Publications by authors named "Andrew Jea"

218 Publications

Standardization of cerebrospinal fluid shunt valves in pediatric hydrocephalus: an analysis of cost, operative time, length of stay, and shunt failure.

J Neurosurg Pediatr 2021 Jan 29:1-6. Epub 2021 Jan 29.

Objective: CSF shunts are the most common procedures performed in the pediatric neurosurgical population. Despite attempts in multiple studies, a superior shunt valve has never been shown. Because of this, the authors aim was to examine the impact of shunt valve standardization at their institution to determine if there is a difference in surgical cost, operative time, or short-term postoperative shunt failure.

Methods: A retrospective analysis at the authors' institution was performed for all new CSF diversion shunts, as well as shunt revisions requiring a new valve, or a new valve and at least a new proximal or distal catheter over a 1-year period (January 1, 2016, to December 31, 2016). After a period of transition, neurosurgeons were encouraged to use only one type of fixed-differential-pressure valve and one type of programmable valve when performing shunt surgeries. These patients who underwent "standardized" shunt surgery over a 1-year period (January 1, 2018, to December 31, 2018) were then compared to patients in the prestandardization epoch. All patients were followed for a 12-month period after surgery. Demographic information, surgical cost, operative time, and postoperative shunt failure data were collected in all patients in the study.

Results: The authors analyzed 87 shunt surgeries in patients prior to standardization and 94 shunt surgeries in patients after standardization. The rate of violation of the standardized shunt valve policy after implementation was 5.3% (5 of 94 procedures). When comparing the prestandardization group to those who received the standardized valve, operative costs were less ($1821.04 vs $1333.75, p = 0.0034). There was no difference in operative times between groups (78 minutes vs 81 minutes, p = 0.5501). There was no difference in total number of shunt failures between the two groups at 12 months after surgery (p = 0.0859). The rate of postoperative infection was consistent with the literature at 8%.

Conclusions: In accordance with quality improvement principles, the reduction of unexplained clinical variance invariably leads to a decrease in cost and, more importantly, increased value. In this study, the implementation of a standardized shunt valve decreased operative cost. There were no differences in postoperative shunt failures at 12 months after surgery and no differences in length of surgery. Standardizing shunt valves in the treatment of pediatric hydrocephalus seems to be cost-effective and safe.
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http://dx.doi.org/10.3171/2020.8.PEDS20477DOI Listing
January 2021

A standardized protocol to reduce preoperative hypothermia in pediatric spinal fusion surgery: a quality improvement initiative.

J Neurosurg Pediatr 2021 Jan 29:1-4. Epub 2021 Jan 29.

Objective: Hypothermia in adult surgical patients has been correlated with an increase in the occurrence of surgical site wound infections, increased bleeding, slower recovery from anesthetics, prolonged hospitalization, and increased healthcare costs. Pediatric surgical patients are at potentially increased risk for hypothermia because of their smaller body size, limited stores of subcutaneous fat, and less effective regulatory capacity. This risk is exacerbated during pediatric spinal surgery by lower preoperative temperature, increased surface exposure to cold during induction and positioning, and prolonged surgical procedure times. The purpose of this quality improvement initiative was to reduce the duration of hypothermia for pediatric patients undergoing spine surgery.

Methods: Demographic and clinical data were collected on 162 patients who underwent spinal deformity surgery between October 1, 2017, and July 31, 2019. Data points included patient age, gender, diagnosis, surgical procedure, and temperature readings throughout different phases of perioperative care. Temperatures were obtained upon arrival to the day of surgery, upon presentation to the operating room, during prone positioning, at incision, and at the end of the procedure. Twelve patients were analyzed prior to implementation of a protocol, while 150 patients composed the post-protocol group.

Results: Using descriptive statistics, the authors found that the average body temperature at the time of incision was 34.0°C prior to the adoption of a preoperative warming protocol, and 35.3°C following a preoperative warming protocol (p = 0.001). There were no complications, such as burns, hyperthermia, or arrhythmias, related to preoperative warming of patients.

Conclusions: The placement of a warming blanket on the bed prior to patient arrival and actively targeting normothermia reduced the incidence and duration of hypothermia in pediatric patients undergoing spine surgery with no adverse events.
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http://dx.doi.org/10.3171/2020.8.PEDS20297DOI Listing
January 2021

Rapid Improvement Project: Improving Caregivers' Understanding of Safety Recommendations for Neurosurgical Devices.

Pediatr Qual Saf 2021 Jan-Feb;6(1):e376. Epub 2020 Dec 28.

theSection of Pediatric Neurosurgery, Riley Hospital for Children, Indiana University School of Medicine, Department of Neurological Surgery, Indianapolis, Ind.

There has been a proliferation in the development of indwelling neuromodulatory devices with varied safety recommendations, making it difficult for providers to remain up-to-date. This deficit presents an opportunity for significant improvement in patient safety.

Methods: We performed a search for monopolar electrocautery and magnetic resonance imaging safety recommendations for several indwelling neuromodulatory devices. We developed a questionnaire followed by an educational compendium and a posttest for 50 care providers.

Results: Overall, there was a poor performance on the pretest (mean 39%, SD 19%) but significant improvement on the posttest (mean 71%, SD 16%), < 0.0001. We placed the educational compendium that included all manufacturer recommendations in the operating room for easy reference. A 2.4 times decrease in the case start times of vagus nerve stimulator cases is evidence of its effectiveness.

Conclusions: The authors highlight the lack of knowledge about manufacturer safety recommendations for indwelling neurosurgical devices, which led to the creation of operating room supplements and educational devices.
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http://dx.doi.org/10.1097/pq9.0000000000000376DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7781352PMC
December 2020

Occipital-Cervical Fusion and Ventral Decompression in the Surgical Management of Chiari-1 Malformation and Syringomyelia: Analysis of Data From the Park-Reeves Syringomyelia Research Consortium.

Neurosurgery 2021 01;88(2):332-341

Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri.

Background: Occipital-cervical fusion (OCF) and ventral decompression (VD) may be used in the treatment of pediatric Chiari-1 malformation (CM-1) with syringomyelia (SM) as adjuncts to posterior fossa decompression (PFD) for complex craniovertebral junction pathology.

Objective: To examine factors influencing the use of OCF and OCF/VD in a multicenter cohort of pediatric CM-1 and SM subjects treated with PFD.

