THE NEUROSURGERY DEPARTMENT
The neurosurgery department treats patients presenting with a pathology involving the encephalon, the spinal cord, the peripheral nerves, their envelopes (skull, vertebral-dorsal column, meninges) and their vessels. The pathology necessitates – or liable to necessitate – neurosurgery and/or radio-surgical treatment in stereotactic and/or endovascular conditions.
These activities include handicap management (of spasticity, in particular) and pain treatment.
Neurosurgery is a regional – and at times extra-regional – activity necessitating readiness to treat 24h/24.
The department contains 56 hospitalization beds, including 19 intensive care beds, and receives more than 2500 hospitalized patients a year, among whom 1600 are operated in the two operation rooms specifically equipped to treat this type of pathology.
In addition, the department pursues activities in research and medical and paramedical teaching.
Neurosurgery emergencies (head trauma and spinal trauma, intracranial hypertension, subarachnoid hemorrhage by ruptured aneurysm, spinal cord compression, paralyzing sciatica and cauda equina syndrome) are managed following contact with the emergency phone number, and they function 24/24h.
Other diseases are treated first in consultation, with as short a waiting period as possible, especially when the situation is distressing (discovery of a brain tumor) or the pathology is painful hyperalgesic sciatica). An appointment can be made either by sending a fax, or by contacting a neurosurgeon (by e-mail or phone).
In close proximity to the neurosurgery consultations, the department offers two specialized consultations:
- multidisciplinary consultation on spasticity and neuro-handicap;
- multidisciplinary consultation on pain.
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TABLE OF CONTENTS
- Brain tumor surgery in adult patients
- Spinal surgery is often essential to treatment of herniated discs and lumbar and cervical stenoses; endoscopy is frequent. This type of surgery can be conducted by all neurosurgeons.
- Vascular neurosurgery. The neurosurgery department is structured so as to organize treatment in a single multidisciplinary unit revolving around a “tripod” (neurosurgery, neuro-radiology and neuro-anesthesia intensive care) in a fully equipped medical and technical environment. The department is consequently strongly and relevantly positioned as regards cerebral vascular malformations necessitating intracranial surgery or application of an endovascular technique.
- Pituitary surgery. It involves collaboration with the internal medicine and endocrinology departments of the Poitou-Charentes region.
- Acoustic neuroma (vestibular schwannona) surgery. It involves collaboration with the ENT department and our ENT correspondents in the region.
- Functional and stereotactic neurosurgery represents a non-destructive and reversible treatment for Parkinson’s disease, Tourette’s syndrome, certain psychiatric disorders, chronic pain and spasticity. .
- Neurosurgery for pain and disability.
BRAIN TUMOR SURGERY IN ADULT PATIENTS
General treatment procedures
Each year, more than 300 adult brain tumor (intracranial neoplasm) patients undergo operations in the neurosurgery department of the Poitiers CHU.
Except for cases requiring emergency surgery, treatment of brain tumor patients is discussed during one or more medical meetings, which bring together the different practitioners involved in their treatment. An initial neuro-oncology multidisciplinary coordination meeting (MCM) (Onco Poitou-Charentes : www.onco-poitou-charentes.fr network) is dedicated to tumors of the nervous system, a second to tumors particularly affecting the spinal column and a third to patients undergoing brain tumor operation in “awake brain surgery”. As regards patients with very rare pathologies, outside opinions can be requested, particularly from in nationwide back-up MCMs.
Available means of treatment
Operations for tumor pathologies draw support from a complete and comprehensive technical platform: computer-enhanced surgery, stereotactic surgery, ventricular and skull base endoscopy, multimodal cortical cartography, electro-physiology monitoring (microscopes, intraoperative ultrasound). The department operates in close coordination with departments: ENT for acoustic neuroma, endocrinology for pituitary tumors, PRC for cancerology.
If necessary, the neuro-radiology department can carry out preoperative treatment, by endovascular embolization, of highly vascularized tumors (particularly for certain meningiomas).
THE SPINAL UNIT – mini-invasive spinal surgery
Mini-invasive spinal surgery consists in a number of surgery techniques of which the main goal is to reduce the surgical traumas associated with surgical approach to the spine. This technological breakthrough is due largely to technical progress in visualization and optical illumination (endoscopy and operating microscope) and to specific instrumentations designed to facilitate “mini-invasive” approaches.
Patient comfort is improved in terms of reduced postoperative pain, shortened hospital stay and a more rapid return to normal physical activity.
At the Poitiers CHU, mini-invasive techniques are now routinely applied by neurosurgeons in cervical disc and lumbar surgery, and also in spinal fusion procedures.
Mini-invasive spinal surgery can remove a lumbar discal hernia. As for patients undergoing mini-invasive surgery for a disc herniation (slipped disc), some can return home on the day of their operation or – more often – the day after, and return to work 2 to 4 weeks after the intervention.
