Publications by authors named "Mark R Proctor"

108 Publications

Association of venous thromboembolism following pediatric traumatic spinal injuries with injury severity and longer hospital stays.

J Neurosurg Spine 2021 Sep 17:1-7. Epub 2021 Sep 17.

1Computational Neurosciences Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital; and.

Objective: Venous thromboembolism (VTE) can cause significant morbidity and mortality in hospitalized patients, and may disproportionately occur in patients with limited mobility following spinal trauma. The authors aimed to characterize the epidemiology and clinical predictors of VTE in pediatric patients following traumatic spinal injuries (TSIs).

Methods: The authors conducted a retrospective cohort analysis of children who experienced TSI, including spinal fractures and spinal cord injuries, encoded within the National Trauma Data Bank from 2011 to 2014.

Results: Of the 22,752 pediatric patients with TSI, 192 (0.8%) experienced VTE during initial hospitalization. Proportionally, more patients in the VTE group (77%) than in the non-VTE group (68%) presented following a motor vehicle accident. Patients developing VTE had greater odds of presenting with moderate (adjusted odds ratio [aOR] 2.6, 95% confidence interval [CI] 1.4-4.8) or severe Glasgow Coma Scale scores (aOR 4.3, 95% CI 3.0-6.1), epidural hematoma (aOR 2.8, 95% CI 1.4-5.7), and concomitant abdominal (aOR 2.4, 95% CI 1.8-3.3) and/or lower extremity (aOR 1.5, 95% CI 1.1-2.0) injuries. They also had greater odds of being obese (aOR 2.9, 95% CI 1.6-5.5). Neither cervical, thoracic, nor lumbar spine injuries were significantly associated with VTE. However, involvement of more than one spinal level was predictive of VTE (aOR 1.3, 95% CI 1.0-1.7). Spinal cord injury at any level was also significantly associated with developing VTE (aOR 2.5, 95% CI 1.8-3.5). Patients with VTE stayed in the hospital an adjusted average of 19 days longer than non-VTE patients. They also had greater odds of discharge to a rehabilitative facility or home with rehabilitative services (aOR 2.6, 95% CI 1.8-3.6).

Conclusions: VTE occurs in a low percentage of hospitalized pediatric patients with TSI. Injury severity is broadly associated with increased odds of developing VTE; specific risk factors include concomitant injuries such as cranial epidural hematoma, spinal cord injury, and lower extremity injury. Patients with VTE also require hospital-based and rehabilitative care at greater rates than other patients with TSI.
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http://dx.doi.org/10.3171/2021.3.SPINE201981DOI Listing
September 2021

Operative Treatment of Cervical Spine Injuries Sustained in Youth Sports.

J Pediatr Orthop 2021 Aug 31. Epub 2021 Aug 31.

Departments of Orthopaedic Surgery Neurosurgery, Boston Children's Hospital (Harvard Teaching Hospital), Boston, MA Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Cleveland, OH.

Background: Little data exists on surgical outcomes of sports-related cervical spine injuries (CSI) sustained in children and adolescent athletes. This study reviewed demographics, injury characteristics, management, and operative outcomes of severe CSI encountered in youth sports.

Methods: Children below 18 years with operative sports-related CSI at a Level 1 pediatric trauma center were reviewed (2004 to 2019). All patients underwent morden cervical spine instrumentation and fusion. Clinical, radiographic, and surgical characteristics were analyzed.

Results: A total of 3231 patients (mean, 11.3±4.6 y) with neck pain were evaluated for CSI. Sports/recreational activities were the most common etiology in 1358 cases (42.0%). Twenty-nine patients (2.1%) with sports-related CSI (mean age, 14.5 y; range, 6.4 to 17.8 y) required surgical intervention. Twenty-five were males (86%). Operative CSI occurred in football (n=8), wrestling (n=7), gymnastics (n=5), diving (n=4), trampoline (n=2), hockey (n=1), snowboarding (n=1), and biking (n=1). Mechanisms were 27 hyperflexion/axial loading (93%) and 2 hyperextension injuries (7%). Most were cervical fractures (79%) and subaxial injuries (79%). Seven patients (24%) sustained spinal cord injury (SCI) and 3 patients (10%) cord contusion or myelomalacia without neurological deficits. The risk of SCI increased with age (P=0.03). Postoperatively, 2 SCI patients (29%) improved 1 American Spinal Injury Association Impairment Scale Grade and 1 (14%) improved 2 American Spinal Injury Association Impairment Scale Grades. Increased complications developed in SCI than non-SCI cases (mean, 2.0 vs. 0.1 complications; P=0.02). Bony fusion occurred in 26/28 patients (93%) after a median of 7.2 months (interquartile range, 6 to 15 mo). Ten patients (34%) returned to their baseline sport and 9 (31%) to lower-level activities.

Conclusions: The incidence of sports-related CSI requiring surgery is low with differences in age/sex, sport, and injury patterns. Older males with hyperflexion/axial loading injuries in contact sports were at greatest risk of SCI, complications, and permanent disability. Prevention campaigns, education on proper tackling techniques, and neck strength training are required in sports at high risk of hyperflexion/axial loading injury.

Level Of Evidence: Level III-retrospective cohort study.
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http://dx.doi.org/10.1097/BPO.0000000000001950DOI Listing
August 2021

Development of best practices in the utilization and implementation of pediatric cervical spine traction: a modified Delphi study.

J Neurosurg Pediatr 2021 Apr 2:1-12. Epub 2021 Apr 2.

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

Objective: Cervical traction in pediatric patients is an uncommon but invaluable technique in the management of cervical trauma and deformity. Despite its utility, little empirical evidence exists to guide its implementation, with most practitioners employing custom or modified adult protocols. Expert-based best practices may improve the care of children undergoing cervical traction. In this study, the authors aimed to build consensus and establish best practices for the use of pediatric cervical traction in order to enhance its utilization, safety, and efficacy.

Methods: A modified Delphi method was employed to try to identify areas of consensus regarding the utilization and implementation of pediatric cervical spine traction. A literature review of pediatric cervical traction was distributed electronically along with a survey of current practices to a group of 20 board-certified pediatric neurosurgeons and orthopedic surgeons with expertise in the pediatric cervical spine. Sixty statements were then formulated and distributed to the group. The results of the second survey were discussed during an in-person meeting leading to further consensus. Consensus was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree).

Results: After the initial round, consensus was achieved with 40 statements regarding the following topics: goals, indications, and contraindications of traction (12), pretraction imaging (6), practical application and initiation of various traction techniques (8), protocols in trauma and deformity patients (8), and management of traction-related complications (6). Following the second round, an additional 9 statements reached consensus related to goals/indications/contraindications of traction (4), related to initiation of traction (4), and related to complication management (1). All participants were willing to incorporate the consensus statements into their practice.

