Systematic CT Scan Research Articles

Diagnosis of isolated right aortic arch: Accuracy of prenatal diagnosis, associated genomic disorders and interest of systematic postnatal imaging. The ARCADE multicentre retrospective observational study

Prenatal diagnosis of isolated right aortic arch (RAA) have increased during the past decades. However, diagnosis accuracy, genetic testing, and post-natal follow-up are still not consensual. We aimed to analyse French pediatric cardiologists practice regarding prenatal diagnosis of isolated RAA. We collected all livebirth with isolated RAA prenatally diagnosed in 14 French congenital heart disease centres from 2015 to 2020. We compare, using kappa coefficient of concordance, the anatomical position of aortic arch, ductus arteriosus and aberrant left subclavian artery described by prenatal echo, postnatal echo, and CT scan when available. We also assessed available genetic results and functional postnatal status. We included 309 neonates with prenatal diagnosis of isolated RAA. Regarding patients with an isolated RAA, left ductus arteriosus have been described in 76% of cases. Diagnosis of aberrant left subclavian artery was missing in 73% of cases. Four patients with prenatal isolated RAA had a postnatal diagnosis of double aortic arch (DAA). Correlation between pre- and post-natal echo was excellent regarding aortic arch position (kappa = 0.97). 108 neonates (35%) underwent postnatal CT scan due to onset of respiratory symptoms (53%) or systematic centre protocol (47%). CT-scan revealed five more unknown DAA. Correlation between prenatal echo and CT-scan was good (kappa = 0.79). Furthermore, systematic CT-scan showed 13 major tracheal compression resulting in six arterial ring surgeries during the study period. Lastly, 165 patients (53%) underwent a genetic testing. Nine patients (5.4%) presented a 22q11 deletion. Performance of prenatal diagnosis of isolated RAA is excellent, with a good correlation between pre- and post-natal echocardiography or gold standard-CT scan. Prenatal diagnosis of aberrant left subclavian artery and DAA is still challenging. CT scan improve anatomical description and functional impact of aortic arch anomalies and may be proposed to complete postnatal follow-up. Lastly, amniocentesis should be considered to detect genetic disorders.

Ankle CT scan allows better management of posterior malleolus fractures than X-rays.

Undiagnosed and undertreated posterior malleolus fractures lead to early ankle instability and arthritis. A preoperative CT scan could improve the management of those fractures. This study assessed the benefits of a systematic ankle CT scanner to diagnose and manage posterior malleolus fracture. A monocentric retrospective cohort study was conducted. Sixty consecutive patients with bimalleolar fractures were operated and underwent a preoperative CT scan. The mean age was 50.0years old (18.6years old) with a mean body mass index of 20.3 (kg/m2) (11.4kg/m2) and 71.7% (43/60) of women. The primary outcome was the rate of posterior malleolus fragment diagnosed on X-rays and on CT scan. Secondly, interobserver and interobserver's agreement were compared between conventional X-rays and CT scan. Thirty-five (58.3%) posterior fragment fractures were observed on X-rays and 53 (88.3%) on the preoperative CT scan (p < 0.01). The intraobserver reproducibility for X-rays was low (0.02 [- 0.23; 0.27]) and moderate for CT scan (0.45 [0.0; 0.84]). The interobserver reproducibility for X-rays was moderate (0.39 [0.15; 0.60]) and excellent for CT scan (0.78 [0.0; 1.0]). A wide proportion of bimalleolar fractures are associated with posterior malleolus fractures and undiagnosed with standard X-rays. We advocate a systematic preoperative CT scan in the management of bimalleolar fractures. Level IV, retrospective cohort study. 2218999v0, date of registration: 11/08/2020 (retrospectively registered).

