Publications by authors named "Nathan R Selden"

126 Publications

Dural augmentation approaches and complication rates after posterior fossa decompression for Chiari I malformation and syringomyelia: a Park-Reeves Syringomyelia Research Consortium study.

J Neurosurg Pediatr 2021 Feb 12:1-10. Epub 2021 Feb 12.

1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO.

Objective: Posterior fossa decompression with duraplasty (PFDD) is commonly performed for Chiari I malformation (CM-I) with syringomyelia (SM). However, complication rates associated with various dural graft types are not well established. The objective of this study was to elucidate complication rates within 6 months of surgery among autograft and commonly used nonautologous grafts for pediatric patients who underwent PFDD for CM-I/SM.

Methods: The Park-Reeves Syringomyelia Research Consortium database was queried for pediatric patients who had undergone PFDD for CM-I with SM. All patients had tonsillar ectopia ≥ 5 mm, syrinx diameter ≥ 3 mm, and ≥ 6 months of postoperative follow-up after PFDD. Complications (e.g., pseudomeningocele, CSF leak, meningitis, and hydrocephalus) and postoperative changes in syrinx size, headaches, and neck pain were compared for autograft versus nonautologous graft.

Results: A total of 781 PFDD cases were analyzed (359 autograft, 422 nonautologous graft). Nonautologous grafts included bovine pericardium (n = 63), bovine collagen (n = 225), synthetic (n = 99), and human cadaveric allograft (n = 35). Autograft (103/359, 28.7%) had a similar overall complication rate compared to nonautologous graft (143/422, 33.9%) (p = 0.12). However, nonautologous graft was associated with significantly higher rates of pseudomeningocele (p = 0.04) and meningitis (p < 0.001). The higher rate of meningitis was influenced particularly by the higher rate of chemical meningitis (p = 0.002) versus infectious meningitis (p = 0.132). Among 4 types of nonautologous grafts, there were differences in complication rates (p = 0.02), including chemical meningitis (p = 0.01) and postoperative nausea/vomiting (p = 0.03). Allograft demonstrated the lowest complication rates overall (14.3%) and yielded significantly fewer complications compared to bovine collagen (p = 0.02) and synthetic (p = 0.003) grafts. Synthetic graft yielded higher complication rates than autograft (p = 0.01). Autograft and nonautologous graft resulted in equal improvements in syrinx size (p < 0.0001). No differences were found for postoperative changes in headaches or neck pain.

Conclusions: In the largest multicenter cohort to date, complication rates for dural autograft and nonautologous graft are similar after PFDD for CM-I/SM, although nonautologous graft results in higher rates of pseudomeningocele and meningitis. Rates of meningitis differ among nonautologous graft types. Autograft and nonautologous graft are equivalent for reducing syrinx size, headaches, and neck pain.
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http://dx.doi.org/10.3171/2020.8.PEDS2087DOI Listing
February 2021

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

Can QuickBrain MRI replace CT as first-line imaging for select pediatric head trauma?

J Am Coll Emerg Physicians Open 2020 Oct 4;1(5):965-973. Epub 2020 Jun 4.

Center for Policy and Research in Emergency Medicine Department of Emergency Medicine Oregon Health & Science University Portland Oregon USA.

Objective: The current standard of care for initial neuroimaging in injured pediatric patients suspected of having traumatic brain injury is computed tomography (CT) that carries risks associated with radiation exposure. The primary objective of this trial was to evaluate the ability of a QuickBrain MRI (qbMRI) protocol to detect clinically important traumatic brain injuries in the emergency department (ED). The secondary objective of this trial was to compare qbMRI to CT in identifying radiographic traumatic brain injury.

Methods: This was a prospective study of trauma patients less than 15 years of age with suspected traumatic brain injury at a level 1 pediatric trauma center in Portland, Oregon between August 2017 and March 2019. All patients in whom a head CT was deemed clinically necessary were approached for enrollment to also obtain a qbMRI in the acute setting. Clinically important traumatic brain injury was defined as the need for neurological surgery procedure, intubation, pediatric intensive care unit stay greater than 24 hours, a total hospital length of stay greater than 48 hours, or death.