Methods: The Park-Reeves Syringomyelia Research Consortium registry was used to examine 637 subjects with cerebellar tonsillar ectopia ≥ 5 mm, syrinx diameter ≥ 3 mm, and at least 1 yr of follow-up after their index PFD. Comparisons were made between subjects who received PFD alone and those with PFD + OCF or PFD + OCF/VD.

Results: All 637 patients underwent PFD, 505 (79.2%) with and 132 (20.8%) without duraplasty. A total of 12 subjects went on to have OCF at some point in their management (PFD + OCF), whereas 4 had OCF and VD (PFD + OCF/VD). Of those with complete data, a history of platybasia (3/10, P = .011), Klippel-Feil (2/10, P = .015), and basilar invagination (3/12, P < .001) were increased within the OCF group, whereas only basilar invagination (1/4, P < .001) was increased in the OCF/VD group. Clivo-axial angle (CXA) was significantly lower for both OCF (128.8 ± 15.3°, P = .008) and OCF/VD (115.0 ± 11.6°, P = .025) groups when compared to PFD-only group (145.3 ± 12.7°). pB-C2 did not differ among groups.

Conclusion: Although PFD alone is adequate for treating the vast majority of CM-1/SM patients, OCF or OCF/VD may be occasionally utilized. Cranial base and spine pathologies and CXA may provide insight into the need for OCF and/or OCF/VD.
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http://dx.doi.org/10.1093/neuros/nyaa460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803430PMC
January 2021

Trigeminal schwannoma presenting with malocclusion: A case report and review of the literature.

Surg Neurol Int 2020 8;11:230. Epub 2020 Aug 8.

Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, United States.

Background: Trigeminal schwannomas are rare tumors of the trigeminal nerve. Depending on the location, from which they arise along the trigeminal nerve, these tumors can present with a variety of symptoms that include, but are not limited to, changes in facial sensation, weakness of the masticatory muscles, and facial pain.

Case Description: We present a case of a 16-year-old boy with an atypical presentation of a large trigeminal schwannoma: painless malocclusion and unilateral masticatory weakness. This case is the first documented instance; to the best of our knowledge, in which a trigeminal schwannoma has led to underbite malocclusion; it is the 19 documented case of unilateral trigeminal motor neuropathy of any etiology. We discuss this case as a unique presentation of this pathology, and the relevant anatomy implicated in clinical examination aid in further understanding trigeminal nerve pathology.

Conclusion: We believe our patient's underbite malocclusion occurred secondary to his trigeminal schwannoma, resulting in associated atrophy and weakness of the muscles innervated by the mandibular branch of the trigeminal nerve. Furthermore, understanding the trigeminal nerve anatomy is crucial in localizing lesions of the trigeminal nerve.
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http://dx.doi.org/10.25259/SNI_482_2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7451153PMC
August 2020

Characterization of a multicenter pediatric-hydrocephalus shunt biobank.

Fluids Barriers CNS 2020 Jul 18;17(1):45. Epub 2020 Jul 18.

Wayne State University Dept. of Chemical Engineering and Materials Science, 6135 Woodward Avenue, Rm 1413, Detroit, MI, 48202, USA.

Background: Pediatric hydrocephalus is a devastating and costly disease. The mainstay of treatment is still surgical shunting of cerebrospinal fluid (CSF). These shunts fail at a high rate and impose a significant burden on patients, their families and society. The relationship between clinical decision making and shunt failure is poorly understood and multifaceted, but catheter occlusion remains the most frequent cause of shunt complications. In order to investigate factors that affect shunt failure, we have established the Wayne State University (WSU) shunt biobank.

Methods: To date, four hospital centers have contributed various components of failed shunts and CSF from patients diagnosed with hydrocephalus before adulthood. The hardware samples are transported in paraformaldehyde and transferred to phosphate-buffered saline with sodium azide upon deposit into the biobank. Once in the bank, they are then available for study. Informed consent is obtained by the local center before corresponding clinical data are entered into a REDCap database. Data such as hydrocephalus etiology and details of shunt revision history. All data are entered under a coded identifier.

Results: 293 shunt samples were collected from 228 pediatric patients starting from May 2015 to September 2019. We saw a significant difference in the number of revisions per patient between centers (Kruskal-Wallis H test, p value < 0.001). The leading etiology at all centers was post-hemorrhagic hydrocephalus, a fisher's exact test showed there to be statistically significant differences in etiology between center (p = 0.01). Regression showed age (p < 0.01), race (p = 0.038) and hospital-center (p < 0.001) to explain significant variance in the number of revisions. Our model accounted for 31.9% of the variance in revisions. Generalized linear modeling showed hydrocephalus etiology (p < 0.001), age (p < 0.001), weight and physician (p < 0.001) to impact the number of ventricular obstructions.

Conclusion: The retrospective analysis identified that differences exist between currently enrolled centers, although further work is needed before clinically actionable recommendations can be made. Moreover, the variables collected from this chart review explain a meaningful amount of variance in the number of revision surgeries. Future work will expand on the contribution of different site-specific and patient-specific factors to identify potential cause and effect relationships.
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http://dx.doi.org/10.1186/s12987-020-00211-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368709PMC
July 2020

Comparison of anticoagulation and antiplatelet therapy for treatment of blunt cerebrovascular injury in children <10 years of age: a multicenter retrospective cohort study.

Childs Nerv Syst 2021 Jan 29;37(1):47-54. Epub 2020 May 29.

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA.

Purpose: Blunt cerebrovascular injury (BCVI) is uncommon in the pediatric population. Among the management options is medical management consisting of antithrombotic therapy with either antiplatelets or anticoagulation. There is no consensus on whether administration of antiplatelets or anticoagulation is more appropriate for BCVI in children < 10 years of age. Our goal was to compare radiographic and clinical outcomes based on medical treatment modality for BCVI in children < 10 years.

Methods: Clinical and radiographic data were collected retrospectively for children screened for BCVI with computed tomography angiography at 5 academic pediatric trauma centers.