These different techniques allow for installation of spinal instrumentation. Vertebral compression fractures, for example osteoporosis in older patients, can also be treated using mini-invasive techniques (kyphoplasty).
Not all patients can be treated by these different mini-invasive approaches. If and when surgery is necessary, during consultation your neurosurgeon will determine, in a discussion with you, whether or not a mini-invasive technique can be an option.
Aneurysms and meningeal hemorrhage (information for patients written by the Société française de neurochirurgie).
Cerebral aneurysm is a hernia of the arterial wall constituting a weak area; it is at times elongated (spindly aneurysm), but more often saccate. This area of weakness can fissure and even rupture, provoking a more or less sizable and severe hemorrhage; that is the most frequent circumstance of discovery. Its gravity is often considerable; one out of two ruptures is responsible for death prior to arrival in hospital! Indeed, rupture can entail the presence of blood on the periphery of the brain and also, in its most severe forms, penetration of the blood in brain tissue with the constitution of a collection of blood in the brain (hematoma and/or in the cavities inside the brain (ventricles).
An emergency scan, carried out at the time of the rupture, will confirm the existence of the hematoma and at times highlight the aneurysm.
More rarely, it is during an examination carried out for an entirely different reason that a scan, which takes place systematically, reveals an aneurysm on one of the pictures taken.
In most cases, it is necessary to perform an arteriography (injection in the vessels of a contrast agent) so as to show not only the aneurysm, but also the condition of the surrounding vessels.
The clinical examination may also identify other, associated aneurysms. Arteriography is also indispensable in view of opting for the best possible treatment of the aneurysm.
The goal of treatment is to separate the aneurysm to avoid a rupture (fortuitous discovery) or to avoid recurrence of the rupture (discovery during hemorrhaging).
Two methods exist:
- Endovascular treatment (embolization) applied by neuro-radiologists; to date; 90% of aneurysms are treated according to this method by Doctors Drouineau and Velasco;
- Surgical treatment (clipping) is carried out by neurosurgeons: Doctors Listrat and Blanc. Choice of treatment is subject to discussion between the neuro-radiologists and the neurosurgeons. All of the above treatments necessitate general anesthesia.
The guiding principles
The principle common to the two methods consists in blocking off the aneurysm while conserving the permeability of the vessels from which it originated. Endovacsular treatment consists, using a small probe placed inside the cavity, in inserting small coils until the aneurysm is completely blocked off. Surgical treatment consists in dissecting the aneurysm-carrying vessels, and then placing a small clip on the insertion zone (area through which the aneurysm communicates with the artery) so as to remove it from circulation.
Often associated with arterial hypertension, these types of hematomas are relatively common. The neurosurgery intensive care unit provides patients in an acute phase with medical treatment; in the event of resistance to the treatment, surgery is proposed.
The term “cerebral arteriovenous malformation” (AVM) or “cerebral angioma” denotes a vascular malformation or abnormal connection between the arteries and the veins of the brain constituting a short-circuit bringing about abnormally elevated blood pressure in the malformation and in the veins draining it and potentially causing bleeding in the brain. AVMs are more frequently located in the cerebrum than in the cerebellum. The volume of the lesion is highly variable, and it can be either deep or, on the contrary, superficial.
The malformation is congenital, which does not means it is hereditary.
Risks of worsening, conditions of discovery :
- 1°The main risk in cases of AVM is rupture entailing hemorrhage, which occurs within the brain, around the lesion. It can be severe in terms of functional – and even vital – danger. It is the most frequent condition of discovery. The risk of rupture by year is 1 to 4%; it is cumulative and consequently higher when the subject is younger.
- 2° Epileptic seizures represent the second means of revelation of AVM (30% of cases); they are associated with irritation of the part of the brain surrounding the lesion.
- 3° More exceptionally, the diversion of blood flow provoked by a voluminous AVM leads to ischemic suffering of the brain; little by little, a motor or neuropsychological neurological deficit develops.
- 4° More and more frequently, however, AVM is fortuitously discovered during a scan or MRI carried out on account of some other problem.
Diagnosis is given on the scanner and/or MRI. With some exceptions, it is not necessary to perform brain angiography to diagnose AVM, which nonetheless represents an indispensable step towards making an informed decision regarding treatment.
Treatment is aimed at eliminating the AVM and thereby precluding the possibility of a hemorrhage.
Three means of treatment are currently at our disposal: embolization through endovascular route, surgery and stereotactic radiosurgery:
- 1° Embolization through endovascular route is meant to occlude the abnormal vessels by injecting acrylic adhesive. It is often difficult to achieve complete and definitive occlusion of an AVM by this treatment alone, even with several sessions of embolization. Total eradication of an AVM is obtained only 15% of the time.