Conclusions: In an attempt to improve and standardize the use of cervical traction in pediatric patients, the authors have identified 49 best-practice recommendations, which were generated by reaching consensus among a multidisciplinary group of pediatric spine experts using a modified Delphi technique. Further study is required to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.
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http://dx.doi.org/10.3171/2020.10.PEDS20778DOI Listing
April 2021

Scoliosis with Chiari I malformation without associated syringomyelia.

Spine Deform 2021 Jul 20;9(4):1105-1113. Epub 2021 Jan 20.

Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA.

Purpose: Many patients with presumed idiopathic scoliosis are found to have Chiari I malformation (CM-I) on MRI. The objective of this study is to report on scoliosis progression in CM-I with no syringomyelia.

Methods: A retrospective review of patients with scoliosis and CM-I was conducted from 1997 to 2015. Patients with syringomyelia and/or non-idiopathic scoliosis were excluded. Clinical and radiographic characteristics were recorded at presentation and latest follow-up. CM-I was defined as the cerebellar tonsil extending 5 mm or more below the foramen magnum on MRI.

Results: Thirty-two patients (72% female) with a mean age of 11 years (range 1-16) at scoliosis diagnosis were included. The average initial curve was 30.3° ± SD 16.3. The mean initial Chiari size was 9.6 mm SD ± 4.0. Fifteen (46.9%) experienced Chiari-related symptoms, and three (9%) patients underwent Posterior Fossa Decompression (PFD) to treat these symptoms. 10 (31%) patients went on to fusion, progressing on average 13.6° (95% CI 1.6-25.6°). No association was detected between decompression and either curve progression or fusion (p = 0.46, 0.60). For those who did not undergo fusion, curve magnitude progressed on average 1.0° (95% CI - 4.0 to 5.9°). There was no association between age, Chiari size, presence of symptoms, initial curve shape, or bracing treatment and fusion.

Conclusion: Patients with CM-I and scoliosis may not require surgical treatment, including PFD and fusion. Scoliosis curvature stabilized in the non-surgical population at an average progression of 1.0°. These results suggest that CM-I with no syringomyelia has minimal effect on scoliosis progression.
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http://dx.doi.org/10.1007/s43390-021-00286-7DOI Listing
July 2021

High-dose versus low-dose tranexamic acid for paediatric craniosynostosis surgery: a double-blind randomised controlled non-inferiority trial.

Br J Anaesth 2020 09 30;125(3):336-345. Epub 2020 Jun 30.

Department of Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.

Background: Tranexamic acid (TXA) reduces blood loss and transfusion in paediatric craniosynostosis surgery. The hypothesis is that low-dose TXA, determined by pharmacokinetic modelling, is non-inferior to high-dose TXA in decreasing blood loss and transfusion in children.

Methods: Children undergoing craniosynostosis surgery were enrolled in a two-centre, prospective, double-blind, randomised, non-inferiority controlled trial to receive high TXA (50 mg kg followed by 5 mg kg h) or low TXA (10 mg kg followed by 5 mg kg h). Primary outcome was blood loss. Low dose was determined to be non-inferior to high dose if the 95% confidence interval (CI) for the mean difference in blood loss was above the non-inferiority margin of -20 ml kg. Secondary outcomes were transfusion, TXA plasma concentrations, and biological markers of fibrinolysis and inflammation.

Results: Sixty-eight children were included. Values were non-inferior regarding blood loss (39.4 [4.4] vs 40.3 [6.2] ml kg [difference=0.9; 95% CI: -14.2, 15.9]) and blood transfusion (21.3 [1.6] vs 23.6 [1.5] ml kg [difference=2.3; 95% CI: -2.1, 6.7]) between high-dose (n=32) and low-dose (n=34) groups, respectively. The TXA plasma concentrations during surgery averaged 50.2 (8.0) and 29.6 (7.6) μg ml. There was no difference in fibrinolytic and inflammatory biological marker concentrations. No adverse events were observed.

Conclusions: Tranexamic acid 10 mg kg followed by 5 mg kg h is not less effective than a higher dose of 50 mg kg and 5 mg kg h in reducing blood loss and transfusion in paediatric craniosynostosis surgery.

Clinical Trial Registration: NCT02188576.
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http://dx.doi.org/10.1016/j.bja.2020.05.054DOI Listing
September 2020

Age at Craniosynostosis Surgery and Its Impact on Ophthalmologic Diagnoses: A Single-Center Retrospective Review.

Plast Reconstr Surg 2020 09;146(3):375e-376e

Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass.

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http://dx.doi.org/10.1097/PRS.0000000000007111DOI Listing
September 2020

Comparative analysis of cranial vault remodeling versus endoscopic suturectomy in the treatment of unilateral lambdoid craniosynostosis.

J Neurosurg Pediatr 2020 Apr 17:1-8. Epub 2020 Apr 17.

Departments of3Neurosurgery and.

Objective: Unilateral lambdoid synostosis is the premature fusion of a lambdoid suture or sutures and represents the least common form of craniosynostosis, occurring in 1 in 40,000 births. Cranial vault remodeling (CVR) and endoscopic suturectomy with helmet therapy (ES) are surgical approaches that are used to allow for normal brain growth and improved craniofacial symmetry. The authors conducted a comparative outcomes analysis of patients with lambdoid synostosis undergoing either CVR or ES.

Methods: The authors conducted a retrospective consecutive cohort study of patients with nonsyndromic lambdoid synostosis who underwent surgical correction identified from a single-institution database of patients with craniosynostosis seen between 2000 and 2018. Cranial growth was measured in head circumference percentile and z score.

Results: Nineteen patients (8 female and 11 male) with isolated unilateral lambdoid synostosis were identified (8 right and 11 left). Six underwent CVR and 13 underwent ES. No statistically significant differences were noted between surgical groups with respect to suture laterality, the patient's sex, and length of follow-up. Patients treated with ES presented and underwent surgery at a younger age than those treated with CVR (p = 0.0002 and p = 0.0001, respectively). Operating and anesthesia time, estimated blood loss, and ICU and total hospital days were significantly lower in ES (all p < 0.05). No significant differences were observed in pre- and postoperative head circumference percentiles or z scores between groups up to 36 months postoperatively. No patients required reoperation as of last follow-up.