Results: Among 651 patients evaluated with computed tomography angiography to screen for BCVI, 17 patients aged less than 10 years were diagnosed with BCVI (7 grade I, 5 grade II, 1 grade III, 4 grade IV) and received anticoagulation or antiplatelet therapy for 18 total injuries: 11 intracranial carotid artery, 4 extracranial carotid artery, and 3 extracranial vertebral artery injuries. Eleven patients were treated with antiplatelets (10 aspirin, 1 clopidogrel) and 6 with anticoagulation (4 unfractionated heparin, 2 low-molecular-weight heparin, 1 transitioned from the former to the latter). There were no complications secondary to treatment. One patient who received anticoagulation died as a result of the traumatic injuries. In aggregate, children treated with antiplatelet therapy demonstrated healing on 52% of follow-up imaging studies versus 25% in the anticoagulation cohort.

Conclusion: There were no observed differences in the rate of hemorrhagic complications between anticoagulation and antiplatelet therapy for BCVI in children < 10 years, with a nonsignificantly better rate of healing on follow-up imaging in children who underwent antiplatelet therapy; however, the study cohort was small despite including patients from 5 hospitals.
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http://dx.doi.org/10.1007/s00381-020-04672-wDOI Listing
January 2021

Editorial. Pediatric neurosurgery along with Children's Hospitals' innovations are rapid and uniform in response to the COVID-19 pandemic.

J Neurosurg Pediatr 2020 Apr 17:1-3. Epub 2020 Apr 17.

13Department of Neurological Surgery, Section of Neurosurgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio.

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http://dx.doi.org/10.3171/2020.4.PEDS20240DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7164397PMC
April 2020

An incidental pure arterial malformation in a child: case report and review of the literature.

Childs Nerv Syst 2020 Nov 12;36(11):2877-2881. Epub 2020 Feb 12.

Section of Pediatric Neurosurgery, Department of Neurological Surgery, Riley Hospital for Children, Indiana University School of Medicine, 705 Riley Hospital Drive, Suite 1601, Indianapolis, IN, 46202, USA.

Purpose: Pure arterial malformations of the brain are rare vascular lesions.

Methods: We present a 10-year-old healthy boy who presented with an incidental finding of pure arterial malformation.

Results: Our case seems to represent the second description of pure arterial malformation discovered incidentally in a child.

Conclusion: We review the clinical presentation, angiographic findings, and management of our case in the context of other reported pediatric cases.
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http://dx.doi.org/10.1007/s00381-020-04539-0DOI Listing
November 2020

PedsQL for prediction of postoperative patient-reported outcomes following Chiari decompression surgery.

J Neurosurg Pediatr 2019 Dec 6:1-6. Epub 2019 Dec 6.

Objective: The purpose of this study is to determine if the preoperative Pediatric Quality of Life Inventory (PedsQL) score is predictive of short- and intermediate-term PedsQL outcomes following Chiari decompression surgery. The utility of preoperative patient-reported outcomes (PROs) in predicting pain, opioid consumption, and long-term PROs has been demonstrated in adult spine surgery. To the best of the authors' knowledge, however, there is currently no widely accepted tool to predict short-, intermediate-, or long-term outcomes after pediatric Chiari decompression surgery.

Methods: A prospectively maintained database was retrospectively reviewed. Patients who had undergone first-time decompression for symptomatic Chiari malformation were identified and grouped according to their preoperative PedsQL scores: mild disability (score 80-100), moderate disability (score 60-79), and severe disability (score < 60). PedsQL scores at the 6-week, 3-month, and/or 6-month follow-ups were collected. Preoperative PedsQL subgroups were tested for an association with demographic and perioperative characteristics using one-way ANOVA or chi-square analysis. Preoperative PedsQL subgroups were tested for an association with improvements in short- and intermediate-term PedsQL scores using one-way ANOVA and a paired Wilcoxon signed-rank test controlling for statistically different demographic characteristics when appropriate.

Results: A total of 87 patients were included in this analysis. According to their preoperative PedsQL scores, 28% of patients had mild disability, 40% had moderate disability, and 32% had severe disability. There was a significant difference in the prevalence of comorbidities (p = 0.009) and the presenting symptoms of headaches (p = 0.032) and myelopathy (p = 0.047) among the subgroups; however, in terms of other demographic or operative factors, there was no significant difference. Patients with greater preoperative disability demonstrated statistically significantly lower PedsQL scores at all postoperative time points, except in terms of the parent-reported PedsQL at 6 months after surgery (p = 0.195). Patients with severe disability demonstrated statistically significantly greater improvements (compared to preoperative scores) in PedsQL scores at all time points after surgery, except in terms of the 6-week and 6-month PROs and the 6-month parent-reported outcomes (p = 0.068, 0.483, and 0.076, respectively).

Conclusions: Patients with severe disability, as assessed by the PedsQL, had lower absolute PedsQL scores at all time points after surgery but greater improvement in short- and intermediate-term PROs. The authors conclude that the PedsQL is an efficient and accurate tool that can quickly assess patient disability in the preoperative period and predict both short- and intermediate-term surgical outcomes.
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http://dx.doi.org/10.3171/2019.9.PEDS19409DOI Listing
December 2019

Posterior transdural approach for odontoidectomy in a child: case report.

J Neurosurg Pediatr 2019 Oct 11:1-5. Epub 2019 Oct 11.

1Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and.

The transoral transpharyngeal approach is the standard approach to resect the odontoid process and decompress the cervicomedullary spinal cord. There are some significant risks associated with this approach, however, including infection, CSF leak, prolonged intubation or tracheostomy, need for nasogastric tube feeding, extended hospitalization, and possible effects of phonation. Other ventral approaches, such as transmandibular and circumglossal, endoscopic transcervical, and endoscopic transnasal, are also viable alternatives but are technically challenging or may still traverse the nasopharyngeal cavity. Far-lateral and posterior extradural approaches to the craniocervical junction require extensive soft-tissue dissection. Recently, a posterior transdural approach was used to resect retro-odontoid cysts in 3 adult patients. The authors present the case of a 12-year-old girl with Down syndrome and significant spinal cord compression due to basilar invagination and a retro-flexed odontoid process. A posterior transdural odontoidectomy prior to occiptocervical fusion was performed. At 12 months after surgery, the authors report satisfactory clinical and radiographic outcomes with this approach.
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http://dx.doi.org/10.3171/2019.7.PEDS19337DOI Listing
October 2019

Assessment of craniocervical motion in Down syndrome: a pilot study of two measurement techniques.

