisedeChirurgieRachidienne, SFCR). Patients were included if they had computed tomography (CT) evidence of hangman's fracture. Follow-up data were collected prospectively. Fracture healing was assessed on CT scans obtained 3 and 12 months after the injury. The type of treatment and complications were recorded routinely.

Results: We included 34 patients. The fracture type according to Effendi modified by Levine and Edwards was I in 68% of patients, II in 29% of patients, and III in a single patient (3%). The treatment was non-operative in 21 (62%) patients and surgical in 11 (32%). All 28 patients re-evaluated after 1 year had evidence of fracture healing. The remaining 6 patients were lost to follow-up.

Conclusion: Hangman's fracture is associated with low rates of mortality and neurological complications. Non-operative treatment is appropriate in Type I hangman's fracture, with a 100% healing rate in our study. Types II and III are characterised by damage to the ligaments and discs requiring either anterior C2-C3 fusion or posterior C1-C3 screw fixation.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.otsr.2019.03.009DOI Listing
June 2019

Anterior cervical spine surgical site infection and pharyngoesophageal perforation. Ten-year incidence in 1475 patients.

Orthop Traumatol Surg Res 2019 06 12;105(4):697-702. Epub 2019 Apr 12.

CHU Montpellier - Gui-de-Chauliac, 80, avenue Augustin-Fliche, 34090 Montpellier, France.

Background: Surgical site infection is reputed to be infrequent in anterior cervical spine surgery. Data on pathophysiological mechanism and risk factors are sparse. The relationship between local site infection and pharyngoesophageal perforation is unclear. The present study aimed: (1) to estimate the incidence of surgical site infection in anterior cervical spine surgery, (2) estimate the incidence of associated pharyngoesophageal perforation, and (3) suggest a decision-tree for early management of this two-fold issue.

Hypothesis: Although with very low incidence, anterior cervical spine surgical site infection and pharyngoesophageal perforation are frequently associated.

Material And Methods: A 2-center retrospective study included all anterior cervical spine surgeries between January 1, 2007 and December 31, 2016. Data were provided by the two medical information departments. Patients undergoing anterior revision surgery on the cervical spine were included. Files were analyzed to determine whether the revision surgery was secondary to surgical site infection.

Results: In total, 1475 patients with anterior cervical spine surgery were identified: 1180 in center A (80%) and 295 in center B (20%). The rate of revision surgery for surgical site infection was 0.34% (5/1475). There were 3 cases of pharyngoesophageal perforation (0.2%).

Discussion: The incidence of revision surgery for anterior cervical spine surgical site infection was comparable to rates in the international literature (0.07-1.6%). An association between surgical site infection and pharyngoesophageal perforation was frequent, but not statistically significant. This complication is extremely serious, requiring urgent multidisciplinary management.

Level Of Evidence: IV, retrospective study.
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http://dx.doi.org/10.1016/j.otsr.2019.02.018DOI Listing
June 2019

Clinical and radiological outcomes of a cervical cage with integrated fixation.

Medicine (Baltimore) 2019 Jan;98(3):e14097

Clinical Affairs Department, Zimmer Biomet Spine, Troyes, France.

Cervical cages with integrated fixation have been increasingly used in anterior cervical discectomy and fusion (ACDF) to avoid complications associated with anterior cervical plates. The purpose of this paper is to provide 2-year follow-up results of a prospective study after implantation of a cervical cage with an integrated fixation system.This was a prospective multicenter outcome study of 90 patients who underwent ACDF with a cage with integrated fixation. Fusion was evaluated from computed tomography images (CT-images) by an independent laboratory at 2-year follow-up (FU). Clinical and radiological findings were recorded preoperatively and at FU visits and complications were reported.At 24 months, the fusion rate was 93.4%. All average clinical outcomes were significantly improved at 2 years FU compared to baseline: neck disability index (NDI) 18.9% vs 44.4%, visual analog scale (VAS) for arm pain 18.2 mm vs 61.9 mm, VAS for neck pain 23.9 mm vs 55.6 mm. Short form-36 (SF-36) scores were significantly improved. One case of dysphagia, which resolved within 12 months, and 1 reoperation for symptomatic pseudarthrosis were reported. Subsidence with no clinical consequence or reoperation was reported for 5/125 of the implanted cages (4%). There was also 1 case of per-operative vertebral body fracture that did not require additional surgery. Superior and inferior adjacent discs showed no significant change of motion at 2-year FU compared to baseline. Disc height index (DHI) and lordosis were enhanced and these improvements were maintained at 1 year.The ACDF using cages with an integrated fixation system demonstrated reliable clinical and radiological outcomes and a high interbody fusion rate. This rate is comparable to the rate reported in recent series using other implants with integrated fixation, but the present device had a lower complication rate.
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http://dx.doi.org/10.1097/MD.0000000000014097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6370175PMC
January 2019

Partial Vertebrectomies without Instrumented Stabilization During En Bloc Resection of Primary Bronchogenic Carcinomas Invading the Spine: Feasibility Study and Results on Spine Balance.