Recommandations françaises du Comité de transplantation de l’association française d’urologie (CTAFU) : lithiase urinaire chez le receveur ou le donneur en transplantation rénale

To define guidelines for the management of kidney stones in kidney transplant (KTx) donor or recipients. Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU to report kidney stone epidemiology, diagnosis and management in KTx donors and recipients with the corresponding level of evidence. Prevalence of kidney stones in deceased donor is unknown but reaches 9.3% in living donors in industrialized countries. Except in Maastrich 2 donors, diagnosis is done on systematic pre-donation CT scan according to standard french procedure. No prospective study has compared therapeutic strategies available for the management of kidney stones in KTx donor: ureteroscopy or an extra corporeal lithotripsy in case of living donor prior to donation, ex vivo approach (pyelotomy or ureteroscopy), ureterocopy in the KTx recipient or surveillance. De novo kidney stones result from a lithogenesis process to be identified and treated in order to avoid recurrences. The context of solitary functional kidney renders the prevention of recurrence of great importance. Diagnosis is suspected when identification of a renal graft dysfunction, hematuria or urinary tract infection with renal pelvis dilatation. Stone size and location are determined by computed tomography. There are no prospective, controlled studies on kidney stone management in the KTx. The therapeutic strategies are similar to standard management in general population. These French recommendations should contribute to improve kidney stones management in KTx donor and recipients.

Is there an interest in performing a systematic CT scan within the first two months after chronic subdural hematoma evacuation? A ten-year single-center retrospective study

ObjectivesThe aims of the present study were to evaluate the frequency of late recurrence after chronic subdural hematoma (CSDH) evacuation and to examine the interest in the use of a systematic CT scan within the first two months after surgery. Patients and MethodsWe performed a retrospective study that included all patients who underwent CSDH evacuation between 2007 and 2017. We evaluated the rate of late recurrence, defined as the need to perform a new surgery after the first month of follow-up. All the patients underwent a clinical examination and a systematic CT scan between one and 2 months after the first surgery (delayed systematic CT scan). We evaluated the rate of clinical recurrence, defined as the association between clinical symptoms and radiological abnormalities, and of radiological recurrence, defined only on CT scan data. ResultsDuring the inclusion period, 696 patients underwent CSDH evacuation in our unit. Overall, 54 patients (7.7%) had recurrence, of whom 21 (39%) had recurrence after 4 weeks (late recurrence). Of the 21 patients with late recurrence, 7 (1%) had radiological recurrence, and 14 (2%) had clinical recurrence. There was no difference in the CT scan characteristics between patients with clinical and radiological recurrence. ConclusionThe use of a delayed systematic CT scan after CSDH surgery has a marginal impact on patient management, and the indication for reoperation without symptoms seems highly subjective. In patients without neurological symptoms, the use of a delayed cerebral CT scan may not be indicated.

Surgery of Renal Artery Aneurysms: A Monocentric Retrospective Study

The aim of the study was to report the results of conventional surgery for renal artery aneurysms (RAAs) in our center. We retrospectively reviewed the files of all the patients operated for RAAs between 2009 and 2018 in our center. We collected demographic, biological (renal function), morphological (computed tomography [CT] scan), and functional (ultrasound examination and resistance index) preoperative and postoperative data. Clinical and paraclinical operative data were examined. Results were expressed as average±standard deviation or median and extremes. A total of 26 aneurysms were operated in 20 kidneys (10 right kidneys) among 19 patients, including 13 (68%) women with an average age of 55 (±12) years. Three (16%) patients presented an aneurysm in a single kidney. The discovery of the aneurysm was fortuitous in 14 (74%) patients. One patient with Marfan syndrome was operated after a postpartum rupture. The median diameter of the operated aneurysms was 22mm (7-48), and 23 (90%) were hilar aneurysms. Arterial repair was carried out in situ in 16 (80%) kidneys. The surgery consisted of a direct arterial repair in 21 cases (81%), including 4 resections and anastomoses, 12 aneurysmorrhaphies, and 5 complex reconstructions. Four arterial replacements were carried out (one prosthetic graft, 2 femoral grafts, and one internal iliac graft). The average duration of renal clamping was 30.5 (±17.3) min. Postoperative renal function was unchanged in all the patients except for one (5.2%) who required 2 days of postoperative dialysis. The resistance index of all the operated kidneys was normal (0.66±0.08) at discharge. Sixteen (70%) of the 23 aneurysms were examined, and anatomopathology concluded them to be of dysplastic origin. At 3 months, a systematic CT scan objectified the patency of 95% of the arterial reconstructions, with 3 stenoses >50%. One stenosis >80% was treated at 7 months by balloon angioplasty. Only one operated kidney presented a loss of viability of its upper pole. The mean duration of follow-up was 54±35months. By the end of the follow-up, primary and secondary patency rates evaluated by Doppler ultrasound were 90% and 95%, respectively. Conventional surgery generally performed in situ remains a sure and effective treatment for RAAs. This challenging surgery for a rare disease should be performed in experimented centers.