Conclusions: Endoscopic management of lambdoid synostosis is safe, efficient, and efficacious in terms of intraoperative and long-term cranial growth outcomes when compared to CVR. The authors recommend this minimally invasive approach as an option for correction of lambdoid synostosis in patients presenting early in their course.
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http://dx.doi.org/10.3171/2020.2.PEDS19522DOI Listing
April 2020

Surgical volume of simple tethered spinal cord releases: review of a large pediatric neurosurgical service experience.

J Neurosurg Pediatr 2020 Apr 3:1-5. Epub 2020 Apr 3.

Objective: The aim of this study was to retrospectively review, from a single busy pediatric neurosurgical service, a consecutive series of patients who had undergone surgery for a simple tethered spinal cord, which was defined by a thickened or fatty filum terminale with a normal conus. The hope was to contribute to benchmark data regarding the expected frequency of surgery for this condition.

Methods: The authors reviewed the electronic medical records of every patient with diagnosed simple tethered spinal cord, defined on spinal MRI as a thickened (> 2 mm in diameter) or fatty filum terminale, and who had undergone primary filum section at Boston Children's Hospital between 2005 and 2011.

Results: A total of 208 patients met the study inclusion criteria. At the time of surgery, patients ranged in age from 0.4 to 19.8 years. One hundred forty-four (69%) patients were symptomatic with one or more of the following: bowel/bladder dysfunction, 94 (45%); neurological dysfunction, 49 (24%); scoliosis, 44 (21%); or back pain, 44 (21%). Sixty-four (31%) patients were asymptomatic and were operated on prophylactically when filum pathology was discovered during the course of a workup for clinical syndromes such as anorectal anomalies and/or suspicious cutaneous lesions. No patients in this series were operated on if they had normal MRI studies, defined as a conus tip no lower than L3 and no distal tethering lesion visualized. Over the study period, approximately 1000 major surgical cases were performed in the department every year, only 30 of which were simple detethering procedures, representing well under 5% of the service's operative volume and approximately 5 cases per surgeon per year. Clinical follow-up, available at a postoperative interval of 6.6 ± 3.8 years, demonstrated that approximately 80% of patients symptomatic with bowel or bladder involvement or neurological dysfunction had improvement or relief of their symptoms and that none of the patients treated prophylactically experienced new-onset symptoms that could be related to spinal tethering.

Conclusions: Simple detethering procedures were relatively uncommon in an active, well-established pediatric neurosurgical service and represented less than 5% of the service's total case volume per year with an average of 5 cases per surgeon per year. No patients with normal MRI studies were operated on during the study period.
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http://dx.doi.org/10.3171/2020.2.PEDS19743DOI Listing
April 2020

Use of recombinant human bone morphogenetic protein for revision cervical spine fusion in children with Down syndrome: a case series.

J Neurosurg Pediatr 2020 Jan 31:1-5. Epub 2020 Jan 31.

Departments of1Orthopaedic Surgery and.

Objective: Patients with trisomy 21 (Down syndrome; DS) often have atlantoaxial instability (AAI), which, if severe, causes myelopathy and neurological deterioration. Children with DS and AAI who undergo cervical spine fusion have a high rate of nonunion requiring revision surgery. Recombinant human bone morphogenetic protein-2 (rhBMP-2) is a TGF-β growth factor that is used to induce bone formation in spine fusion. Although previous studies in the adult population have reported no reduction in pseudarthrosis rates with the use of rhBMP-2, there is a lack of literature in the pediatric DS population. This study describes the use of rhBMP-2 in children with DS and AAI during revision to treat nonunion.

Methods: A retrospective review of a cervical spine fusion database (n = 175) was conducted. This database included all cervical spine fusions using modern instrumentation at the authors' institution from 2002 to 2019. Patients with DS who underwent a revision utilizing rhBMP-2 were included in the study. The number of prior fusions, use of rhBMP-2 in fusions, length of stay, halo use, and surgical data were collected. Postoperative complications and length of follow-up were also recorded.

Results: Eight patients (75% female) met the inclusion criteria. The average age at revision with rhBMP-2 was 11 years (range 3-19 years). All patients were diagnosed with nonunion after an initial cervical fusion. All revisions were posterior fusions of C1-2 (n = 2) or occiput to cervical (n = 6). All revisions included implant revisions, iliac crest bone grafting, and rhBMP-2 use. One patient required irrigation and debridement of an rhBMP-induced seroma. Another patient required return to the operating room to repair a dural tear. There were no neurological, infectious, airway, or implant-related complications. Revision utilizing rhBMP-2 achieved fusion in 100% (n = 8) of patients. The average length of follow-up was 42.6 months. All patients demonstrated solid fusion mass on the last radiograph.

Conclusions: This is the first case series reporting the successful use of rhBMP-2 to facilitate cervical spine fusion in patients with DS after previous nonunion. In addition, few rhBMP-2-related postoperative complications occurred.
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http://dx.doi.org/10.3171/2019.11.PEDS19622DOI Listing
January 2020

Chiari I malformations with syringomyelia: long-term results of neurosurgical decompression.

Spine Deform 2020 04 13;8(2):233-243. Epub 2020 Jan 13.

Department of Orthopaedic Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA.

Study Design: Retrospective case series.

Objectives: The objective was to assess the long-term outcomes on scoliosis following Chiari-I (CM-I) decompression in patients with CM-I and syringomyelia (SM). A secondary objective was to identify risk factors of scoliosis progression.

Background: The association between CM-I with SM and scoliosis is recognized, but it remains unclear if CM-I decompression alters the long-term evolution of scoliosis in patients with associated syringomyelia.

Methods: A retrospective review of children with scoliosis, CM-I, and SM during 1997-2015 was performed. Congenital, syndromic, and neuromuscular scoliosis were excluded. Clinical and radiographic characteristics were recorded at presentation, pre-decompression, after 1-year, and latest follow-up. A scale to measure syringomyelia area on MRI was used to evaluate SM changes post-decompression.

Results: 65 children with CM-I, SM, and scoliosis and a mean age of 8.9 years (range 0.7-15.8) were identified. Mean follow-up was 6.9 years (range 2.0-20.4). Atypical curves were present in 28 (43%) children. Thirty-eight patients (58%) underwent decompression before 10 years. Syringomyelia size reduced a mean of 70% after decompression (p < 0.001). Scoliosis improved in 26 (40%), stabilized in 17 (26%), and progressed in 22 (34%) cases. Early spinal fusion was required in 7 (11%) patients after a mean of 0.5 ± 0.37 years and delayed fusion in 16 (25%) patients after 6.0 ± 3.24 years. The remaining 42 (65%) patients were followed for a median of 6.1 years (range 2.0-12.3) without spine instrumentation or fusion. Fusion patients experienced less improvement in curve magnitude 1-year post-decompression (p < 0.001) and had larger curves at presentation (43° vs. 34°; p = 0.004).