Results: A total of 73 patients underwent both CT and qbMRI. The median age was 4 years (interquartile range [IQR] = 1-10 years). Twenty-two patients (30%) of patients had a clinically important traumatic brain injury, and of those, there were 2 deaths (9.1%). QbMRI acquisition time had a median of 4 minutes and 52 seconds (IQR = 3 minutes 49 seconds-5 minutes 47 seconds). QbMRI had sensitivity for detecting clinically important traumatic brain injury of 95% (95% confidence interval [CI] = 77%-99%). For any radiographic injury, qbMRI had a sensitivity of 89% (95% CI = 78%-94%).

Conclusion: Our results suggest that qbMRI has good sensitivity to detect clinically important traumatic brain injuries. Further multi-institutional, prospective trials are warranted to either support or refute these findings.
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http://dx.doi.org/10.1002/emp2.12113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7593443PMC
October 2020

Continuous improvement in patient safety and quality in neurological surgery: the American Board of Neurological Surgery in the past, present, and future.

J Neurosurg 2020 Oct 16:1-7. Epub 2020 Oct 16.

22Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California.

The American Board of Neurological Surgery (ABNS) was incorporated in 1940 in recognition of the need for detailed training in and special qualifications for the practice of neurological surgery and for self-regulation of quality and safety in the field. The ABNS believes it is the duty of neurosurgeons to place a patient's welfare and rights above all other considerations and to provide care with compassion, respect for human dignity, honesty, and integrity. At its inception, the ABNS was the 13th member board of the American Board of Medical Specialties (ABMS), which itself was founded in 1933. Today, the ABNS is one of the 24 member boards of the ABMS.To better serve public health and safety in a rapidly changing healthcare environment, the ABNS continues to evolve in order to elevate standards for the practice of neurological surgery. In connection with its activities, including initial certification, recognition of focused practice, and continuous certification, the ABNS actively seeks and incorporates input from the public and the physicians it serves. The ABNS board certification processes are designed to evaluate both real-life subspecialty neurosurgical practice and overall neurosurgical knowledge, since most neurosurgeons provide call coverage for hospitals and thus must be competent to care for the full spectrum of neurosurgery.The purpose of this report is to describe the history, current state, and anticipated future direction of ABNS certification in the US.
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http://dx.doi.org/10.3171/2020.6.JNS202066DOI Listing
October 2020

Factors associated with syrinx size in pediatric patients treated for Chiari malformation type I and syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium.

J Neurosurg Pediatr 2020 Mar 6:1-11. Epub 2020 Mar 6.

34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri.

Objective: Factors associated with syrinx size in pediatric patients undergoing posterior fossa decompression (PFD) or PFD with duraplasty (PFDD) for Chiari malformation type I (CM-I) with syringomyelia (SM; CM-I+SM) are not well established.

Methods: Using the Park-Reeves Syringomyelia Research Consortium registry, the authors analyzed variables associated with syrinx radiological outcomes in patients (< 20 years old at the time of surgery) with CM-I+SM undergoing PFD or PFDD. Syrinx resolution was defined as an anteroposterior (AP) diameter of ≤ 2 mm or ≤ 3 mm or a reduction in AP diameter of ≥ 50%. Syrinx regression or progression was defined using 1) change in syrinx AP diameter (≥ 1 mm), or 2) change in syrinx length (craniocaudal, ≥ 1 vertebral level). Syrinx stability was defined as a < 1-mm change in syrinx AP diameter and no change in syrinx length.