World Neurosurg 2019 Feb 22;122:e1542-e1550. Epub 2018 Nov 22.

Department of Neurosurgery, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France; INSERM U1198, University of Montpellier, Montpellier, France.

Objective: It is unknown whether spinal instrumentation is required to prevent deformity after partial vertebrectomy in the treatment of primary bronchogenic carcinomas invading the spine (PBCIS). In this study, we focus on the postoperative spine deformity in patients who underwent operation for partial vertebrectomies without instrumentation during en bloc PBCIS resection. Our objective was to determine whether deformity depends on the type of vertebral resection and if any vertebral resection threshold can be observed to justify additional spinal instrumentation.

Methods: This is a retrospective study, including all patients with PBCIS operated without spinal instrumentation from 2009 to 2018. Partial vertebrectomies were classified into categories A, B, and C depending on vertebral resection. Patients had long-term radiologic follow-up to assess the spine deformity evolution.

Results: Eighteen patients were included. The median follow-up was 27 months. Four patients underwent a secondary posterior instrumentation surgical procedure due to progressive spinal deformity. A low-risk group of deformation was characterized as type A resection and type B resection on less than 3 vertebrae.

Conclusions: There are no validated criteria to justify a systematic spinal instrumentation when performing a partial vertebrectomy during en bloc resection of PBCIS. Performed alone without spine instrumentation, both type A and type B resections on less than 3 resected vertebrae were not subject to sagittal and coronal deformity even after a long follow-up, emphasizing that a systematic stabilization is not needed in this low-risk group. These results could help to reduce the perioperative morbidity of these procedures that are usually long and complex.
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http://dx.doi.org/10.1016/j.wneu.2018.11.098DOI Listing
February 2019

Mortality, complication, and fusion rates of patients with odontoid fracture: the impact of age and comorbidities in 204 cases.

Arch Orthop Trauma Surg 2019 Jan 13;139(1):43-51. Epub 2018 Oct 13.

Service de neurochirurgie C et chirurgie du rachis, Hôpital P Wertheimer, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, 59 boulevard Pinel, 69003, Lyon, France.

Purpose: The French Society of Spine Surgery (SFCR) conducted a prospective epidemiologic multicenter study. The purpose was to investigate mortality, complication, and fusion rates in patients with odontoid fracture, depending on age, comorbidities, fracture type, and treatment.

Methods: Out of 204 patients, 60 were ≤ 70 years and 144 were > 70 years. Demographic data, comorbidities, treatment types and complications (general medical, infectious, neurologic, and mechanical), and death were registered within the first year. Fractures were classified according to Anderson-D'Alonzo and Roy-Camille on the initial CT. A 1-year follow-up CT was available in 144 patients to evaluate fracture consolidation.

Results: Type II and oblique-posterior fractures were the most frequent patterns. The treatment was conservative in 52.5% and surgical in 47.5%. The mortality rate in patients ≤ 70 was 3.3% and 16.7% in patients > 70 years (p = 0.0002). Fracture pattern and treatment type did not influence mortality. General medical complications were significantly more frequent > 70 years (p = 0.021) and after surgical treatment (p = 0.028). Neurologic complications occurred in 0.5%, postoperative infections in 2.0%, and implant-related mechanical complications in 10.3% (associated with pseudarthrosis). Fracture fusion was observed in 93.5% of patients ≤ 70 years and in 62.5% >70 years (p < 0.0001). Pseudarthrosis was present in 31.5% of oblique-posterior fractures and in 24.3% after conservative treatment.

Conclusions: Age and comorbidities influenced mortality and medical complication rates most regardless of fracture type and treatment choice. Pseudarthrosis represented the main complication, which increased with age. Pseudarthrosis was most frequent in type II and oblique-posterior fractures after conservative treatment.
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http://dx.doi.org/10.1007/s00402-018-3050-6DOI Listing
January 2019

C1 fracture: Analysis of consolidation and complications rates in a prospective multicenter series.

Orthop Traumatol Surg Res 2018 11 9;104(7):1049-1054. Epub 2018 Oct 9.

Service de neurochirurgie C et chirurgie du Rachis, université Claude-Bernard Lyon 1, hôpital P. Wertheimer, 59, boulevard Pinel, 69003 Lyon, France.

Introduction: Three types of C1 fracture have been described, according to location: type 1 (anterior or posterior arc), type 2 (Jefferson: anterior and posterior arc), and type 3 (lateral mass). Stability depends on transverse ligament integrity. The main aim of the present study was to analyze complications and consolidation rates according to fracture type, age and treatment.

Material And Methods: The French Society of Spinal Surgery (SFCR) performed a multicenter prospective study on C1-C2 trauma. All patients with recent fracture diagnosed on CT were included. Consolidation on CT was studied at 3 months and 1 year. Medical, neurologic, infectious and mechanical complications were inventoried using the KEOPS data-base.