Conclusions: Syringomyelia size decreased by 70% after CM-I decompression and scoliosis stabilized or improved in two-thirds of patients. Greater curve improvement within the first year post-decompression and smaller curves at presentation decreased the risk of spinal fusion. Neurosurgical decompression is recommended in children with CM-I, SM, and scoliosis with the potential to treat all three conditions.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1007/s43390-019-00009-zDOI Listing
April 2020

A review of the management of single-suture craniosynostosis, past, present, and future.

J Neurosurg Pediatr 2019 12;24(6):622-631

2Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts.

Background: Craniosynostosis is a condition in which 2 or more of the skull bones fuse prematurely. The spectrum of the disorder most commonly involves the closure of a single suture in the skull, but it can also involve syndromic diagnoses in which multiple skull bones and/or bones outside of the cranium are affected. Craniosynostosis can result in cosmetic deformity as well as potential limitations in brain growth and development, and the neurocognitive impact of the condition is just starting to be studied more thoroughly. Our knowledge regarding the genetics of this condition has also evolved substantially. In this review, the authors explore the medical and surgical advancements in understanding and treating this condition over the past century, with a focus on how the diagnosis and treatment have evolved.

Methods: In this review article, the authors, who are the leaders of a craniofacial team at a major academic pediatric hospital, focus on single-suture craniosynostosis (SSC) affecting the 6 major cranial sutures and discuss the evolution of the treatment of SSC from its early history in modern medicine through the current state of the art and future trends. This discussion is based on the authors' broad experience and a comprehensive review of the literature.

Summary: The management of SSC has evolved substantially over the past 100 years. There have been major advances in technology and medical knowledge that have allowed for safer treatment of this condition through the use of newer techniques and technologies in the fields of surgery, anesthesia, and critical care. The use of less invasive surgical techniques along with other innovations has led to improved outcomes in SSC patients. The future of SSC treatment will likely be guided by elucidation of the causes of neurocognitive delay in these children and assessment of how the timing and type of surgery can mitigate adverse outcomes.
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http://dx.doi.org/10.3171/2019.7.PEDS18585DOI Listing
December 2019

Acute Implant-related Complications in Pediatric Cervical Spine Fusion.

J Pediatr Orthop 2020 Aug;40(7):e662-e666

Department of Orthopaedic Surgery.

Background: The use of modern rigid instrumentation in pediatric cervical fusions decreases the risk of implant-related complications, both acute and long term. However, previous studies have indicated that acute implant-related issues still occur in the adult population. Reports of pediatric acute implant complications, occurring within 3 months of surgery, are under-represented in the literature. The purpose of this study is to document the prevalence of acute implant-related complications in a pediatric cervical fusion population.

Methods: A retrospective review of instrumented cervical fusions from August 2002 to December 2018 was conducted. Acute implant-related complications were defined as malposition, fracture, or disengagement of cervical instrumentation, including screws, rods, and plates, within 90 days of surgery.

Results: A total of 166 cases were included (55% male individuals) with an average age at surgery of 12.5 years (SD, ±5.28). Acute implant-related complications occurred in 5 patients (3%). All 5 patients had a syndromic diagnosis: Loeys-Dietz (n=1), osteopetrosis (n=1), neurofibromatosis (n=1), trisomy 20 (n=1), and achondroplasia (n=1). One case involved asymptomatic screw protrusion, 1 case lateral mass screw pull-out, 2 more had screw-rod disengagement, and the last experienced dislodgement of the anterior plate. The median time until the presentation was 25 days (range, 1 to 79 d). All patients (n=5) required surgical revision.

Conclusions: This case series suggests that the overall incidence of acute cervical implant failure is low. However, failure is more likely to occur in patients with underlying syndromes compared with patients with different etiologies. Intraoperative use of 3-dimensional computed tomography imaging is recommended to evaluate the screw position and potentially avoid later surgery.
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http://dx.doi.org/10.1097/BPO.0000000000001471DOI Listing
August 2020

Surgical Fixation Using Screw-Rod Construct Instrumentation for Upper Cervical Instability in Pediatric Down Syndrome Patients.

Spine Deform 2019 11;7(6):957-961

Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA; Department of Orthopedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. Electronic address:

Study Design: Retrospective case series.

Objectives: To describe the indications and outcomes of cervical fixation using modern instrumentation in a case series of pediatric Down syndrome (DS) patients.

Summary Of Background Data: Cervical instability is the major cervical spine concern in children with DS. Although fixation techniques have advanced over the past quarter-century, the outcome of fixation with modern instrumentation for upper cervical instability in DS patients has not been thoroughly investigated.

Methods: We searched the orthopedic database at our institution for patients with a diagnosis of DS who had undergone a cervical spine fusion between 2006 and 2017. Patient demographics, diagnoses, surgical indications, surgical details, and complications were recorded. Preoperative imaging was reviewed to determine atlanto-dens intervals and spinal cord signal changes. Postoperative radiographs or CT scans were reviewed to determine union.

Results: Twelve DS patients met our inclusion criteria. The mean age at surgery was 9.3 years (range 3.8-18.8 years). Patients with secondary causes of instability included 7 patients with os odontoideum and 1 patient with a pars fracture. Three patients (25%) were identified on asymptomatic screening, with none of these having cord signal changes on magnetic resonance imaging (MRI). Modern implants (screws, plates, cages) were used in every patient in our series. The mean number of levels fused was 1.9 (range 1-5). The overall complication rate was 41.7% (5/12). Four patients required repeat surgery for nonunion. All patients with adequate radiographic follow-up demonstrated union (11/11, 100%). One patient was lost to follow-up.

Conclusions: Fixation for cervical instability is a critical component of the management of DS. A minority of patients receiving surgery were identified through asymptomatic screening. There was a high complication risk associated with surgery in our study; however, the addition of rigid fixation has lessened the complication rate compared with previous studies.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1016/j.jspd.2019.03.002DOI Listing
November 2019

Minimally Invasive Endoscopic Surgery for Infantile Craniosynostosis: A Longitudinal Cohort Study.

J Pediatr 2020 01 1;216:142-149.e2. Epub 2019 Nov 1.

Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA. Electronic address:

Objective: To evaluate patient outcomes of minimally invasive endoscopic strip craniectomy (ESC) for craniosynostosis.