Results: The authors identified 380 patients with CM-I+SM who underwent PFD or PFDD. Cox proportional hazards modeling revealed younger age at surgery and PFDD as being independently associated with syrinx resolution, defined as a ≤ 2-mm or ≤ 3-mm AP diameter or ≥ 50% reduction in AP diameter. Radiological syrinx resolution was associated with improvement in headache (p < 0.005) and neck pain (p < 0.011) after PFD or PFDD. Next, PFDD (p = 0.005), scoliosis (p = 0.007), and syrinx location across multiple spinal segments (p = 0.001) were associated with syrinx diameter regression, whereas increased preoperative frontal-occipital horn ratio (FOHR; p = 0.007) and syrinx location spanning multiple spinal segments (p = 0.04) were associated with syrinx length regression. Scoliosis (HR 0.38 [95% CI 0.16-0.91], p = 0.03) and smaller syrinx diameter (5.82 ± 3.38 vs 7.86 ± 3.05 mm; HR 0.60 [95% CI 0.34-1.03], p = 0.002) were associated with syrinx diameter stability, whereas shorter preoperative syrinx length (5.75 ± 4.01 vs 9.65 ± 4.31 levels; HR 0.21 [95% CI 0.12-0.38], p = 0.0001) and smaller pB-C2 distance (6.86 ± 1.27 vs 7.18 ± 1.38 mm; HR 1.44 [95% CI 1.02-2.05], p = 0.04) were associated with syrinx length stability. Finally, younger age at surgery (8.19 ± 5.02 vs 10.29 ± 4.25 years; HR 1.89 [95% CI 1.31-3.04], p = 0.01) was associated with syrinx diameter progression, whereas increased postoperative syrinx diameter (6.73 ± 3.64 vs 3.97 ± 3.07 mm; HR 3.10 [95% CI 1.67-5.76], p = 0.003), was associated with syrinx length progression. PFD versus PFDD was not associated with syrinx progression or reoperation rate.

Conclusions: These data suggest that PFDD and age are independently associated with radiological syrinx improvement, although forthcoming results from the PFDD versus PFD randomized controlled trial (NCT02669836, clinicaltrials.gov) will best answer this question.
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http://dx.doi.org/10.3171/2020.1.PEDS19493DOI Listing
March 2020

External retrospective validation of Brain Injury Guidelines criteria and modified guidelines for improved care value in the management of patients with low-risk neurotrauma.

J Neurosurg 2019 Nov 8:1-6. Epub 2019 Nov 8.

Objective: Conventional management of patients with neurotrauma frequently consists of routine, repeat head CT at preordained intervals with ICU-level monitoring, regardless of injury severity. The Brain Injury Guidelines (BIG) are a classification tool for stratifying patients into injury severity and risk-of-progression categories based on presenting clinical and radiographic findings. In the present study, the authors aimed to validate BIG criteria at a single level 1 trauma center.

Methods: Patients were classified according to BIG criteria and evaluated for subsequent radiographic progression or development of neurological decline. A 2-year retrospective cohort review of consecutive patients with neurotrauma (n = 590) was undertaken. The authors then developed a modified BIG algorithm for use at their institution and followed its implementation prospectively over 555 consecutive patients.

Results: In the retrospective analysis, no patient in the BIG 1 category (n = 88, 14.9%) demonstrated progression or neurological decline, and 7.5% of BIG 2 patients (n = 107, 18.1%) demonstrated mild radiographic progression without any decline or need for additional neurosurgical or medical intervention, whereas 15.4% of BIG 3 patients (n = 395, 66.9%) underwent additional neurosurgical procedures. In the prospective analysis, no BIG 1 (n = 105, 18.9%) or BIG 2 (n = 48, 8.6%) patients demonstrated a clinical decline or required any further neurosurgical intervention. By contrast, 12.9% of BIG 3 patients (n = 402, 72%) required immediate neurosurgical intervention, and a further 2.0% required delayed intervention based on clinical and/or radiographic evidence of injury progression.

Conclusions: Application of the BIG criteria in a single large level 1 trauma center reliably sorted patients into appropriate risk categories that accurately guided ongoing management.
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http://dx.doi.org/10.3171/2019.6.JNS19584DOI Listing
November 2019

The authors reply.

Pediatr Crit Care Med 2019 11;20(11):1105-1107

Department of Critical Care Medicine, Anesthesiology, Pediatrics, Bioengineering, and Clinical and Translational Science, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA Department of Neurology and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR Pediatric Neurosurgery, BARROW Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ Department of Neurological Surgery, Oregon Health & Science University, Portland, OR Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR Critical Care Medicine, Children's National Medical Center, Washington, DC Pediatrics, University of Utah, Salt Lake City, UT Department of Neurosurgery, Stanford University, Stanford, CA Department of Pediatrics, British Columbia's Children's Hospital, Clinical Investigator, Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada School of Nursing/School of Medicine, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University, Durham, NC Anesthesiology & Pain Medicine, Pediatrics, Harborview Injury Prevention and Research Center (HIPRC), University of Washington, Seattle, WA Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, WA.