J Neurosurg Pediatr 2019 Oct 4:1-7. Epub 2019 Oct 4.

6Department of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah.

Objective: Hypermobility of the craniocervical junction (CCJ) in patients with Down syndrome (DS) is common. Whereas atlantoaxial (C1-2) hypermobility is well characterized, occipitoatlantal (Oc-C1) laxity is recognized but poorly defined. A clear understanding of the risks associated with DS-related hypermobility is lacking. Research efforts to address the topic of axial cervical spine instability in the patient with DS require a reliable and reproducible means of assessing CCJ mobility. The authors conducted a pilot study comparing two methods of quantifying motion of the CCJ on dynamic (flexion/extension) plain radiographs: the delta-condyle-axial interval (ΔCAI) and the delta-basion-axial interval (ΔBAI) methods.

Methods: Dynamic radiographs from a cohort of 10 patients with DS were evaluated according to prescribed standards. Independent movement of Oc-C1, C1-2, and Oc-C2 was calculated. Interrater and intrarater reliability for CCJ mobility was then calculated for both techniques.

Results: Measurement using the ΔCAI technique had excellent fidelity with intraclass correlation coefficients (ICCs) of 0.77, 0.71, and 0.80 for Oc-C1, C1-2, and Oc-C2, respectively. The ΔBAI technique had lower fidelity, yielding respective ICCs of 0.61, 0.65, and 0.50.

Conclusions: This pilot study suggests that ΔCAI is a superior measurement technique compared to ΔBAI and may provide reliable assessment of the mobility of the CCJ on dynamic radiographs in the pediatric patient with DS. The use of reliable and reproducible measurement techniques strengthens the validity of research derived from pooled database efforts.
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http://dx.doi.org/10.3171/2019.7.PEDS191DOI Listing
October 2019

Commentary: Essential Neurosurgery for Medical Students.

Authors:
Andrew Jea

Oper Neurosurg (Hagerstown) 2019 09;17(3):E133

Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana.

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http://dx.doi.org/10.1093/ons/opz188DOI Listing
September 2019

Frontal Occipital and Frontal Temporal Horn Ratios: Comparison and Validation of Head Ultrasound-Derived Indexes With MRI and Ventricular Volumes in Infantile Ventriculomegaly.

AJR Am J Roentgenol 2019 10 16;213(4):925-931. Epub 2019 Jul 16.

Department of Radiology and Imaging Sciences, Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Dr, Indianapolis, IN 46202.

The purpose of our study was to assess whether linear ventricular dimensions-specifically, the frontal occipital horn ratio (FOHR) and frontal temporal horn ratio (FTHR) obtained from ultrasound (US)-are reliable measures of ventriculomegaly in infants. Our hypothesis was that these US measures would show good correlation with linear ventricular indexes and ventricular volumes obtained from MRI. We retrospectively identified 90 infants (age ≤ 6 months corrected gestational age) with ventriculomegaly from 2014 to 2017 who had a total of 100 sets of US and MRI studies performed in a 3-day period. FOHR and FTHR were independently measured on US and MRI by two pediatric radiologists and two pediatric neuroradiologists, respectively. Ventricular and brain volumes were segmented from the MR images, and the ventricle-to-intracranial volume ratio was calculated. MRI served as the reference standard. Intraclass correlation coefficients and Bland-Altman analyses were generated to evaluate interobserver and US-MRI concordance. We assessed correlation of the FOHR and FTHR with the ventricle-to-intracranial volume ratio. Bland-Altman plots of the FOHR and FTHR between US and MRI showed excellent concordance with a bias of 0.05 (95% CI, -0.04 to 0.14) and 0.03 (95% CI, -0.06 to 0.13), respectively. There was good-to-excellent interobserver concordance for FOHR and FTHR on head US or MRI ( = 0.86-0.96). There was good correlation between ventricle-to-intracranial volume ratios and US- and MRI-derived FOHRs and FTHRs ( = 0.79-0.87). FOHR and FTHR obtained from US in infants with ventriculomegaly have excellent interobserver concordance, are concordant with MRI-derived linear ratios, and correlate with MRI-derived ventricular volumes. Therefore, US-derived FOHR and FTHR are reliable indexes for clinical follow-up of infantile ventriculomegaly.
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http://dx.doi.org/10.2214/AJR.19.21261DOI Listing
October 2019

Increased complications without neurological benefit are associated with prophylactic spinal cord untethering prior to scoliosis surgery in children with myelomeningocele.

Childs Nerv Syst 2019 11 2;35(11):2187-2194. Epub 2019 Jul 2.

Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, NY, USA.

Purpose: Children with myelomeningocele (MMC) are at increased risk of developing neuromuscular scoliosis and spinal cord re-tethering (Childs Nerv Syst 12:748-754, 1996; Neurosurg Focus 16:2, 2004; Neurosurg Focus 29:1, 2010). Some centers perform prophylactic untethering on asymptomatic MMC patients prior to scoliosis surgery because of concern that additional traction on the cord may place the patient at greater risk of neurologic deterioration peri-operatively. However, prophylactic untethering may not be justified if it carries increased surgical risks. The purpose of this study was to determine if prophylactic untethering is necessary in asymptomatic children with MMC undergoing scoliosis surgery.

Methods: A multidisciplinary, retrospective cohort study from seven children's hospitals was performed including asymptomatic children with MMC < 21 years old, managed with or without prophylactic untethering prior to scoliosis surgery. Patients were divided into three groups for analysis: (1) untethering at the time of scoliosis surgery (concomitant untethering), (2) untethering within 3 months of scoliosis surgery (prior untethering), and (3) no prophylactic untethering. Baseline data, intra-operative reports, and 90-day post-operative outcomes were analyzed to assess for differences in neurologic outcomes, surgical complications, and overall length of stay.