Results: Sixty-three of the 417 patients (15.1%) had C1 fracture: type 1 (33.3%), type 2 (38.1%), or type 3 (28.6%). The transverse ligament was intact in 53.9% of cases. Treatment was non-operative in 63.5% of cases, surgical in 27.0%, and surgical after failure of non-operative treatment in 9.5%. There were 8 medical complications, more frequently in patients aged >70 years, following surgery (p<0.0001). The consolidation rate was 84.2% with non-operative treatment, 100% for primary surgery, and 33.3% for secondary surgery (p=0.002). There were 10 cases of non-union, in 4.8% of type 1, 13.6% of type 2 and 33.3% of type 3 fractures (p=0.001).

Conclusion: Medical complications showed association with age and with type of treatment. Non-operative treatment was suited to types 1, 2 and 3 with minimal displacement and intact transverse ligament. C1-C2 fusion was suited to displaced unstable type 2 fracture. Displaced type 3 fracture incurred risk of non-union. Early surgery may be recommended.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.otsr.2018.06.014DOI Listing
November 2018

Bow Hunter's Syndrome: Surgical Vertebral Artery Decompression Guided by Dynamic Intraoperative Angiography.

World Neurosurg 2018 Oct 27;118:290-295. Epub 2018 Jul 27.

Department of Neurosurgery, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France; INSERM U1198, University of Montpellier, Montpellier, France.

Background: Bow hunter's syndrome is a symptomatic vertebrobasilar insufficiency resulting from a rotational stenosis or occlusion of a dominant vertebral artery (VA). The VA is dynamically compressed by cervical osteoarthritis (discovertebral structure or osteophytes) during head rotation or neck extension. Diagnosis is based on dynamic computed tomography angiography and confirmed with dynamic catheter angiography. Surgery tends to be the best treatment option in most cases. Dynamic intraoperative assessment of VA decompression seems to improve surgical results but remains poorly evaluated in the literature.

Case Description: A 70-year-old man with bow hunter's syndrome related to left VA compression by C3-4 osteophyte protrusion presented with syncopal episodes during left head rotation. Bow hunter's syndrome was successfully managed with an anterior transuncal surgical decompression of the left VA and C3-4 fusion. Surgical decompression was guided by dynamic intraoperative catheter angiography and secured with an intra-arterial remodeling balloon placed just before surgery. The patient was symptom-free after surgery.

Conclusions: Surgical decompression guided by dynamic intraoperative catheter angiography leads to selective VA release and allows real-time assessment of the efficacy of the decompression. This multidisciplinary treatment involving neurosurgical and neuroradiologic teams is a simple and effective treatment. Dynamic intraoperative catheter angiography is an essential guide to perform selective decompression of the VA, and implementation of an intra-arterial remodeling balloon can improve the safety of surgery making this method valuable compared with other intraoperative assessment techniques, such as Doppler ultrasound and indocyanine green fluorescent videography.
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http://dx.doi.org/10.1016/j.wneu.2018.07.152DOI Listing
October 2018

Surgeon's and patient's radiation exposure during percutaneous thoraco-lumbar pedicle screw fixation: A prospective multicenter study of 100 cases.

Orthop Traumatol Surg Res 2018 09 30;104(5):597-602. Epub 2018 Jun 30.

Neurosurgery Unit, Hôpital Gui-de-Chauliac, CHU de Montpellier, 34000 Montpellier, France. Electronic address:

Hypothesis: Percutaneous pedicle screw fixations (PPSF) are increasingly used in spine surgery, minimizing morbidity through less muscle breakdown but at the cost of intraoperative fluoroscopic guidance that generates high radiation exposure. Few studies have been conducted to measure them accurately.

Material And Methods: The objective of our study is to quantify, during a PPSF carried out in different experimented centers respecting current radiation protection recommendations, this irradiation at the level of the surgeon and the patient. We have prospectively included 100 FPVP procedures for which we have collected radiation doses from the main operator. For each procedure, the doses of whole-body radiation, lens and extremities were measured.

Results: Our results show a mean whole body, extremity and lens exposure dose per procedure reaching 1.7±2.8μSv, 204.7±260.9μSv and 30.5±25.9μSv, respectively. According to these values, the exposure of the surgeon's extremities and lens will exceed the annual limit allowed by the International Commission on Radiological Protection (ICRP) after 2440 and 4840 procedures respectively.

Conclusion: Recent European guidelines will reduce the maximum annual exposure dose from 150 to 20mSv. The number of surgical procedures to not reach the eye threshold, according to our results, should not exceed 645 procedures per year. Pending the democratization of neuronavigation systems, the use of conventional fluoroscopy exposes the eyes in the first place. Therefore they must be protected by leaded glasses.

Level Of Proof: IV, case series.
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http://dx.doi.org/10.1016/j.otsr.2018.05.009DOI Listing
September 2018

A Novel Translational Model of Spinal Cord Injury in Nonhuman Primate.