Impact of emergency physician experience on decision-making in patients with suspected community-acquired pneumonia and undergoing systematic thoracic CT scan

ObjectivesTo determine whether the impact of a thoracic CT scan on community-acquired pneumonia (CAP) diagnosis and patient management varies according to emergency physician’s experience (≤10 vs >10 years).MethodsEarly thoracic CT...

High heterogeneity in community-acquired pneumonia inclusion criteria: does this impact on the validity of the results of randomized controlled trials?

BackgroundThere is no consensus on the most accurate combination of diagnostic criteria to define community acquired pneumonia (CAP). We describe inclusion criteria in randomized controlled trials (RCT) of CAP and assess their performance for the diagnosis of formally identified CAP.MethodsRCTs related to CAP recorded on ClinicalTrials.gov were analysed. Due to high heterogeneity, we divided close CAP inclusion criteria into patterns (i.e. combinations of inclusion criteria). To assess their diagnostic performances, these CAP definition patterns were applied to a reference population of 319 suspected CAP patients, in whom the CAP diagnosis had been confirmed (n = 163) or excluded (n = 156) by an adjudication committee after a systematic thoracic CT-scan and a 28-day follow-up period.ResultsIn the 47 RCTs included in the analysis, 42 different CAP inclusion criteria combinations were identified and 8 patterns created. This heterogeneity was not explained either by the trials’ methodology or by their objectives. When applied to the reference population, the performance ranges of the 8 definition patterns were 9.8–56.4% for sensitivities, 56.4 97.4% for specificities, 63.6 83.6% for positive predictive values and 50.8–66.7% for negative predictive values. None of the CAP definitions had both sensitivity and specificity superior to 65%. Depending on the CAP definition, the rate of included patients without CAP (“false positives”) ranged from 1 to 21%.ConclusionsCAP diagnostic criteria within RCTs are heterogeneous, which may have far-reaching consequences on validity of RCT results.

1086. Impact of Systematic Thoraco-Abdomino-Pelvic CT Scan on the Diagnosis of Infective Endocarditis

BackgroundThe incidence of embolic events (EE) is high in patients with infective endocarditis (IE). EE influence patient management in different settings because they are minor criteria in the Duke classification and may lead to changes medical therapy or surgical strategy. If current guidelines suggest that systematic thoraco-abdominopelvic CT scan (TAP-CT) may be helpful, reliable data are lacking. The main objective of this study was to describe how systematic TAP-CT affects the diagnosis of patients with IE. Secondary objectives were to assess the impact of the TAP-CT on the management of patients with IE and the incidence of contrast-induced acute kidney injury (CI-AKI).MethodsIn this multicenter cohort study between January 2013 and July 2016, we included consecutive patients who had definite or possible acute IE according to the Duke-modified criteria, and after validation by the endocarditis teams. The main exclusion criterion was the absence of TAP-CT scan. We compared the Duke classification diagnosis data and treatment data (medical and/or surgical) regarding the presence or the absence of EE on the CT and investigated the tolerance of this examination as well.ResultsOf the 522 patients included in this study, 217 (41.6%) had one or more EE on the TAP-CT. The two major Duke modified criteria were found in 397 patients (76,1%) and 457 patients (87,6%) had a definite endocarditis. On the basis of TAP-CT results in asymptomatic patients, diagnostic classification was upgraded from possible endocarditis to definite endocarditis for only four cases which represent 0.8% of the population. The presence of EE on CT did not modify the duration of antibiotic treatment (P = 0.55) and the decision of surgical treatment (P = 0.39). Specific treatment of the EE was necessary in 42 patients (8.0%) but only nine of these EE (1.9%) were asymptomatic. CI-AKI was observed in 78 patients (14.9%).ConclusionThe CT-scan findings slightly affected diagnosis of IE. The impact on the therapeutic management is low and the incidence of CI-AKI should not be underestimated. Additional studies are needed to assess whether CT-scan improves patient outcomes, leads to unnecessary procedures and increased costs.Disclosures All authors: No reported disclosures.