Results: A total of 208 patients were included for analysis (mean age 9.4 years, 52% girls). No patient in any of the groups exhibited worsened motor or sensory function at 90 days post-operatively. However, comparing the prophylactic untethering groups with the group that was not untethered, there was an increased risk of surgical site infection (SSI) (31.3% concomitant, 28.6% prior untethering vs. 12.3% no untethering; p = 0.0104), return to the OR (43.8% concomitant, 23.8% prior untethering vs. 17.4% no untethering; p = 0.0047), need for blood transfusion (51.6% concomitant, 57.1% prior untethering vs. 33.8% no untethering; p = 0.04), and increased mean length of stay (LOS) (13.4 days concomitant, 10.6 days prior untethering vs. 6.8 days no untethering; p < 0.0001). In multivariable logistic regression analysis, prophylactic untethering was independently associated with increased adjusted relative risks of surgical site infection (aRR = 2.65, 95% CI 1.17-5.02), unplanned re-operation (aRR = 2.17, 95% CI 1.02-4.65), and any complication (aRR = 2.25, 95% CI 1.07-4.74).

Conclusion: In this study, asymptomatic children with myelomeningocele who underwent scoliosis surgery developed no neurologic injuries regardless of prophylactic untethering. However, those who underwent prophylactic untethering were more likely to experience SSIs, return to the OR, need a blood transfusion, and have increased LOS than children not undergoing untethering. Based on these data, prophylactic untethering in asymptomatic MMC patients prior to scoliosis surgery does not provide any neurological benefit and is associated with increased surgical risks.
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http://dx.doi.org/10.1007/s00381-019-04276-zDOI Listing
November 2019

Protecting Against Postoperative Dyspnea and Dysphagia After Occipitocervical Fusion.

Oper Neurosurg (Hagerstown) 2020 03;18(3):254-260

Section of Pediatric Neurosurgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana.

Background: Upper airway obstruction leading to dyspnea and dysphagia after occipitocervical fusion is a rare complication that has significant morbidity.

Objective: To estimate the frequency of postoperative dyspnea and dysphagia in children after occipitocervical fusion and to identify variables associated with its occurrence.

Methods: We retrospectively reviewed outcomes from all pediatric occipitocervical fusions at our institution between 2007 and 2014. Pre- and postoperative computed tomography (CT) scans were compared to determine differences in the clivoaxial (OC2) angles.

Results: Sixty-seven pediatric patients underwent occipitocervical fusions. Median age was 9.6 yr (range 6 mo-18 yr). Fifty-six of 62 patients (90.3%) with at least 1 yr of follow-up had successful fusions. Eleven had pre-existing symptoms or otherwise compromised examination (eg, severe traumatic brain injury). None of 15 patients placed in extension (>2 degrees) relative to preoperative CT in Situ position developed new dyspnea or dysphagia. Nine of forty patients (23%) kept in Situ or flexed position developed new symptoms of dyspnea or dysphagia. Dysphagia in patients fused in the in Situ position was milder and resolved within a few weeks. No patient under age 5 (n = 20) developed symptoms of dyspnea or dysphagia regardless of head position. There were 3 cases of infection, 1 clinically silent vertebral artery injury, and 3 deaths at last follow-up.

Conclusion: Positioning of the child's head prior to occipitocervical fusion has considerable impact on outcomes, especially in older children. Careful measurements of the OC2 angle during surgery to ensure optimal head positioning in Situ or slightly extended position may prevent postoperative dysphagia or dyspnea.
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http://dx.doi.org/10.1093/ons/opz122DOI Listing
March 2020

Reconstruction of the anterior craniocervical junction using an expandable cage after resection of a C1 chordoma in a 5-year-old child: case report.

J Neurosurg Pediatr 2019 04;24(1):62-65

1Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana; and.

Chordomas are histologically benign tumors with local aggressive behavior. They arise from embryological remnants of the notochord at the clivus, mobile spine, and sacrum. Chordomas are rare tumors in the pediatric age group. Their surgical management is difficult, given their propensity for inaccessible anatomical regions, and proximity to critical neurovascular structures. While en bloc resection with surgical margins has been advocated as the preferred approach for chordomas, tumor characteristics and violation of adjacent anatomical boundaries may not allow for safe en bloc resection of the tumor. Here, the authors present the case of a C1 chordoma in a 5-year-old boy with epidural and prevertebral extension. The patient's treatment consisted of a far-lateral approach for resection of the tumor and C1 arch, followed by circumferential reconstruction of the craniocervical junction with an expandable cage spanning the skull base to C2, and posterior occipitocervical spinal instrumentation. At 42 months after surgery, the patient remains neurologically intact with stable oncological status, and no evidence of craniocervical junction instrumentation failure.
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http://dx.doi.org/10.3171/2019.2.PEDS18752DOI Listing
April 2019

Single-Event Multilevel Surgery: Contender or Pretender.

Pediatrics 2019 04;143(4)

Departments of Pediatric Orthopedic Surgery and.

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http://dx.doi.org/10.1542/peds.2019-0102DOI Listing
April 2019

Spinal instrumentation in infants, children, and adolescents: a review.

J Neurosurg Pediatr 2019 01;23(1):1-15

1Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana; and.

OBJECTIVEThe evolution of pediatric spinal instrumentation has progressed in the last 70 years since the popularization of the Harrington rod showing the feasibility of placing spinal instrumentation into the pediatric spine. Although lacking in pediatric-specific spinal instrumentation, when possible, adult instrumentation techniques and tools have been adapted for the pediatric spine. A new generation of pediatric neurosurgeons with interest in complex spine disorder has pushed the field forward, while keeping the special nuances of the growing immature spine in mind. The authors sought to review their own experience with various types of spinal instrumentation in the pediatric spine and document the state of the art for pediatric spine surgery.METHODSThe authors retrospectively reviewed patients in their practice who underwent complex spine surgery. Patient demographics, operative data, and perioperative complications were recorded. At the same time, the authors surveyed the literature for spinal instrumentation techniques that have been utilized in the pediatric spine. The authors chronicle the past and present of pediatric spinal instrumentation, and speculate about its future.RESULTSThe medical records of the first 361 patients who underwent 384 procedures involving spinal instrumentation from July 1, 2007, to May 31, 2018, were analyzed. The mean age at surgery was 12 years and 6 months (range 3 months to 21 years and 4 months). The types of spinal instrumentation utilized included occipital screws (94 cases); C1 lateral mass screws (115 cases); C2 pars/translaminar screws (143 cases); subaxial cervical lateral mass screws (95 cases); thoracic and lumbar spine traditional-trajectory and cortical-trajectory pedicle screws (234 cases); thoracic and lumbar sublaminar, subtransverse, and subcostal polyester bands (65 cases); S1 pedicle screws (103 cases); and S2 alar-iliac/iliac screws (56 cases). Complications related to spinal instrumentation included hardware-related skin breakdown (1.8%), infection (1.8%), proximal junctional kyphosis (1.0%), pseudarthroses (1.0%), screw malpositioning (0.5%), CSF leak (0.5%), hardware failure (0.5%), graft migration (0.3%), nerve root injury (0.3%), and vertebral artery injury (0.3%).CONCLUSIONSPediatric neurosurgeons with an interest in complex spine disorders in children should develop a comprehensive armamentarium of safe techniques for placing rigid and nonrigid spinal instrumentation even in the smallest of children, with low complication rates. The authors' review provides some benchmarks and outcomes for comparison, and furnishes a historical perspective of the past and future of pediatric spine surgery.
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http://dx.doi.org/10.3171/2018.10.PEDS18327DOI Listing
January 2019