Study Design: This is a retrospective cohort analysis (2004-2018) of 500 consecutive infants with craniosynostosis treated by ESC with orthotic therapy at a single center. Operative outcomes included transfusions, complications, and reoperations as well as head circumference change based on World Health Organization percentiles. Multivariable logistic regression was used to identify risk factors associated with blood transfusion. Paired t tests were used for within-patient comparisons and Fisher exact test to compare syndromic and nonsyndromic subgroups.

Results: ESC was associated with low rates of blood transfusion (6.6%), complications (1.4%), and reoperations (3.0%). Risk factors for transfusion included syndromic craniosynostosis (P = .01) and multiple fused sutures (P = .02). Median surgical time was 47 minutes, and hospital length of stay 1 day. Transfusion and reoperation rates were higher among syndromic patients (both P < .001). Head circumference normalized by 12 months of age relative to World Health Organization criteria in infants with sagittal, coronal, and multisuture craniosynostosis (all P < .001).

Conclusions: ESC is a safe, effective, and durable correction of infantile craniosynostosis. ESC can achieve head growth normalization with low risks of blood transfusion, complications, or reoperation. Early identification of craniosynostosis in the newborn period and prompt referral by pediatricians allows families the option of ESC vs larger and riskier open reconstruction procedures.
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http://dx.doi.org/10.1016/j.jpeds.2019.09.037DOI Listing
January 2020

Long-term outcomes of lumbar microdiscectomy in the pediatric population: a large single-institution case series.

J Neurosurg Pediatr 2019 Aug 30:1-9. Epub 2019 Aug 30.

6Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School; and.

Objective: Few studies describe long-term functional outcomes of pediatric patients who have undergone lumbar microdiscectomy (LMD) because of the rarity of pediatric disc herniation and the short follow-up periods. The authors analyzed risk factors, clinical presentation, complications, and functional outcomes of a single-institution series of LMD patients over a 19-year period.

Methods: A retrospective case series was conducted of pediatric LMD patients at a large pediatric academic hospital from 1998 to 2017. The authors examined premorbid risk factors, clinical presentation, physical examination findings, type and duration of conservative management, indications for surgical intervention, complications, and postoperative outcomes.

Results: Over the 19-year study period, 199 patients underwent LMD at the authors' institution. The mean age at presentation was 16.0 years (range 12-18 years), and 55.8% were female. Of these patients, 70.9% participated in competitive sports, and among those who did not play sports, 65.0% had a body mass index greater than 25 kg/m2. Prior to surgery, conservative management had failed in 98.0% of the patients. Only 3 patients (1.5%) presented with cauda equina syndrome requiring emergent microdiscectomy. Complications included 4 cases of postoperative CSF leak (2.0%), 1 case of a noted intraoperative CSF leak, and 3 cases of wound infection (1.5%). At the first postoperative follow-up appointment, minimal or no pain was reported by 93.3% of patients. The mean time to return to sports was 9.8 weeks. During a mean follow-up duration of 8.2 years, 72.9% of patients did not present again after routine postoperative appointments. The total risk of reoperation was a rate of 7.5% (3.5% of patients underwent reoperation for the same level; 4.5% underwent adjacent-level decompression, and one patient [0.5%] ultimately underwent a fusion).

Conclusions: Microdiscectomy is a safe and effective treatment for long-term relief of pain and return to daily activities among pediatric patients with symptomatic lumbar disc disease in whom conservative management has failed.
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http://dx.doi.org/10.3171/2019.6.PEDS18716DOI Listing
August 2019

Perioperative acute neurological deficits in instrumented pediatric cervical spine fusions.

J Neurosurg Pediatr 2019 Aug 16:1-11. Epub 2019 Aug 16.

1Department of Orthopaedic Surgery, Boston Children's Hospital; and.

Objective: Pediatric cervical deformity is a complex disorder often associated with neurological deterioration requiring cervical spine fusion. However, limited literature exists on new perioperative neurological deficits in children. This study describes new perioperative neurological deficits in pediatric cervical spine instrumentation and fusion.

Methods: A single-center review of pediatric cervical spine instrumentation and fusion during 2002-2018 was performed. Demographics, surgical characteristics, and neurological complications were recorded. Perioperative neurological deficits were defined as the deterioration of preexisting neurological function or the appearance of new neurological symptoms.

Results: A total of 184 cases (160 patients, 57% male) with an average age of 12.6 ± 5.30 years (range 0.2-24.9 years) were included. Deformity (n = 39) and instability (n = 36) were the most frequent indications. Syndromes were present in 39% (n = 71), with Down syndrome (n = 20) and neurofibromatosis (n = 12) the most prevalent. Eighty-seven (48%) children presented with preoperative neurological deficits (16 sensory, 16 motor, and 55 combined deficits).A total of 178 (96.7%) cases improved or remained neurologically stable. New neurological deficits occurred in 6 (3.3%) cases: 3 hemiparesis, 1 hemiplegia, 1 quadriplegia, and 1 quadriparesis. Preoperative neurological compromise was seen in 4 (67%) of these new deficits (3 myelopathy, 1 sensory deficit) and 5 had complex syndromes. Three new deficits were anticipated with intraoperative neuromonitoring changes (p = 0.025).Three (50.0%) patients with new neurological deficits recovered within 6 months and the child with quadriparesis was regaining neurological function at the latest follow-up. Hemiplegia persisted in 1 patient, and 1 child died due a complication related to the tracheostomy. No association was found between neurological deficits and indication (p = 0.96), etiology (p = 0.46), preoperative neurological symptoms (p = 0.65), age (p = 0.56), use of halo vest (p = 0.41), estimated blood loss (p = 0.09), levels fused (p = 0.09), approach (p = 0.07), or fusion location (p = 0.07).

Conclusions: An improvement of the preexisting neurological deficit or stabilization of neurological function was seen in 96.7% of children after cervical spine fusion. New or progressive neurological deficits occurred in 3.3% of the patients and occurred more frequently in children with preoperative neurological symptoms. Patients with syndromic diagnoses are at higher risk to develop a deficit, probably due to the severity of deformity and the degree of cervical instability. Long-term outcomes of new neurological deficits are favorable, and 50% of patients experienced complete neurological recovery within 6 months.
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http://dx.doi.org/10.3171/2019.5.PEDS19200DOI Listing
August 2019

Intraoperative Use of O-arm in Pediatric Cervical Spine Surgery.

J Pediatr Orthop 2020 Apr;40(4):e266-e271

Department of Orthopaedic Surgery, Boston Children's Hospital.