Postoperative collections after liver surgery: predictors, and long-term outcomes

Introduction: Postoperative collection (PC) can occur after liver surgery (LS), but little is know on their impact on short and long-term outcomes. The aim of this study was to analyze factors predicting the occurrence of PC, the need of drainage and their impact on oncologic outcomes. Methods: . This prospective, single-center, cohort-study included all patients undergoing LS from 2008 to 2017. A systematic postoperative CT scan was realized on day7. The primary outcome was to determine variables associated with PC, defined as the presence of a fluid collection, and infected in case of positive bacterial culture. Secondary outcomes were to determine factors predicting drainage requirement, and the impact of infected PC on 5-y overall (OS) survival. Results: We included 254 patients: 45% (n=114) experienced PC. In the multivariate analysis, variables associated to PC occurrence were BMI (25-30=OR1.56(95%IC:0.78,3.13), 30-35=OR1.99(95%IC:0.67,5.89) p=0.002) and surgical resection (anatomic=reference, nonanatomic=OR1.22(95%IC:0.52,2.85), combined=OR2.09(95%IC:0.72,6.07), p=0.014). In the PC subgroup (n=114), variables predicting drainage requirement were antibiotic use OR14.01(95%CI:1.25,157 p= 0.015) and C-reactive protein (CRP) OR1.02(95%CI:1,1.05 p=0.043). The AUROC (0.71, 95%CI:0.59,0.83 p=0.002) found 152 mg/L as the optimal CRP cutoff value associated with PC drainage. In the malignant disease subgroup with PC (n=96), we observed lower 5-y OS among patients with infected vs non-infected PC (33% vs 56%, Log-Rank=0.03). Conclusions: In this cohort study we observed how nonanatomic or combined LS and BMI are associated to PC after LS, and those with CRP higher than 152 mg/L may require drainage. Moreover, the presence of an infected PC negatively impact 5-y OS.

Can we refine the management of blunt liver trauma?

To describe the management of blunt liver injury and to study the potential relation between delayed complications, type of trauma mechanisms and liver lesions. This is a retrospective single center study including 116 consecutive patients admitted with blunt liver injury between 2007 and 2015. Initial CT-scan identified an active bleeding in 33 (28%) patients. AAST (American Association for the Surgery of Trauma) grade was 1 to 3 in 82 (71%) patients and equal to 5 in 15 (13%) patients. Eighty (69%) patients had NOM, with a success rate of 96%. Other abdominal organ lesions were associated to invasive initial management. A follow-up CT-scan was useful to detect hepatic and extra-hepatic complications (46 complications in 80 patients), even without clinical or biological abnormalities. Subsequent hepatic complications such as bleeding, pseudo aneurysms, biloma and biliary peritonitis developed in 15 patients and were associated with the severity of blunt liver injury according to AAST classification (3.7±1.0 vs. 3.0±1.1, P=0.010). Total biliary complications occurred in 13 patients and were significantly more frequently observed in patients with injury of central segments 1, 4 and 9 (69% vs. 36%, P=0.033). Non-operative management is possible in most blunt liver injury with a success rate of 96%. A systematic CT-scan should be advocated during follow-up, especially when AAST grade is equal or superior to 3. Biliary complications should be suspected when lesions involve segments 1, 4 and 9.