Pre- and Postoperative Gait Analysis and Video for Selective Dorsal Rhizotomy in Spastic Diplegia: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2019 Sep;17(3):E103-E104

Section of Pediatric Neurosurgery, Department of Neurological Surgery, Riley Hospital for Children, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana.

Severe lower limb spasticity can hinder motor tasks and negatively impacts the quality of life in patients with cerebral palsy. Selective dorsal rhizotomy is a well-established neurosurgical intervention aimed at reducing muscle spasticity in patients with such neuromuscular conditions. Long-term outcomes of selective dorsal rhizotomy have been promising among the authors' institutional series of patients. In this case, we demonstrate the use of L1-S1 osteoplastic laminoplasty and L1-S1 selective dorsal rhizotomy in a 5-year-old male patient with cerebral palsy and spastic lower extremity diplegia. Favorable selection criteria for this case included disabling lower extremity diplegia, young age, good core strength, no cognitive delay, and strong rehabilitation potential. The patient's preoperative functional status was noncommunity ambulator (Gross Motor Function Classification System Level III) with walker use and good dynamic balance. Prior to the procedure, he demonstrated an overall decreased muscle strength in bilateral lower extremities with bilateral hamstring spasticity (Ashworth 3) and bilateral heel cord spasticity (Ashworth 4). Rhizotomy was performed with identification and selective sectioning of dorsal nerve roots with abnormal stimulation patterns. Fibers with unsustained discharge of appropriate muscles were identified and spared. No intraoperative or postoperative complications were encountered. The patient had minimal back pain and surgical morbidity postoperatively. Following the procedure and highly structured inpatient and outpatient rehabilitation therapies, the patient exhibited significant improvement in gait velocity (84%) and gait cadence (66%) at 5 months. Additionally, the patient demonstrated greater independence of activities of daily living and improvements in mobility by Pediatric Evaluation Disability Index. Patient consent was obtained from the parent.
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http://dx.doi.org/10.1093/ons/opy392DOI Listing
September 2019

Pharmacologic chaos: severe hypotension from interactions of anesthetics, marijuana, amphetamines, and paroxetine.

J Clin Anesth 2019 08 24;55:17. Epub 2018 Dec 24.

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http://dx.doi.org/10.1016/j.jclinane.2018.12.040DOI Listing
August 2019

Surgical Management of Trigeminal Neuralgia in Children.

World Neurosurg 2019 Jan 19;121:217-221. Epub 2018 Oct 19.

Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indiana University School of Medicine, Indianapolis, Indiana, USA. Electronic address:

Background: Trigeminal neuralgia (TN) is a well-recognized facial pain syndrome. Discrete forms with disparate pain symptoms include classic and atypical. However, atypical facial pain includes neuralgiform pain along a spectrum. Most cases of TN are diagnosed in the adult population. Case reports and series of children have presented TN as a similar entity, with treatment similar to that for adults. We reviewed the pertinent data and present 2 pediatric TN cases successfully treated with microvascular decompression (MVD).

Case Description: Two pediatric patients (age 12 and 15 years) with TN refractory to previous medical therapy were identified. Both patients were deemed appropriate surgical candidates and underwent MVD to manage their TN. TN compression was arterial in both cases and involved portions of the anterior inferior cerebellar artery. Patient 1 was pain free 6 months after the procedure. Patient 2 was pain free immediately after the procedure and had been weaned off preoperative symptomatic management at the latest follow-up visit. The most recent follow-up examination was 12 and 8 months for patients 1 and 2, respectively, with both experiencing continued freedom from pain.

Conclusions: Few studies have reported on the effectiveness of MVD in the pediatric population for the management of TN. The supporting data and our 2 cases have demonstrated that MVD is effective for pediatric patients to treat their TN. Furthermore, the side effects appear to be minimal, with excellent pain relief after MVD in this patient population.
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http://dx.doi.org/10.1016/j.wneu.2018.10.074DOI Listing
January 2019

Neurosurgical Management of Spastic Conditions of the Upper Extremity.

Hand Clin 2018 Nov 18;34(4):547-554. Epub 2018 Aug 18.

Section of Pediatric Neurosurgery, Department of Neurosurgery, Goodman Campbell Brain and Spine, Riley Hospital for Children, Indiana University School of Medicine, 705 Riley Hospital Drive, Suite #1134, Indianapolis, IN 46202, USA. Electronic address:

Spasticity is a hypertonic segmental reflex pathway caused by a central nervous system injury. Spasticity of the upper extremity causes loss of function, joint contracture, pain, and poor cosmesis. Treatment aims to reduce or change the pathophysiology underlying the hyperactive reflex from dorsal sensory rootlets through the intrinsic machinery of the spinal cord to the neuromuscular junction. There are many treatments for upper extremity spasticity including oral medication, physiotherapy, intrathecal baclofen, and lesional or neuromodulatory surgical approaches. Goals of treatment must always be clearly defined, but neurosurgical management is most effective when paired with multidisciplinary therapies and caregiver participation.
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http://dx.doi.org/10.1016/j.hcl.2018.06.012DOI Listing
November 2018

Development of best practices to minimize wound complications after complex tethered spinal cord surgery: a modified Delphi study.

J Neurosurg Pediatr 2018 Dec;22(6):701-709

1Department of Neurological Surgery, Columbia University Medical Center, New York, New York.