Neurotherapeutics 2018 07;15(3):751-769

INSERM U1051, Rue Augustin Fliche, F-34095, Montpellier Cedex 5, France.

Spinal cord injuries (SCI) lead to major disabilities affecting > 2.5 million people worldwide. Major shortcomings in clinical translation result from multiple factors, including species differences, development of moderately predictive animal models, and differences in methodologies between preclinical and clinical studies. To overcome these obstacles, we first conducted a comparative neuroanatomical analysis of the spinal cord between mice, Microcebus murinus (a nonhuman primate), and humans. Next, we developed and characterized a new model of lateral spinal cord hemisection in M. murinus. Over a 3-month period after SCI, we carried out a detailed, longitudinal, behavioral follow-up associated with in vivo magnetic resonance imaging (H-MRI) monitoring. Then, we compared lesion extension and tissue alteration using 3 methods: in vivo H-MRI, ex vivo H-MRI, and classical histology. The general organization and glial cell distribution/morphology in the spinal cord of M. murinus closely resembles that of humans. Animals assessed at different stages following lateral hemisection of the spinal cord presented specific motor deficits and spinal cord tissue alterations. We also found a close correlation between H-MRI signal and microglia reactivity and/or associated post-trauma phenomena. Spinal cord hemisection in M. murinus provides a reliable new nonhuman primate model that can be used to promote translational research on SCI and represents a novel and more affordable alternative to larger primates.
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http://dx.doi.org/10.1007/s13311-017-0589-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6095780PMC
July 2018

A Combination of Diffusion MRI and Multiphoton to Study Microglia/Monocytes Alterations after Spinal Cord Injury.

Front Aging Neurosci 2017 19;9:230. Epub 2017 Jul 19.

Institut National de la Santé et de la Recherche Médicale, U1051Montpellier, France.

Central nervous system (CNS) injury has been observed to lead to microglia activation and monocytes infiltration at the lesion site. diffusion magnetic resonance imaging (diffusion MRI or DWI) allows detailed examination of CNS tissues, and recent advances in clearing procedures allow detailed imaging of fluorescent-labeled cells at high resolution. No study has yet combined diffusion MRI and clearing procedures to establish a possible link between microglia/monocytes response and diffusion coefficient in the context of spinal cord injury (SCI). We carried out MRI of the spinal cord at different time-points after spinal cord transection followed by tetrahydrofuran based clearing and examined the density and morphology of microglia/monocytes using two-photon microscopy. Quantitative analysis revealed an early marked increase in microglial/monocytes density that is associated with an increase in the extension of the lesion measured using diffusion MRI. Morphological examination of microglia/monocytes somata at the lesion site revealed a significant increase in their surface area and volume as early as 72 hours post-injury. Time-course analysis showed differential microglial/monocytes response rostral and caudal to the lesion site. Microglia/monocytes showed a decrease in reactivity over time caudal to the lesion site, but an increase was observed rostrally. Direct comparison of microgliamonocytes morphology, obtained through multiphoton, and the longitudinal apparent diffusion coefficient (ADC), measured with diffusion MRI, highlighted that axonal integrity does not correlate with the density of microglia/monocytes or their somata morphology. We emphasize that differential microglial/monocytes reactivity rostral and caudal to the lesion site may thus coincide, at least partially, with reported temporal differences in debris clearance. Our study demonstrates that the combination of diffusion MRI and two-photon microscopy may be used to follow structural tissue alteration. Lesion extension coincides with microglia/monocytes density; however, a direct relationship between ADC and microglia/monocytes density and morphology was not observed. We highlighted a differential rostro-caudal microglia/monocytes reactivity that may correspond to a temporal difference in debris clearance and axonal integrity. Thus, potential therapeutic strategies targeting microglia/monocytes after SCI may need to be adjusted not only with the time after injury but also relative to the location to the lesion site.
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http://dx.doi.org/10.3389/fnagi.2017.00230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5515855PMC
July 2017

Instrumented Circumferential Fusion in Two Stages for Instable Lumbar Fracture: Long-Term Results of a Series of 74 Patients on Sagittal Balance and Functional Outcomes.

World Neurosurg 2017 Jul 20;103:303-309. Epub 2017 Apr 20.

Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier, France. Electronic address:

Objective: To report the radiologic and functional results of a multicenter, prospective case series of patients with comminuted lumbar fractures treated with 2-stage circumferential arthrodesis.

Methods: A multicenter prospective case series of 74 patients with comminuted lumbar fractures was analyzed. The strategy entailed initial posterior osteosynthesis, followed by physical replacement with an expandable titanium cage filled with autologous bone via retroperitoneal lumbotomy. The mechanism of lesion formation and epidemiologic characteristics were recorded. Clinical and quality-of-life analyses (visual analog scale [VAS], Oswesty Disability Index [ODI], Short Form 12 [SF-12]) were performed over a minimum observation period of 1 year. Radiologic parameters, including deformity measurements, were recorded at each evaluation. Fusion was analyzed by means of a 1-year monitoring scan.