Introduction: Traditionally, fluoroscopy and postoperative computed tomographic (CT) scans are used to evaluate screw position after pediatric cervical spine fusion. However, noncontained screws detected postoperatively can require revision surgery. Intraoperative O-arm is a 3-dimensional CT imaging technique, which allows intraoperative evaluation of screw position and potentially avoids reoperations because of implant malposition. This study's objective was to evaluate the use of intraoperative O-arm in determining the accuracy of cervical implants placed by a free-hand technique using anatomic landmarks or fluoroscopic guidance in pediatric cervical spine instrumentation.

Methods: A single-center retrospective study of consecutive examinations of children treated with cervical spine instrumentation and intraoperative O-arm from 2014 to 2018 was performed. In total, 44 cases (41 children, 44% men) with a mean age of 11.9 years (range, 2.1 to 23.5 y) were identified. Instability (n=16, 36%) and deformity (n=10, 23%) were the most frequent indications. Primary outcomes were screw revision rate, neurovascular complications caused by noncontained screws, and radiation exposure.

Results: A total of 272 screws were inserted (60 occipital and 212 cervical screws). All screws were evaluated on fluoroscopy as appropriately placed. Four screws (1.5%) in 4 cases (9%) were noncontained on O-arm imaging and required intraoperative revision. A mean of 7.7 levels (range, 5 to 13) were scanned. The mean CT dose index and dose-length product were 15.2±6.87 mGy and 212.3±120.48 mGy×cm. Mean effective dose was 1.57±0.818 mSv. There was no association between screw location and noncontainment (P=0.129). No vertebral artery injuries, dural injuries, or neurologic deficits were related to the 4 revised screws.

Conclusions: Intraoperative non-navigated O-arm is a safe and efficient method to evaluate screw position in pediatric patients undergoing cervical spine instrumentation. Noncontained screws were detected in 9% of cases (n=4). O-arm delivers low radiation doses, allows for intraoperative screw revision, and negates the need for postoperative CT scans after confirmation of optimal implant position.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1097/BPO.0000000000001416DOI Listing
April 2020

Evaluation of Endoscopic Strip Craniectomy and Orthotic Therapy for Bilateral Coronal Craniosynostosis.

J Craniofac Surg 2019 Mar/Apr;30(2):453-457

Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, MO.

Background: Bilateral coronal craniosynostosis is the premature fusion of both coronal sutures. Traditionally, this condition is treated by frontal-orbital advancement (FOA). Endoscopic strip craniectomy with cranial orthotic therapy, which has gained popularity in treating single suture craniosynostosis, has recently been adapted for the treatment of bicoronal synostosis. There have been few studies documenting the outcomes of this treatment. The objective of this study is to compare the morphological outcomes of endoscopic strip craniectomy and FOA in patients with bicoronal synostosis.

Methods: A retrospective case series was done on 24 patients with bilateral coronal synostosis treated with endoscopic strip craniectomy or FOA at 2 institutions. Patients with preoperative and 1-year postoperative computed tomography scans were included. Multiple measures of cranial shape and size were assessed: cephalic index, turricephaly index, basofrontal angle, circumference Z-score, and cranial vault volume Z-score.

Results: The 2 groups were similar statistically in terms of morphology at preoperative scan. There were no statistical differences between the FOA group and endoscopic group at postoperative scan in any of the morphologic outcomes measured. Cranial vault volume Z-scores increased postoperatively in both the endoscopic (P < 0.001) and FOA (P = 0.034) groups.

Conclusions: One year after repair there were no significant morphological difference between patients with bicoronal synostosis treated with the endoscopic approach and those treated by FOA.
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http://dx.doi.org/10.1097/SCS.0000000000005118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6541507PMC
August 2019

Nonsyndromic Unilateral Coronal Synostosis: A Comparison of Fronto-Orbital Advancement and Endoscopic Suturectomy.

Plast Reconstr Surg 2019 03;143(3):838-848

From the Departments of Plastic and Oral Surgery, Ophthalmology, and Neurosurgery, Boston Children's Hospital; and the Department of Plastic and Reconstructive Surgery, Children's National Health System.

Background: Comparative effectiveness research is needed to optimize treatment of unilateral coronal synostosis. This study compares perioperative morbidity, ophthalmic, and aesthetic outcomes of patients with nonsyndromic unilateral coronal synostosis treated by endoscopic suturectomy or fronto-orbital advancement.

Methods: From 2004 to 2015, patients with unilateral coronal synostosis were reviewed and data recorded for operative details, reoperations, and aesthetic results using the Whitaker classification, severity of strabismus, and need for surgical correction. Categorical data were analyzed using the Fisher's exact test and continuous data were analyzed using the Wilcoxon rank sum test.

Results: Ninety-four patients were treated with endoscopic suturectomy (n = 60) or fronto-orbital advancement (n = 34). Median age at follow-up was 3.5 years (range, 1 to 9 years) for endoscopic suturectomy and 5.0 years (range, 2 to 11 years) for fronto-orbital advancement (p = 0.06). The endoscopic suturectomy group had a lower operative time (42 minutes versus 216 minutes), length of stay (1 day versus 4 days), blood loss (25 cc versus 260 cc), and transfusion rate (0 percent versus 88 percent). Two patients treated with fronto-orbital advancement required secondary intervention for intracranial pressure. Thirty-one percent (16 of 52) of the endoscopic suturectomy group and 65 percent (19 of 29) of the fronto-orbital advancement group developed clinically significant strabismus requiring surgical repair (p = 0.002). In the endoscopic suturectomy group, 88 percent (50 of 57) were Whitaker class I and 5 percent were class II. In the fronto-orbital advancement group, 41 percent (14 of 34) were class I and 44 percent class II. Need for bony revision (two of 57 versus three of 34) and need for secondary cranial procedure (two of 57 versus two of 34) were similar following endoscopic suturectomy and fronto-orbital advancement.

Conclusions: For treatment of unilateral coronal synostosis, endoscopic suturectomy is associated with lower morbidity and comparable aesthetics. Patients treated with endoscopic suturectomy are half as likely to require strabismus surgery compared with those treated with fronto-orbital advancement.

Clinical Question/level Of Evidence: Therapeutic, III.
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March 2019

Headache, Chiari I malformation and foramen magnum decompression.

Curr Opin Pediatr 2018 12;30(6):786-790

Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Purpose Of Review: With increasing use of MRI, more patients are being diagnosed with Chiari I malformation (CM1), many of whom are asymptomatic. When symptoms are present, headache is the most frequent presenting feature, although symptoms can be variable. The purpose of this review is to help primary care clinicians better understand the relationship between an individual's presenting symptoms and the presence of radiographic CM1, and to describe the expected outcomes for patients who undergo decompression surgery.