Rational use of systematic postoperative CT scans after neurosurgical craniotomy.

The aim of this retrospective study was to evaluate the relevance of a systematic postoperative CT scan after neurosurgical craniotomy and to identify predictive factors of complications. This retrospective analysis included all the patients at our institution who benefited from a cerebral postoperative CT scan within 24 hours post-craniotomy. Patient characteristics and neuroimaging abnormalities were recorded. Predictive factors were identified using a recursive partitioning analysis. A total of 633 patients were included. Of these, 17.9% of patients suffered from postoperative complications and 7.4% of them required a new surgery. The decision for reoperation was based on the neurological deterioration and the CT scan, but never on the CT scan alone. The mortality rate was 1.1%. The risk to be reoperated was correlated to the occurrence of a new postoperative neurological deficit (P<0.001, HR=4.60) and in situ hemorrhage (P<0.001, HR=4.19). The risk of postoperative hematoma was correlated to the supratentorial location versus infratentorial (P=0.027, HR=2.50). With clinical factors, such as location and etiology of the lesion, schedule type of surgery, and the age of patients, we proposed six classes with the risk to present with hemorrhage or midline shift on postoperative CT scans. The post-craniotomy CT scan did not impact patient management as an independent decisional tool. We identified several variables associated with the risk of clinical modification that can impact the decision to reoperate and allow establishment of a risk score. This score could be an interesting tool in order to reduce the systematic use of CT scans in the post-surgical period but has to be validated in a prospective study.

Early liver metastases in resectable periampullary cancer: Incidence and risk factors

PurposeThe aim of the present study was to estimate the incidence of very early hepatic metastases (HMs) (<6 months) and their imaging patterns after cephalic duodenopancreatectomy (CDP) for periampullary carcinoma (excluding duodenal carcinoma) and to identify their associated risk factors. MethodsFrom January 2003 to June 2016, all patients who underwent surgical treatment for periampullary carcinoma by CDP at our institution and with adequate pre- and postoperative CT scans were included. Univariate and multivariate logistic regressions were performed to determine factors associated with very early HM and recurrence. ResultsOf the 132 patients included retrospectively, 27 (20.5%) patients developed HMs. The mean time to diagnosis of HM was 103.9±55.2days. HMs were multiple in 81.4% of cases and bilobar in 59.3% of cases; their mean maximum size was 16.7±12.7mm.In univariate logistic analysis, lymphovascular emboli were significantly associated with HM (p=0.02). No independent risk factors for HM were found in multivariate analysis. In multivariate logistic analysis, two independent risk factors were identified for the occurrence of early recurrence: tumor size >23mm on preoperative CT scan (OR: 3.3; 95% CI: [1.2–9.3]; p=0.02) and tumor differentiation (poor vs. good: OR 15.5; 95 CI [1.5–158.3]; moderate vs. good: OR: 17.1; 95% CI: [1.9–154.4]; p=0.04). ConclusionsNearly one in five patients developed HM after CDP within 6 months with a highly consistent pattern. A thorough preoperative assessment, combining CT scan and MRI with a delay of less than three weeks before surgery, appears essential. A routine systematic postoperative CT scan at 8 weeks is also required prior to initiating adjuvant chemotherapy.The type of surgical intervention does not seem to be a risk factor, although the risk of HM occurrence appears to be related to the lymphovascular invasion of the tumor and maybe its degree of differentiation, elements not assessable by imaging.

Interest of Denosumab for the Treatment of Giant-cells Tumors and Aneurysmal Bone Cysts of the Spine. About Nine Cases.