Results: The mean patient age was 38.1 years, and median duration of follow-up was 2.1 years (interquartile range, 1.3-2.9). The distribution of fractures according to the Magerl classification scheme was as follows: A, 64.8%; B, 16.7%; C, 18.5%. At the last follow-up, fusion was considered certain in 57 cases (77%). The mean VAS score was 2.1 ± 1.3, mean ODI was 14.7 ± 8.0, mean SF-12 Physical Component Summary score was 43.2 ± 9.3, and mean SF-12 Mental Component Summary score was 50.8 ± 5.9. Correction of the regional sagittal deformity was significant during the postoperative period, with a mean increase in lordosis of 9.0° (P < 0.0001). The loss of mean correction at the last follow-up (-2.9°) was not significant.

Conclusions: Circumferential arthrodesis, including posterior osteosynthesis and physical replacement with an expandable cage and autologous graft, is applicable to the treatment of comminuted lumbar fractures. A high rate of fusion was obtained with significant and long-lasting correction of the sagittal deformity. Functional scores measured at 1 year suggest mild disability. The ODI, SF-12, and VAS scores were positively correlated with fusion at the last follow-up.
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http://dx.doi.org/10.1016/j.wneu.2017.04.074DOI Listing
July 2017

RNA-Seq Analysis of Microglia Reveals Time-Dependent Activation of Specific Genetic Programs following Spinal Cord Injury.

Front Mol Neurosci 2017 3;10:90. Epub 2017 Apr 3.

MMDN, University of Montpellier; EPHE, Institut National de la Santé et de la Recherche Médicale U1198Montpellier, France.

Neurons have inherent competence to regrow following injury, although not spontaneously. Spinal cord injury (SCI) induces a pronounced neuroinflammation driven by resident microglia and infiltrating peripheral macrophages. Microglia are the first reactive glial population after SCI and participate in recruitment of monocyte-derived macrophages to the lesion site. Both positive and negative influence of microglia and macrophages on axonal regeneration had been reported after SCI, raising the issue whether their response depends on time post-lesion or different lesion severity. We analyzed molecular alterations in microglia at several time-points after different SCI severities using RNA-sequencing. We demonstrate that activation of microglia is time-dependent post-injury but is independent of lesion severity. Early transcriptomic response of microglia after SCI involves proliferation and neuroprotection, which is then switched to neuroinflammation at later stages. Moreover, SCI induces an autologous microglial expression of astrocytic markers with over 6% of microglia expressing glial fibrillary acidic protein and vimentin from as early as 72 h post-lesion and up to 6 weeks after injury. We also identified the potential involvement of DNA damage and in particular tumor suppressor gene () in microglia after SCI. Finally, we established that BRCA1 protein is specifically expressed in non-human primate spinal microglia and is upregulated after SCI. Our data provide the first transcriptomic analysis of microglia at multiple stages after different SCI severities. Injury-induced microglia expression of astrocytic markers at RNA and protein levels demonstrates novel insights into microglia plasticity. Finally, increased microglia expression of BRCA1 in rodents and non-human primate model of SCI, suggests the involvement of oncogenic proteins after CNS lesion.
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http://dx.doi.org/10.3389/fnmol.2017.00090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5376598PMC
April 2017

Coxsackievirus Adenovirus Receptor Loss Impairs Adult Neurogenesis, Synapse Content, and Hippocampus Plasticity.

J Neurosci 2016 09;36(37):9558-71

Institut de Génétique Moléculaire de Montpellier, Centre National de la Recherche Scientifique 5535, 34293 Montpellier, France, Université de Montpellier, 34000 Montpellier, France,

Unlabelled: Although we are beginning to understand the late stage of neurodegenerative diseases, the molecular defects associated with the initiation of impaired cognition are poorly characterized. Here, we demonstrate that in the adult brain, the coxsackievirus and adenovirus receptor (CAR) is located on neuron projections, at the presynapse in mature neurons, and on the soma of immature neurons in the hippocampus. In a proinflammatory or diseased environment, CAR is lost from immature neurons in the hippocampus. Strikingly, in hippocampi of patients at early stages of late-onset Alzheimer's disease (AD), CAR levels are significantly reduced. Similarly, in triple-transgenic AD mice, CAR levels in hippocampi are low and further reduced after systemic inflammation. Genetic deletion of CAR from the mouse brain triggers deficits in adult neurogenesis and synapse homeostasis that lead to impaired hippocampal plasticity and cognitive deficits. We propose that post-translational CAR loss of function contributes to cognitive defects in healthy and diseased-primed brains.