Recent Findings: Recent literature has shown that asymptomatic patients with CM1 tend to have a benign natural history. For symptomatic Chiari malformation, headache is the most common presenting symptom and the majority of patients that present with headache will have symptom improvement after foramen magnum decompression. This improvement is most reliable for patients with classic Chiari-type headache, which are described as occipital or cervical and tussive in nature, but has also been shown in patients with atypical headaches who have undergone surgery.

Summary: CM1 is a common radiographic finding and associated symptoms can be variable. The relevance of this finding to a particular patient and need for intervention must be made on an individual basis.
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http://dx.doi.org/10.1097/MOP.0000000000000679DOI Listing
December 2018

Craniometric Analysis of Endoscopic Suturectomy for Bilateral Coronal Craniosynostosis.

Plast Reconstr Surg 2019 01;143(1):183-196

From the Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital; the Department of Neurologic Surgery, University of Virginia School of Medicine; and the Departments of Neurosurgery, Radiology, and Plastic and Oral Surgery, Boston Children's Hospital.

Background: Endoscopic suturectomy and helmeting represents a successful first-line surgical treatment for bilateral coronal craniosynostosis. Its effect on cranial morphology has not been previously described.

Methods: Patients were identified who had bilateral coronal craniosynostosis treated with endoscopic suturectomy and postoperative helmeting at Boston Children's Hospital between 2005 and 2013 and who underwent preoperative and postoperative computed tomography. Two normative patient populations were identified from our trauma registry with computed tomographic scans completed at the same age as our pretreatment and posttreatment scans. Craniometric indices were used to quantify the effect of treatment.

Results: Twenty-seven patients were identified who underwent bilateral coronal suturectomy. Twelve patients had preoperative and postoperative computed tomographic studies. Eight patients (66.7 percent) were syndromic. The average ages for preoperative and postoperative computed tomographic scan were 1.1 months (range, 0.03 to 2.6 months) and 19.6 months (range, 10.8 to 37.5 months). Thirteen patients with an average age of 1.1 months (range, 0.5 to 1.6 months) were identified as a preoperative control group. Fourteen patients with an average age of 18.5 months (range, 15.5 to 22.9 months) were identified as a postoperative control group. The anterior cranial height stabilized with treatment and the anterior cranial base length increased. The anterior cranial height-to-anterior cranial base length ratio significantly decreased with treatment (p = 0.128). Frontal bossing normalized with endoscopic suturectomy (craniosynostosis versus control: preoperatively, p = 0.001; postoperatively, p = 0.8). Cephalic indices also normalized with treatment (craniosynostosis versus control: preoperatively, p = 0.02; postoperatively, p = 0.13). No cases of hydrocephalus were observed.

Conclusion: Endoscopic suturectomy and helmeting improves anterior turricephaly and corrects frontal bossing and brachycephaly in patients with bilateral coronal craniosynostosis.

Clinical Question/level Of Evidence: Therapeutic, IV.
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January 2019

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

Modification of the Melbourne Method for Total Calvarial Vault Remodeling.

Plast Reconstr Surg Glob Open 2018 Jul 9;6(7):e1848. Epub 2018 Jul 9.

Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Mass.

Background: Sagittal synostosis is the most common form of single suture synostosis. It often results in characteristic calvarial deformities, including a long, narrow head, frontal bossing, a bullet-shaped occiput, and an anteriorly placed vertex. Several methods for correcting the phenotypic deformities have been described, each with their own advantages and challenges. In this study, we describe a modification of the Melbourne method of total calvarial remodeling for correcting scaphocephaly.

Methods: We conducted a retrospective review of all consecutive patients who underwent total calvarial remodeling using a modified version of the Melbourne technique from 2011 to 2015. We evaluated clinical photographs, computed tomographic imaging, and cephalic indices both pre- and postoperatively to determine morphologic changes after operation.

Results: A total of 9 patients underwent the modified Melbourne technique for calvarial vault remodeling during the study period. Intraoperative blood loss was 260 mL (range, 80-400 mL), and mean intraoperative transfusion was 232 mL (range, 0-360 mL). The average length of stay in the hospital was 3.9 days. The mean cephalic indices increased from 0.66 to 0.74 postoperatively ( < 0.01).

Conclusions: A modified Melbourne method for calvarial vault reconstruction addresses the phenotypic aspects of severe scaphocephaly associated with isolated sagittal synostosis and maintains a homeotopic relationship across the calvaria. It is associated with shorter operative times, lower blood loss, and lower transfusion requirements.
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http://dx.doi.org/10.1097/GOX.0000000000001848DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6110696PMC
July 2018

Analysis of clinical outcomes for treatment of sagittal craniosynostosis: a comparison of endoscopic suturectomy and cranial vault remodeling.

J Neurosurg Pediatr 2018 Nov;22(5):467-474

2Neurosurgery, Boston Children's Hospital, Boston, Massachusetts.

The authors compared the effectiveness of two main surgical techniques used for treating sagittal craniosynostosis (SC): endoscopic suturectomy (ES) and cranial vault remodeling (CVR). The safety, head growth, and aesthetic results following ES and CVR were compared by reviewing the charts of more than 200 patients. By comparing the effectiveness of these two treatments, this study will help guide selection of the optimal surgical treatment for patients with SC.
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http://dx.doi.org/10.3171/2018.5.PEDS1846DOI Listing
November 2018

Noninvasive Thermal Evaluation of Ventriculoperitoneal Shunt Patency and Cerebrospinal Fluid Flow Using a Flow Enhancing Device.

Neurosurgery 2019 08;85(2):240-249

Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: While a noninvasive flow determination would be desirable in the diagnosis of cerebrospinal fluid shunt malfunction, existing studies have not yet defined a role for thermal flow detection.

Objective: To evaluate a revised test protocol using a micropumper designed to transiently enhance flow during thermal testing to determine whether thermal detection of flow is associated with progression to shunt revision surgery.

Methods: Eighty-two unique tests were performed in 71 shunts. The primary outcome, need for revision within 7 d of testing, was compared with results of micropumper-augmented thermal flow detection. Statistical analysis was based on blind interpretation of test results and raw temperature data recorded during testing.

Results: The test was sensitive (73%) and specific (68%) in predicting need for revision, with 5.6-fold higher probability of revision when flow was not detected. Negative predictive value in our sample was 94.2%. The probability of not requiring revision increased with increasing total temperature drop. Analysis of various possible thresholds showed that the optimal temperature cutoff may be lower than suggested by the manufacturer (0.125°C vs 0.2°C).