- 2° Surgery is aimed at achieving complete and definitive ablation of the AVM; it is possible only when the lesion does not exceed a certain volume and is not deeply anchored in the brain. This type of treatment can be applied in certain hemorrhagic emergencies, particularly in children. Postoperative arteriographic control is necessary before affirmation that the AVM has been eliminated; if a residual fragment remains, another operation – or radio-surgery – can be envisaged.
- 3° Stereotactic radiosurgery consists in irradiation administered in a single session, the rays being precisely focused on the AVM. It is proposed when AVM diameter le less than 3 centimeters and, most often, is located deep in the brain.. The result is achieved only 2 or 3 years later, the reason being that the treatment provokes a delayed reaction at the level of the abnormal vessels, which little by little are blocked off. Only an arteriography will justify the affirmation that the AVM has been eliminated; as long as elimination has not been ascertained, hemorrhagic risk remains present. In 69 to 90% of cases, according to the dimensions of the AVM, radiosurgery leads to its eradication.
These three forms of treatment all have precise indications that are considered in discussions between neurosurgeons, neuro-radiologists and radiotherapists. At times the treatments are blended or combined in view of achieving occlusion or complete and definitive eradication, which is the main and essential goal.
The more voluminous the arteriovenous malformation, the more it affects complex cerebral areas, and the greater the extent to which complete treatment will be difficult or dangerous. Incomplete palliative treatment may consequently be the only realistic option. Therapeutic abstention can be justified when a hemorrhagic clinical episode has never occurred.
ACOUSTIC NEUROMA (vestibular schwannona) SURGERY
FUNCTIONAL AND STEREOTACTIC NEUROSURGERY
The department in charge of stereotactic and functional neurosurgery with regard to abnormal movements and psychiatric disorders is recognized in its field as the interregional reference center. Deep brain stimulation (DBS) has been carried out as a key activity in the neuroscience center in the unit known as “neuromodulation and pathologies of movement and behavior” in collaboration with Pr Houeto (neurologist) and Dr Jaafari (psychiatrist). The activity consisting in deep brain stimulation is coupled with major activities in research.
See a report on brain stimulation (in French)
Source : La Nouvelle République / Centre presse – February 2012
Deep brain stimulation is used as treatment in certain cases of Parkinson’s. It consists in electrically stimulating targeted structures in the brain, namely the subthalamic nucleus (STN) and the internal globus pallidus (IGP), which regulate movements and muscle function. A probe equipped with tiny electrodes is surgically implanted in the brain and subcutaneously connected by means of an extension to a neurostimulator implanted near the clavicle. Electrical stimulation can be non-invasively regulated according to the precise needs of a given patient.
The stimulation system is implanted by the functional neurosurgery team using a stereotactic frame and imaging techniques such as magnetic resonance imagery (MRI) to map and locate the target in the brain. The probe is introduced in the skull through a “burr hole” and implanted in the targeted area of the brain.
The operation is carried out under general anesthesia and involves 1 or 2 phases of intraoperative awareness. Once the “burr hole” has been placed (trepanning), a test electrode is introduced in the brain. The patient being awake and aware, the neurosurgeon and a movement disorder specialist test the stimulation in view of optimizing the suppression of symptoms and reducing as much as possible any side effects, prior to putting into place a probe for chronic stimulation.
Once the chronic stimulation neural probe has been implanted, general anesthesia ensues. An extension is installed under the scalp and under the skin of the neck and shoulder to connect the probe to the neurostimulator. Finally, a small incision is made near the clavicle and the neurostimulator is surgically positioned under the skin.
Shortly after the operation, the patient returns to consult the neurologist so that initial programming of the neurostimulator can be carried out. By programming the neurostimulator, the physician attempts to optimize mastery of Parkinson’s symptoms and to attenuate any possible side effects. He then plans out the follow-up consultations.
In order to regulate stimulation, the neurologist uses a program communicating by radio-frequency with the neurostimulator; this is a painless and non-invasive way of achieving regulation according to a patient’s needs.
Deep brain stimulation does not cure Parkinson’s disease, for which there does not currently exist any remedy. While it can treat some symptoms and improve some functions, it can by no means eliminate the underlying pathology. If the treatment is discontinued, the symptoms reappear.
Brain stimulation can act on not only neurological symptoms (Parkinson’s disease, Tourette syndrome, essential tremor and dystonia), but also on psychiatric phenomena such as OCD or major depression, fields in which our team is actively involved, internationally as well as nationally.
NEUROSURGERY FOR PAIN AND HANDICAPS
Functional neurosurgery uses implantable pumps for spasiticity and pain, implantable stimulators (chronic pain, intractable epilepsy) and some microsurgical interventions (neurovascular decompression for neuralgia or hemifacial spasm).
The neurosurgery department is particularly innovative in treatment of chronic pain.