OBJECTIVEComplications after complex tethered spinal cord (cTSC) surgery include infections and cerebrospinal fluid (CSF) leaks. With little empirical evidence to guide management, there is variability in the interventions undertaken to limit complications. Expert-based best practices may improve the care of patients undergoing cTSC surgery. Here, authors conducted a study to identify consensus-driven best practices.METHODSThe Delphi method was employed to identify consensual best practices. A literature review regarding cTSC surgery together with a survey of current practices was distributed to 17 board-certified pediatric neurosurgeons. Thirty statements were then formulated and distributed to the group. Results of the second survey were discussed during an in-person meeting leading to further consensus, which was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree).RESULTSSeventeen consensus-driven best practices were identified, with all participants willing to incorporate them into their practice. There were four preoperative interventions: (1, 2) asymptomatic AND symptomatic patients should be referred to urology preoperatively, (3, 4) routine preoperative urine cultures are not necessary for asymptomatic AND symptomatic patients. There were nine intraoperative interventions: (5) patients should receive perioperative cefazolin or an equivalent alternative in the event of allergy, (6) chlorhexidine-based skin preparation is the preferred regimen, (7) saline irrigation should be used intermittently throughout the case, (8) antibiotic-containing irrigation should be used following dural closure, (9) a nonlocking running suture technique should be used for dural closure, (10) dural graft overlay should be used when unable to obtain primary dural closure, (11) an expansile dural graft should be incorporated in cases of lipomyelomeningocele in which primary dural closure does not permit free flow of CSF, (12) paraxial muscles should be closed as a layer separate from the fascia, (13) routine placement of postoperative drains is not necessary. There were three postoperative interventions: (14) postoperative antibiotics are an option and, if given, should be discontinued within 24 hours; (15) patients should remain flat for at least 24 hours postoperatively; (16) routine use of abdominal binders or other compressive devices postoperatively is not necessary. One intervention was prioritized for additional study: (17) further study of additional gram-negative perioperative coverage is needed.CONCLUSIONSA modified Delphi technique was used to develop consensus-driven best practices for decreasing wound complications after cTSC surgery. Further study is required to determine if implementation of these practices will lead to reduced complications. Discussion through the course of this study resulted in the initiation of a multicenter study of gram-negative surgical site infections in cTSC surgery.
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http://dx.doi.org/10.3171/2018.6.PEDS18243DOI Listing
December 2018

Spinal Column Shortening for Secondary Tethered Cord Syndrome in Children: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2019 Jun;16(6):E168

Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana.

Tethered cord syndrome is a constellation of signs and symptoms involving sensory and motor dysfunction of the lower extremities, bladder, and bowel. The pathophysiology may be from a mechanical stretch of the distal spinal cord causing deleterious changes in blood supply and metabolism. The standard of care for tethered cord syndrome has been tethered cord release. However, drawbacks of traditional tethered cord release include neurological injury, cerebrospinal fluid leak, and intradural scarring and retethering of the spinal cord (secondary tethering). As such, spinal column shortening was described to avoid these risks.1 We applied spinal column shortening to children and transitional adults with secondary tethered cord syndrome.1 As shown in cadaveric biomechanical studies, the objective of surgery is to shorten by the spinal column by 1.5 to 2.5 cm, to obtain the equivalent relief of traction on the spinal cord and nerve roots as direct circumferential untethering.2 In this video, we present the case of an 11-yr-old boy with a history of VATERL (vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities) and tethered cord syndromes manifest as bladder dysfunction. Our patient had segmentation and formation anomalies of the lumbosacral junction, imperforate anus, and leg length discrepancy. He had already undergone multiple tethered cord releases with no durable improvement in bladder function. After discussion of the advantages and disadvantages of spinal column shortening with the patient and his father, we decided to proceed with this treatment alternative. At 9 mo after surgery, the patient has satisfactory clinical and radiographic outcomes. Informed consent was obtained from the parents of the patient.
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http://dx.doi.org/10.1093/ons/opy247DOI Listing
June 2019

Letter: Trends in Attendance at the Annual AANS/CNS Section on Pediatric Neurological Surgery Meeting.

Neurosurgery 2018 10;83(4):E182-E187

Section of Pediatric Neurosurgery Riley Hospital for Children Department of Neurosurgery Indiana University School of Medicine Goodman Campbell Brain and Spine Indianapolis, Indiana.

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http://dx.doi.org/10.1093/neuros/nyy317DOI Listing
October 2018

Evaluation of lateral atlantodental interval asymmetry in the pediatric age group: normative values.

J Neurosurg Pediatr 2018 08 18;22(2):195-199. Epub 2018 May 18.

OBJECTIVE The revelation of normative radiographic measurements for the developing pediatric spine is incomplete. The purpose of this analysis was to determine the normal range of asymmetry of the lateral atlantodental interval (LADI) and define age- and sex-related differences. METHODS A total of 3072 children aged 0-18 years who underwent CT scanning of the cervical spine were identified at Riley Hospital for Children between 2005 and 2017. Patients were stratified by sex and age (in years) into 36 cohorts. Following this stratification, patients within each group were randomly selected for inclusion until 15 patients in each group had been measured (quota sampling). A total of 540 patients were included for study. Right and left linear measurements were performed in the CT axial plane at the C-1 midlateral mass level. RESULTS The overall mean difference between the right and left LADI was 0.09 ± 1.23 mm (range -6.05 to 4.87 mm). The magnitude of this asymmetry remained statistically insignificant across age groups (p = 0.278) and sex (p = 0.889). The intraclass correlation coefficient was 0.805 (95% CI 0.779-0.829). CONCLUSIONS Asymmetry of the LADI is not unusual in asymptomatic children. There is no appreciable difference in magnitude of this asymmetry across age ranges and sex. Measurement of LADI asymmetry shows "good" reliability and is easy to perform. Pediatric neurosurgeons, emergency department physicians, and radiologists should be aware of normative values of asymmetry when interpreting CT scans of the cervical spine. This may prevent unnecessary further workup with dynamic CT or MRI.
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http://dx.doi.org/10.3171/2018.2.PEDS17694DOI Listing
August 2018

Growth and alignment of the pediatric subaxial cervical spine following rigid instrumentation and fusion: a multicenter study of the Pediatric Craniocervical Society.

J Neurosurg Pediatr 2018 07 20;22(1):81-88. Epub 2018 Apr 20.