Conclusion: This is the first study to report a strong association between thermal flow evaluation and a clinical impression that a shunt is not malfunctioning. The current recommended threshold may increase the false positive rate unnecessarily, and as clinicians gain experience with the method, they may find value in examining the temperature curves themselves. Multicenter studies are suggested to further define a role for this diagnostic test.
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http://dx.doi.org/10.1093/neuros/nyy246DOI Listing
August 2019

C2 Translaminar Screw Fixation in Children.

J Pediatr Orthop 2018 Jul;38(6):e312-e317

Harvard Medical School.

Background: Axis (C2) screw fixation has been shown to be effective in treating disorders that necessitate cervical stabilization. Although translaminar C2 screws have demonstrated clinical efficacy in adults, this technique has not yet been thoroughly investigated in children. This study describes the indications, technique, and results of translaminar C2 screw fixation in a case series of pediatric cervical spine disorders.

Methods: We searched the orthopaedic database at our institution for patients who had undergone a cervical spinal fusion that encompassed C2 between 2007 and 2017. Operative records were reviewed to determine if C2 screw fixation was performed and, if so, the type of C2 screw fixation. Clinical data with regard to patient age at surgery, diagnosis, procedure details, intraoperative complications, and postoperative complications were recorded. Preoperative and postoperative computer tomographic scans were reviewed to determine laminar measurements and containment, respectively.

Results: In total, 39 C2 translaminar screws were placed in 23 patients that met our inclusion criteria. The mean age was 12.6 years (range, 5.2 to 17.8 y) with a mean of 2 levels fused (range, 1 to 6). Diagnoses included 7 patients with instability related to skeletal dysplasia, 6 os odontoideum, 4 congenital deformities, 3 basilar invaginations, 2 cervical spine tumors, and 1 fracture. Indications for C2 translaminar screws included 14 cases with distorted anatomy favoring C2 translaminar screws, 6 cases without explicit reasoning for translaminar screw usage in the patient records, and 3 cases with intraoperative vertebral artery injury (1 sacrificed secondary to tumor load and 2 others injured during exposure because of anomalous anatomy). The vertebral artery injuries were not due to placement of any instrumentation. There were no screw-related intraoperative or postoperative complications and no neurological injuries. All patients demonstrated clinical union or healing on follow-up with no episodes of nonunion.

Conclusions: Translaminar C2 screw fixation can be reliably used in the pediatric population. Our series contained no screw-related complications, no neurological injuries, and all patients demonstrated clinical union or healing.

Level Of Evidence: Level IV-Case series.
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http://dx.doi.org/10.1097/BPO.0000000000001176DOI Listing
July 2018

The Temporal Region in Unilateral Coronal Craniosynostosis: Fronto-orbital Advancement Versus Endoscopy-Assisted Strip Craniectomy.

Cleft Palate Craniofac J 2018 03 14;55(3):423-429. Epub 2017 Dec 14.

1 Division of Plastic and Reconstructive Surgery, Washington University in St Louis, St Louis, MO, USA.

Objective: To compare postoperative temporal expansion in patients treated with fronto-orbital advancement or endoscopy-assisted craniectomy with cranial orthotic therapy.

Design: This is a retrospective, multicenter cohort study of patients with unilateral coronal craniosynostosis (UCS).

Setting: Computed tomographic (CT) scans were drawn from UCS patients treated at Boston Children's Hospital or St Louis Children's Hospital.

Patients: The study included 56 patients with UCS after fronto-orbital advancement (n = 32) or endoscopic repair (n = 24) and 10 age-matched controls.

Intervention: Fronto-orbital advancement entails a craniotomy of the frontal bone and superior orbital rim followed by reshaping and forward advancement. Endoscopic repair is the release of the synostotic suture and guidance of further growth of the cranium using a molding orthotic.

Main Outcome Measures: Measures included posterior temporal width, anterior temporal width, orbital width, and anterior cranial fossa area taken preoperatively and 1 year postoperatively. Linear regression was performed to assess 1 year postoperative improvement in symmetry; covariates included preoperative symmetry and type of surgery.

Results: Both treatments showed improvement in orbital width and anterior cranial fossa area symmetry 1 year postoperatively ( P < .001), but no significant improvement in posterior or anterior temporal width symmetry. Linear regression revealed no difference between the 2 procedures in any of the 4 measurements (.096 ≤ P ≤ .898).

Conclusions: Fronto-orbital advancement and endoscopic repair show equivalent outcomes 1 year postoperatively in all 3 width measurements and anterior cranial fossa area. Neither procedure produced significant improvement in temporal width.
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http://dx.doi.org/10.1177/1055665617739000DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6937201PMC
March 2018

Severe Traumatic Brain Injury.

Neurosurgery 2018 01;82(1):N9-N10

Department of Neurological Surgery Boston Children's Hospital Harvard Medical School Boston, Massachusetts.

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http://dx.doi.org/10.1093/neuros/nyx539DOI Listing
January 2018

Neurenteric cyst at the dorsal craniocervical junction in a child: Case report.

J Clin Neurosci 2018 Feb 11;48:86-89. Epub 2017 Nov 11.

Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA. Electronic address:

Neurenteric cysts, also known as enterogenous cysts, are uncommon, benign, congenital lesions that usually occur in the posterior mediastinum but can be seen at any level of the neuraxis. Here, we report a pediatric patient with a neurenteric cyst in the dorsal craniocervical junction as the only third reported pediatric case in the literature in this rare location, and describe the clinical course and pathologic findings with a review of the literature on this rare entity.
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http://dx.doi.org/10.1016/j.jocn.2017.10.014DOI Listing
February 2018

Comprehensive Review of the ThinkFirst Injury Prevention Programs: A 30-Year Success Story for Organized Neurosurgery.

Neurosurgery 2017 Sep;81(3):416-421

Department of Neurology, Oregon Health & Science University, Portland, Oregon.

Traumatic brain and spinal cord injuries are major public health issues causing significant death and long-term disability in the United States, with higher incidences in young and older adults. The ThinkFirst National Injury Prevention Foundation is a nonprofit organization focused on injury prevention education and awareness for people of all ages, with a particular focus on educating children, teens, and young adults. ThinkFirst chapters have evaluated the effectiveness of the ThinkFirst programs in both children and teens by demonstrating significant improvement in knowledge regarding high-risk behaviors postintervention. Here, we review the available literature studying the efficacy of the ThinkFirst National Injury Prevention Foundation programs, outline current ThinkFirst activity, and discuss future directions of the program. This review discusses the efforts of a number of ThinkFirst chapters in terms of research, legislation, and public communication. It showcases the success of ThinkFirst interventions and suggests future directions which can help improve national injury prevention efforts.
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http://dx.doi.org/10.1093/neuros/nyx053DOI Listing
September 2017
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