A prospective cohort study. The aim of this study was to evaluate the interest of denosumab in the treatment of spinal giant-cells tumors (GCTs) and aneurysmal bone cysts (ABCs). To treat GCTs and ABCs, surgical resection remains the best treatment to limit local recurrence (LR) but constitutes an aggressive treatment with potential morbidity. Denosumab, a human antibody anti-RankL, inhibiting the differentiation of osteoclasts, could be an alternative treatment to avoid aggressive surgery. Patients suffering from GCTs and ABCs of the spine were included. Patients received a monthly subcutaneous injection of denosumab (120 mg) during a minimum of 6 months either as a neoadjuvant or as an adjuvant therapy. In association with denosumab, an osteosynthesis was added in case of vertebral fracture and a laminectomy in case of spinal cord compression. Clinical and computed tomography (CT)-scan outcomes were analyzed. Eight GCTs and one ABC were included. The mean age was 35 years (range: 22-55 yr). Five patients had neurologic deficit. All patients were operated: six osteosynthesis, one "en bloc" resection, four curettages, and two of them associated with an osteosynthesis. Average duration of denosumab therapy was 12.9 months (range: 3.2-24 months). Among them, four patients began denosumab 6 months at least before the surgery. With a mean follow-up of 19.3 months (range: 3.2-52.4 months), back pain and neurologic deficit improved for all patients. Systematic CT-scan at 6 months showed decrease of tumor size and bone consolidation. Regarding patients treated by neoadjuvant denosumab treatment, intraoperative histologic analysis showed an absence of giant cells and a maximum of 10% of alive tumor cells. Denosumab allows bone formation and tumor regression with a maximum efficacy after 6 months of treatment without widely substituting surgery. Long-term results are mandatory to confirm the interest of denosumab and to evaluate LR when stopping denosumab. 3.

Thyroid adenoma and nasopharyngeal carcinoma with metastasis to cervical lymph nodes is misdiagnosed and treated for thyroid carcinoma: A case report.

Lymph node metastasis of nasopharyngeal carcinoma follows an orderly pattern, and diagnosis of nasopharyngeal carcinoma is often made by lymph node biopsy. In the present study, following neck palpation, ultrasonography and cervical computer tomography, a 52-year-old female patient with thyroid adenoma and enlarged cervical lymph nodes was misdiagnosed as thyroid carcinoma without undergoing preoperative biopsy, followed by unnecessary total thyroidectomy. Systematic CT scan and nasal endoscopic biopsy confirmed the correct diagnosis of primary NPC concurrent with thyroid adenoma. The patient received palliative radiotherapy and L-thyroxine substitution therapy, and was followed up closely via internet-based approaches with life-style intervention, medication consultation and psychological support for improvement of life quality after radiotherapy. In conclusion, primary malignancies with thyroid metastasis must be considered in the differential diagnosis of thyroid tumors with enlarged cervical lymph nodes.

Is systematic post-operative CT scan indicated after chronic subdural hematoma surgery? A case-control study.

The aim of the present study was to evaluate the interest of systematic post-operative CT scan after unilateral chronic subdural hematoma (CSDH) evacuation. To achieve this goal, we chose to evaluate the ability of post-operative CT scan to predict the most frequent complication of CSDH: hematoma recurrence. We performed a retrospective case-control study. Cases were defined as patients who had CSDH recurrence; controls were those who did not. We first studied clinical data and pre-operative CT scan data. We then studied post-operative CT scan data: hematoma thickness and its decrease, persistence of midline shift, its value and its decrease, and presence of compressive pneumocephalus. Among 654 patients, 15 were defined as cases, and were matched with 30 non-recurrent patients defined as controls. Regarding systematic post-operative CT scan findings, unilateral CSDH recurrence was clearly associated with the persistence of midline shift induced by the presence of compressive pneumocephalus. Systematic post-operative CT scan after unilateral CSDH evacuation could predict hematoma recurrence. We therefore considered it as recommended, to adapt the clinical and radiological follow-up of CSDH patients.

Diagnostic accuracy of C-reactive protein and procalcitonin in suspected community-acquired pneumonia adults visiting emergency department and having a systematic thoracic CT scan.