Significance Statement: This study addressed the role of the coxsackievirus and adenovirus receptor (CAR), a single-pass cell adhesion molecule, in the adult brain. Our results demonstrate that CAR is expressed by mature neurons throughout the brain. In addition, we propose divergent roles for CAR in immature neurons, during neurogenesis, and at the mature synapse. Notably, CAR loss of function also affects hippocampal plasticity.
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http://dx.doi.org/10.1523/JNEUROSCI.0132-16.2016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6601941PMC
September 2016

Surgeon's and Patient's Radiation Exposure Through Vertebral Body Cement Augmentation Procedures: A Prospective Multicentric Study of 49 Cases.

World Neurosurg 2016 Sep 1;93:371-6. Epub 2016 Jun 1.

Department of Orthopedic and Spine Surgery, Hôpital Universitaire Carémeau, Nîmes, France.

Objective: Vertebral body cement augmentation as a treatment option for osteoporotic or traumatic fractures has become increasingly popular during the past decade. However, these surgical procedures require numerous fluoroscopic examinations, resulting in high radiation exposure for the patient and the surgical team. The aim of this study was to evaluate the level of radiation exposure of the spine surgeon and the patient during these percutaneous procedures.

Methods: Forty-nine patients admitted for single- or 2-level vertebral compression fracture were prospectively included and treated with vertebral body cement augmentation. For each procedure, radiation dose was measured on the surgeon's whole body, lens, and extremities as well as patient irradiation. Each surgeon wore 2 thermoluminescent dosimeters to measure lens and extremities radiation exposure and 1 electronic personal dosimeter. Patient clinical and surgical data, effective dose to patient, and surgeon were analyzed.

Results: Mean operative time was 31.5 ± 11.7 minutes. The average fluoroscopic time was 61.0 ± 27.1 seconds. The average whole-body radiation dose per procedure was 1.4 ± 2.1 μSv. The average equivalent dose to lens and extremities were 44 μSv and 59 μSv, respectively.

Conclusions: Values of radiation doses for surgeon and patient were lower than those reported in the previous literature. The recommended annual dose limit is set to 500 mSv for extremities and 150 mSv for lens. According to our results, the exposure dose to the eye exceeds the annual limit after 3500 procedures. However, there is increasing concern among surgeons about radiation exposure, and there is still a need for solutions as preventive measures.
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http://dx.doi.org/10.1016/j.wneu.2016.05.070DOI Listing
September 2016

Assessment of the Radiation Exposure of Surgeons and Patients During a Lumbar Microdiskectomy and a Cervical Microdiskectomy: A French Prospective Multicenter Study.

World Neurosurg 2016 05 12;89:329-36. Epub 2016 Feb 12.

Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier, France.

Objective: Cervical and lumbar disk herniations are the most frequently carried out procedures in spinal surgery. Often, a few snapshots during the procedure are necessary to validate the level or to position the implant. The objective of this study is to quantitatively estimate the radiation received by a spine surgeon and patient during a low-dose radiation procedure.

Methods: We conducted a prospective multicenter study in France from November 2014 to April 2015. Four spine centers were monitored for radiation received by surgeons during interventions for lumbar disk herniation and cervical disk herniation.

Results: A total of 134 patients were included. For lumbar disk herniation, the average exposure for the surgeon was 0.584 μSv on the chest, 5.291 μSv on the lens, and 9.295 μSv on the hands per procedure. For these procedures, the dose area product (DAP) was 94.2 ± 198.4 cGy·cm(2), and the fluoroscopic time was 10.2 ± 16.9 seconds. For a herniated cervical disk, the average exposure for the surgeon was 0.122 μSv on the chest, 3.106 μSv on the lens, and 7.143 μSv on the hands per procedure. For these procedures, the DAP was 35.7 ± 72.1 cGy·cm(2), and the fluoroscopic time was 19.7 ± 13.7 seconds.

Conclusions: Exposure to x-rays for surgeons and patients during surgery for lumbar disk herniation is higher than during surgery for cervical herniation disk. Our results show that radiation exposure to the spine surgeon is still far below the annual dose limits.
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http://dx.doi.org/10.1016/j.wneu.2016.02.021DOI Listing
May 2016

Spinal Cervical Meningiomas: The Challenge Posed by Ventral Location.

World Neurosurg 2016 May 4;89:464-73. Epub 2016 Feb 4.

National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom.

Objective: To evaluate the incidence, clinical presentation, operative techniques, and long-term outcome of spinal cervical meningiomas after surgery.

Methods: Twenty-two patients harboring spinal meningiomas on cervical region were treated between 2004 and 2014 in our department. Diagnosis was made via magnetic resonance imaging and confirmed histologically. Microsurgical resection was performed through different surgical approaches according to location of the tumor. To remove the tumor, the posterior, far-lateral, and combined approaches were used, respectively, in 13 patients (56%), 8 patients (35%), and 2 patients (9%).

Results: The mean follow-up was 40 ± 26.5 months. The most common site of dural attachment of meningioma was ventral or ventrolateral to the spinal cord. Macroscopic resection was considered complete in 55% of cases. Neurologic improvement was observed in 60% of cases. The rate of operative mortality and morbidity was high (26.5%). Five patients underwent postoperative radiotherapy according to the actual recommendation, and the overall recurrence rate was 9%.