1Department of Pediatric Neurosurgery, Children's Hospital of New York, Columbia-Presbyterian, New York, New York.

OBJECTIVE The long-term effects of surgical fusion on the growing subaxial cervical spine are largely unknown. Recent cross-sectional studies have demonstrated that there is continued growth of the cervical spine through the teenage years. The purpose of this multicenter study was to determine the effects of rigid instrumentation and fusion on the growing subaxial cervical spine by investigating vertical growth, cervical alignment, cervical curvature, and adjacent-segment instability over time. METHODS A total of 15 centers participated in this multi-institutional retrospective study. Cases involving children less than 16 years of age who underwent rigid instrumentation and fusion of the subaxial cervical spine (C-2 and T-1 inclusive) with at least 1 year of clinical and radiographic follow-up were investigated. Charts were reviewed for clinical data. Postoperative and most recent radiographs, CT, and MR images were used to measure vertical growth and assess alignment and stability. RESULTS Eighty-one patients were included in the study, with a mean follow-up of 33 months. Ninety-five percent of patients had complete clinical resolution or significant improvement in symptoms. Postoperative cervical kyphosis was seen in only 4 patients (5%), and none developed a swan-neck deformity, unintended adjacent-level fusion, or instability. Of patients with at least 2 years of follow-up, 62% demonstrated growth across the fusion construct. On average, vertical growth was 79% (4-level constructs), 83% (3-level constructs), or 100% (2-level constructs) of expected growth. When comparing the group with continued vertical growth to the one without growth, there were no statistically significant differences in terms of age, sex, underlying etiology, surgical approach, or number of levels fused. CONCLUSIONS Continued vertical growth of the subaxial spine occurs in nearly two-thirds of children after rigid instrumentation and fusion of the subaxial spine. Failure of continued vertical growth is not associated with the patient's age, sex, underlying etiology, number of levels fused, or surgical approach. Further studies are needed to understand this dichotomy and determine the long-term biomechanical effects of surgery on the growing pediatric cervical spine.
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http://dx.doi.org/10.3171/2018.1.PEDS17551DOI Listing
July 2018

Placement of baclofen pump catheter through a C1-2 puncture: technical note.

J Neurosurg Pediatr 2018 04 26;21(4):389-394. Epub 2018 Jan 26.

1Section of Pediatric Neurosurgery, Riley Hospital for Children.

Intrathecal baclofen has been suggested as an effective and safe treatment for intractable spasticity and dystonia. Techniques of lumbar and intraventricular catheter placement have been previously described. The purpose of this study was to describe a technique to implant catheters for intrathecal baclofen infusion through C1-2 puncture. Four of 5 consecutively treated patients underwent successful placement of catheters for intrathecal baclofen. There were no instances of infection, CSF leak, or catheter migration seen during a follow-up period of at least 6 months; furthermore, there were no occurrences of vertebral artery or spinal cord injury. All patients had an effective stabilization or reduction of their upper-extremity, lower-extremity, or trunk tone. There were no cases of worsening hypertonia. The authors' preliminary experience with C1-2 puncture for placement of the intrathecal baclofen catheter seems to indicate that this is a safe and efficacious technique. Lessons learned from the failed attempt at C1-2 puncture will be delineated.
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http://dx.doi.org/10.3171/2017.9.PEDS17289DOI Listing
April 2018

Parent/guardian knowledge regarding implanted shunt type, setting, and symptoms of malfunction/infection.

J Neurosurg Pediatr 2018 04 12;21(4):359-366. Epub 2018 Jan 12.

1Goodman Campbell Brain and Spine and.

OBJECTIVE Patients with shunts often interact with providers distant from their primary hospital, making it important that the parent(s)/guardian(s) is well versed in the type of shunt implanted and symptoms of malfunction/infection. This is particularly important with magnetic-sensitive programmable valves, as the use of MRI becomes more prevalent. METHODS Over a 6-month period, primary caregivers of 148 consecutive patients who received shunts were prospectively administered questionnaires at clinic visits. Caregivers were asked to do the following: 1) identify shunt valve name, type, and setting if applicable; 2) list symptoms of shunt malfunction/infection; and 3) indicate whether they had access to references regarding shunt type/setting, booklets from the Hydrocephalus Association, and quick reference cards with symptoms of shunt malfunction/infection. One cohort of caregivers (n = 75) was asked to carry informational cards with shunt valve/setting information (group I); this cohort was compared with another subgroup of caregivers (n = 73) not carrying cards (group II). RESULTS The mean (± SD) age of patients at implantation/revision was 3.71 ± 4.91 years, and the age at follow-up was 6.12 ± 5.4 years. The average time from surgery to administration of the questionnaire was 2.38 ± 3.22 years. There were 86 new shunt insertions and 62 revisions. One hundred twenty-eight caregivers (87%) could identify the type of valve (programmable vs nonprogrammable). On the other hand, only 72 caregivers (49%) could identify the valve name. Fifty-four of 73 (74%) caregivers of patients who had shunts with programmable valves could correctly identify the valve setting. One hundred caregivers (68%) had a copy of the Hydrocephalus Association booklet, and 103 (70%) had quick reference cards. Eighty caregivers (54%) had references on shunt type/setting. Most caregivers (127 [86%]) could name ≥ 3 signs/symptoms of shunt malfunction, with vomiting (61%), headache (49%), and sleeps more/lethargic (35%) most frequently reported. Caregivers of patients in group I were more likely to have cards with symptoms of shunt infection or malfunction (p = 0.015); have information cards regarding shunt type/setting (p < 0.001); and correctly identify valve type (p = 0.001), name (p < 0.001), and setting if programmable (p = 0.0016). There were no differences in ability to list symptoms of shunt malfunction or infection (p = 0.8812) or in access to Hydrocephalus Association booklets (p = 0.1288). There were no significant demographic differences between the groups, except that group I patients had a shorter time from surgery to last follow-up (1.66 vs 3.17 years; p = 0.0001). CONCLUSIONS Education regarding the care of patients with shunts by providing written cards with shunt type/setting and access to reference materials seems to be effective. Developing plans for guided instruction with assessment in the clinic setting of a caregiver's knowledge is important for patient safety.
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http://dx.doi.org/10.3171/2017.9.PEDS17253DOI Listing
April 2018