IntroductionCommunity-acquired pneumonia (CAP) requires prompt treatment, but its diagnosis is complex. Improvement of bacterial CAP diagnosis by biomarkers has been evaluated using chest X-ray infiltrate as the CAP gold standard, producing conflicting results. We analyzed the diagnostic accuracy of biomarkers in suspected CAP adults visiting emergency departments for whom CAP diagnosis was established by an adjudication committee which founded its judgment on a systematic multidetector thoracic CT scan.MethodsIn an ancillary study of a multi-center prospective study evaluating the impact of systematic thoracic CT scan on CAP diagnosis, sensitivity and specificity of C-reactive protein (CRP) and procalcitonin (PCT) were evaluated. Systematic nasopharyngeal multiplex respiratory virus PCR was performed at inclusion. An adjudication committee classified CAP diagnostic probability on a 4-level Likert scale, based on all available data.ResultsTwo hundred patients with suspected CAP were analyzed. The adjudication committee classified 98 patients (49.0 %) as definite CAP, 8 (4.0 %) as probable, 23 (11.5 %) as possible and excluded in 71 (35.5 %, including 29 patients with pulmonary infiltrates on chest X-ray). Among patients with radiological pulmonary infiltrate, 23 % were finally classified as excluded. Viruses were identified by PCR in 29 % of patients classified as definite. Area under the curve was 0.787 [95 % confidence interval (95 % CI), 0.717 to 0.857] for CRP and 0.655 (95 % CI, 0.570 to 0.739) for PCT to detect definite CAP. CRP threshold at 50 mg/L resulted in a positive predictive value of 0.76 and a negative predictive value of 0.75. No PCT cut-off resulted in satisfactory positive or negative predictive values. CRP and PCT accuracy was not improved by exclusion of the 25 (25.5 %) definite viral CAP cases.ConclusionsFor patients with suspected CAP visiting emergency departments, diagnostic accuracy of CRP and PCT are insufficient to confirm the CAP diagnosis established using a gold standard that includes thoracic CT scan. Diagnostic accuracy of these biomarkers is also insufficient to distinguish bacterial CAP from viral CAP.Trial registrationClinicalTrials.gov registry NCT01574066 (February 7, 2012)Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-1083-6) contains supplementary material, which is available to authorized users.

Early percutaneous fixation of spinal thoracolumbar fractures in polytrauma patients

IntroductionCare of polytrauma patients is complex and requires that a particular treatment sequence be followed during what is typically a short period of time. Early, temporary stabilization of injuries (damage control orthopedics [DCO]) is a validated strategy for the care of polytrauma patients. Application of this concept to spinal fractures has also led to good outcomes for patients. The recent development of percutaneous thoracolumbar fixation could improve the initial care of these vulnerable patients even more. The purpose of this study was to evaluate preliminary results in a series of polytrauma patients presenting with thoracolumbar fractures without neurological deficits who were treated according to DCO principles using early percutaneous fixation. Materials and methodsAll severe polytrauma patients admitted with a thoracic and/or lumbar spine fracture without neurological deficit were included in this prospective study. The care was standardized according to the degree of urgency of the initial injuries, with percutaneous spinal fixation being performed as early as feasible. The outcomes were evaluated using clinical parameters (duration of stay in intensive care unit, surgical data, blood loss) and radiographic parameters measured during a systematic postoperative CT scan (traumatic deformity, placement of pedicle screws, fusion rate). If needed, an anterior intervertebral graft was performed during a secondary procedure. ResultsIn all, 10 patients (average age of 40years) were included, corresponding to 18 vertebral fractures. During the initial assessment, at least one peripheral bone fracture was found in 90% of cases and at least one organ was injured in all patients (thoracic in 80% of cases, cerebral in 50%, facial area in 40% and abdominal-pelvis in 30%). The average time elapsed between admission and spine surgery was 4days (80% of cases before day 7). There were no cases of deep infection in any of the patients. An additional anterior procedure was needed in three patients within 1month of the initial surgery. DiscussionThe strategy for treating thoracolumbar fractures in polytrauma patients is still not widely accepted. The presence of associated lesions could make it difficult to perform conventional spine surgery early on. Development of percutaneous techniques that reduce perioperative morbidity seems to be an alternative approach well-suited to DCO, as long as there are no neurological deficits. However, a secondary evaluation of the anterior spine is essential to determining if an anterior graft remains needed. Level of evidenceLevel IV.