Conclusions: Spinal meningiomas are benign tumors for which advances in imaging tools and microsurgical techniques have yielded better results. The goal of surgery should be the total resection, which significantly decreases the risk of recurrence with an acceptable morbidity. Cervical locations represent a challenge particularly for ventro and ventrolaterally located tumors. Despite the difficulty of performing a complete resection, the results obtained in this work advocate for the use of the far-lateral approach to manage meningiomas locate anterior to the neural axis.
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http://dx.doi.org/10.1016/j.wneu.2016.01.029DOI Listing
May 2016

Nontraumatic spinal subdural hematoma complicating direct factor Xa inhibitor treatment (rivaroxaban): a challenging management.

Eur Spine J 2016 05 31;25 Suppl 1:100-3. Epub 2015 Jul 31.

Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Hospital Center, Montpellier, France.

Purpose: We report on a 72-year-old male patient who developed a nontraumatic spinal subdural hematoma (SSDH) during rivaroxaban therapy, a relatively new orally administered direct factor Xa inhibitor.

Case Description: The patient sustained a sudden onset of interscapular pain, followed by gait impairment and paraplegia. Magnetic resonance imaging (MRI) of the spine demonstrated SSDH from T6 to T8. Laboratory tests revealed a high rivaroxaban level, associated with a major hemorrhagic risk. Surgery was, therefore, performed the following morning, after normalization of coagulation parameters.

Conclusion: Determining the time of safe surgery remains challenging when hemorrhagic complications happen with direct factor Xa inhibitor, especially when neurological prognosis is engaged. Spinal subdural hematoma has not previously been reported following rivaroxaban therapy.
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http://dx.doi.org/10.1007/s00586-015-4160-2DOI Listing
May 2016

Correlation of in vivo and ex vivo (1)H-MRI with histology in two severities of mouse spinal cord injury.

Front Neuroanat 2015 5;9:24. Epub 2015 Mar 5.

Institute for Neurosciences of Montpellier, INSERM U1051 Montpellier, France ; Department "Biologie-Mécanismes du Vivant," Faculty of Science, University of Montpellier Montpellier, France.

Spinal cord injury (SCI) is a debilitating neuropathology with no effective treatment. Magnetic resonance imaging (MRI) technology is the only method used to assess the impact of an injury on the structure and function of the human spinal cord. Moreover, in pre-clinical SCI research, MRI is a non-invasive method with great translational potential since it provides relevant longitudinal assessment of anatomical and structural alterations induced by an injury. It is only recently that MRI techniques have been effectively used for the follow-up of SCI in rodents. However, the vast majority of these studies have been carried out on rats and when conducted in mice, the contusion injury model was predominantly chosen. Due to the remarkable potential of transgenic mice for studying the pathophysiology of SCI, we examined the use of both in and ex vivo (1)H-MRI (9.4 T) in two severities of the mouse SCI (hemisection and over-hemisection) and documented their correlation with histological assessments. We demonstrated that a clear distinction between the two injury severities is possible using in and ex vivo (1)H-MRI and that ex vivo MR images closely correlate with histology. Moreover, tissue modifications at a remote location from the lesion epicenter were identified by conventional ex vivo MRI analysis. Therefore, in vivo MRI has the potential to accurately identify in mice the progression of tissue alterations induced by SCI and is successfully implemented by ex vivo MRI examination. This combination of in and ex vivo MRI follow-up associated with histopathological assessment provides a valuable approach for further studies intended to evaluate therapeutic strategies on SCI.
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http://dx.doi.org/10.3389/fnana.2015.00024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4350395PMC
March 2015

Robot-assisted spine surgery: feasibility study through a prospective case-matched analysis.

Eur Spine J 2016 Mar 10;25(3):947-55. Epub 2015 Jan 10.

Department of Neurosurgery, Hôpital Gui de Chauliac, 80 Avenue Augustin Fliche, 34090, Montpellier, France.

Purpose: While image guidance and neuronavigation have enabled a more accurate placement of pedicle implants, they can inconvenience the surgeon. Robot-assisted placement of pedicle screws appears to overcome these disadvantages. However, recent data concerning the superiority of currently available robots in assisting spinal surgeons are conflicting. The aim of our study was to evaluate the percentage of accurately placed pedicle screws, inserted using a new robotic-guidance system.

Method: 20 Patients were operated on successively by the same surgeon using robotic assistance (ROSA™, Medtech) (Rosa group 10 patients, n = 40 screws) or by the freehand conventional technique (Freehand group 10 patients, n = 50 screws). Patient characteristics as well as the duration of the operation and of exposure to X rays were recorded.