Kyphoplastie antérolatérale dans la prise en charge des métastases rachidiennes cervicales

Management of spinal metastasis is still controversial and must take into account various parameters. The aim of this study is to report the technical feasibility of a less invasive anterior cervical balloon kyphoplasty for vertebral body reinforcement. Six consecutive patients with an osteolytic cervical metastasis, without neurologic compromise, and for whom a curative treatment was not indicated, were retrospectively reviewed. All patients underwent balloon kyphoplasty through a small anterolateral cervicotomy. Evaluation of the technique outcomes was clinical and radiologic with a systematic CT-scan. During the follow-up period (6 months average), neurologic examination was normal in all cases with reduced cervical pain and without reported loss of motion of the cervical spine. A cement leakage was noticed in two cases without clinical consequences. This less invasive procedure was feasible and provided satisfactory preliminary results. It can therefore be a valuable alternative in selected cases where a curative treatment is not indicated. Level IV retrospective observational study.

Anterolateral kyphoplasty in the management of cervical spinal metastasis

Management of spinal metastasis is still controversial and must take into account various parameters. The aim of this study is to report the technical feasibility of a less invasive anterior cervical balloon kyphoplasty for vertebral body reinforcement. Six consecutive patients with an osteolytic cervical metastasis, without neurologic compromise, and for whom a curative treatment was not indicated, were retrospectively reviewed. All patients underwent balloon kyphoplasty through a small anterolateral cervicotomy. Evaluation of the technique outcomes was clinical and radiologic with a systematic CT-scan. During the follow-up period (6 months average), neurologic examination was normal in all cases with reduced cervical pain and without reported loss of motion of the cervical spine. A cement leakage was noticed in two cases without clinical consequences. This less invasive procedure was feasible and provided satisfactory preliminary results. It can therefore be a valuable alternative in selected cases where a curative treatment is not indicated.

Mucocele after transnasal endoscopic repair of traumatic anterior skull base fistula in children

Objectives To report the long-term sinonasal complications after endoscopic repair of anterior skull base fractures in children. This study describes mucocele formation in 6 patients treated endoscopically for posttraumatic CSF fistulae. We aim to address possible etiologic factors, specific treatments and follow-up modalities. Patients and methods 12 children, mean age 5.8 years (3–10), treated endoscopically at our institution between 2004 and 2010 for an anterior cranial base fracture complicated by a CSF fistula. An iatrogenic mucocele was observed in 6 cases. A retrospective review of the files of these 6 patients was carried out demonstrating demographic characteristics, presenting signs/symptoms, site of skull base defect, repair technique, timing and onset of the mucoceles, their presentation and management. A systematic CT-scan and/or MRI was carried out at 3 months, 1 year and then annually. Results 3 patients presented after cranial trauma with persistent CSF nasal leak, and 4 with meningitis. Posttraumatic defects reached the posterior wall of the frontal sinus and the junction of ethmoid and frontal bone in 3 cases, and the cribriform plate in 3 cases. Endoscopic closure was performed in all cases, with the middle turbinate as an overlay patch. No recurrence of a CSF leak was observed. After a mean period of 16 months, a single iatrogenic mucocele was observed in 4 patients (radiological detection only), and multiple mucoceles in 2 patients. Surgical treatment was advocated in cases of proptosis, quick expansion of the mucocele leading to sinus bony wall remodelling or erosion (2 cases), and meningitis related to an erosion of the cribriform plate by the mucocele. Three mucoceles were successfully treated endoscopically, and 1 required an external approach. Conclusion Mucocele incidence after endoscopic repair of skull base fractures in children is not insignificant (50% in our 12 patients series). Paediatric anatomical features, cranial trauma, and the transethmoidal approach may play a role in mucocele pathogenesis. Long-term clinical and radiological follow-up is therefore recommended. These mucoceles may be managed endoscopically with good outcomes.