Results: The mean age of patients in each group (RG and FHG) was 63 years. Mean BMI and operating time among the RG and FHG were, respectively, 26 and 27 kg/m(2), and 187 and 119 min. Accurate placement of the implant (score A and B of the Gertzbein Robbins classification) was achieved in 97.3% of patients in the RG (n = 36) and in 92% of those in the FHG (n = 50). Four implants in the RG were placed manually following failed robotic assistance.

Conclusion: We report a higher rate of precision with robotic as compared to the FH technique. Providing assistance by permanently monitoring the patient's movements, this image-guided tool helps more accurately pinpoint the pedicle entry point and control the trajectory. Limitations of the study include its small sized and non-randomized sample. Nevertheless, these preliminary results are encouraging for the development of new robotic techniques for spinal surgery.
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http://dx.doi.org/10.1007/s00586-015-3758-8DOI Listing
March 2016

Surgical-site infection in spinal injury: incidence and risk factors in a prospective cohort of 518 patients.

Eur Spine J 2015 Mar 23;24(3):543-54. Epub 2014 Aug 23.

Tumor and Spine Unit, Orthopaedic Department, Bicêtre University Hospital, AP-HP Paris, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France,

Purpose: To investigate the incidence of surgical-site infection (SSI) and determinate the risk factors of SSI in the context of spinal injury.

Methods: From February 1, 2011 to July 31, 2011, for a multicentre cohort of patients with acute spinal injury, we prospectively censored those with SSI for at least 12 months. We recorded epidemiologic characteristics and details of surgical procedure and postoperative care for each patient. We calculated the incidence of SSI at 1, 3 and 12 months after surgery. Univariate and multivariate analysis were used to establish the association of risk factors and SSI. We studied clinical outcomes by a visual analog scale for pain and physical and mental component summaries (PCS and MCS) of the Medical Outcomes Survey 36-Item Short Form (SF-36).

Results: At 1 year, among 518 patients, we recorded 25 SSI events, with median occurrence at 16 days (25-75 % quartile: 13-44 days). Incidence of SSI was 3.2 % (95 % confidence interval [1.9-5.3 %]) at 1 month, 3.7 % (95 % [2.2-5.8 %]) at 3 months and 4.6 % (95 % CI [3-6.9 %]) at 12 months. On multivariate analysis, age, presence of diabetes and surgical duration were predictors of SSI (p = 0.009, p = 0.047, and p = 0.015 respectively). At 12 months, infected and non-infected patients did not differ in pain (p = 0.58) or SF-36 PCS (p = 0.8) or MCS (p = 0.68).

Conclusions: In this large prospective multicentre study in the context of spinal injury, we obtained an equivalent incidence rate and risk factors of SSI as found in the literature for elective spinal surgery.
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http://dx.doi.org/10.1007/s00586-014-3523-4DOI Listing
March 2015

Spinal metastases in breast cancer: single center experience.

World Neurosurg 2014 Dec 10;82(6):1344-50. Epub 2014 Aug 10.

Department of Neurosurgery, CHU Gui de Chauliac, Montpellier, France; INSERM U1051, Institut des Neurosciences de Montpellier, Montpellier, France. Electronic address:

Objective: Metastases to the spine are a common manifestation of breast cancer leading to considerable reduction in the patient's quality of life. Physicians must consider the different treatments available to decrease pain, reduce tumor burden, and ensure spinal stability to prevent neurological compromises. The first objective of this study is to analyze the epidemiology and outcomes of patients with spinal metastases from breast cancer and describe changes over time in these lesions. The second objective is to establish the current treatment of spinal metastases in this type of cancer.

Methods: A total of 140 patients with breast cancer and spinal metastasis involvement were studied retrospectively. Demographic, clinical, and radiologic parameters were assessed, and the effects of systemic and local treatments on spinal metastasis were analyzed.

Results: Median patient age at diagnosis of breast cancer was 50 years (19-86 years) and average follow-up was 100 months (4-384 months). Median overall survival after diagnosis of spinal metastasis was 18.6 months. Fractures were present in 24 patients (19.3%) at diagnosis and in up to 60 cases (48.6%) by the end of the study period.

Conclusions: The survival rate was better in patients with spinal metastases who received specific treatment. The evolution from lytic spinal metastasis to mixed and blastic subtypes is observed with adjunctive therapy for spinal metastases (bisphosphonates, radiotherapy). Increased attention must be given for high-grade breast cancer, as spinal metastases declare faster for these stages. This study provides evidence that a multidisciplinary tumor board specifically focusing on bone metastasis is essential to effectively manage patients with breast cancer and spinal metastasis.
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http://dx.doi.org/10.1016/j.wneu.2014.08.010DOI Listing
December 2014

Giant spine lumbar schwannoma: complete resection with a transforaminal approach.

Spine J 2014 Apr 30;14(4):714-5. Epub 2013 Oct 30.

Department of Neurosurgery, Gui de Chauliac Hospital, 80 Ave. Augustin Fliche, 34091 Montpellier cedex 05, France.

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http://dx.doi.org/10.1016/j.spinee.2013.10.013DOI Listing
April 2014
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