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http://dx.doi.org/10.1097/PCC.0000000000002095DOI Listing
November 2019

Outcomes in children undergoing posterior fossa decompression and duraplasty with and without tonsillar reduction for Chiari malformation type I and syringomyelia: a pilot prospective multicenter cohort study.

J Neurosurg Pediatr 2019 Oct 18:1-9. Epub 2019 Oct 18.

1Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin.

Objective: Despite significant advances in diagnostic and surgical techniques, the surgical management of Chiari malformation type I (CM-I) with associated syringomyelia remains controversial, and the type of surgery performed is surgeon dependent. This study's goal was to determine the feasibility of a prospective, multicenter, cohort study for CM-I/syringomyelia patients and to provide pilot data that compare posterior fossa decompression and duraplasty (PFDD) with and without tonsillar reduction.

Methods: Participating centers prospectively enrolled children suffering from both CM-I and syringomyelia who were scheduled to undergo surgical decompression. Clinical data were entered into a database preoperatively and at 1-2 weeks, 3-6 months, and 1 year postoperatively. MR images were evaluated by 3 independent, blinded teams of neurosurgeons and neuroradiologists. The primary endpoint was improvement or resolution of the syrinx.

Results: Eight clinical sites were chosen based on the results of a published questionnaire intended to remove geographic and surgeon bias. Data from 68 patients were analyzed after exclusions, and complete clinical and imaging records were obtained for 55 and 58 individuals, respectively. There was strong agreement among the 3 radiology teams, and there was no difference in patient demographics among sites, surgeons, or surgery types. Tonsillar reduction was not associated with > 50% syrinx improvement (RR = 1.22, p = 0.39) or any syrinx improvement (RR = 1.00, p = 0.99). There were no surgical complications.

Conclusions: This study demonstrated the feasibility of a prospective, multicenter surgical trial in CM-I/syringomyelia and provides pilot data indicating no discernible difference in 1-year outcomes between PFDD with and without tonsillar reduction, with power calculations for larger future studies. In addition, the study revealed important technical factors to consider when setting up future trials. The long-term sequelae of tonsillar reduction have not been addressed and would be an important consideration in future investigations.
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http://dx.doi.org/10.3171/2019.8.PEDS19154DOI Listing
October 2019

Radiological and clinical predictors of scoliosis in patients with Chiari malformation type I and spinal cord syrinx from the Park-Reeves Syringomyelia Research Consortium.

J Neurosurg Pediatr 2019 Aug 16:1-8. Epub 2019 Aug 16.

1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri.

Objective: Scoliosis is frequently a presenting sign of Chiari malformation type I (CM-I) with syrinx. The authors' goal was to define scoliosis in this population and describe how radiological characteristics of CM-I and syrinx relate to the presence and severity of scoliosis.

Methods: A large multicenter retrospective and prospective registry of pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and syrinx (≥ 3 mm in axial width) was reviewed for clinical and radiological characteristics of CM-I, syrinx, and scoliosis (coronal curve ≥ 10°).

Results: Based on available imaging of patients with CM-I and syrinx, 260 of 825 patients (31%) had a clear diagnosis of scoliosis based on radiographs or coronal MRI. Forty-nine patients (5.9%) did not have scoliosis, and in 516 (63%) patients, a clear determination of the presence or absence of scoliosis could not be made. Comparison of patients with and those without a definite scoliosis diagnosis indicated that scoliosis was associated with wider syrinxes (8.7 vs 6.3 mm, OR 1.25, p < 0.001), longer syrinxes (10.3 vs 6.2 levels, OR 1.18, p < 0.001), syrinxes with their rostral extent located in the cervical spine (94% vs 80%, OR 3.91, p = 0.001), and holocord syrinxes (50% vs 16%, OR 5.61, p < 0.001). Multivariable regression analysis revealed syrinx length and the presence of holocord syrinx to be independent predictors of scoliosis in this patient cohort. Scoliosis was not associated with sex, age at CM-I diagnosis, tonsil position, pB-C2 distance (measured perpendicular distance from the ventral dura to a line drawn from the basion to the posterior-inferior aspect of C2), clivoaxial angle, or frontal-occipital horn ratio. Average curve magnitude was 29.9°, and 37.7% of patients had a left thoracic curve. Older age at CM-I or syrinx diagnosis (p < 0.0001) was associated with greater curve magnitude whereas there was no association between syrinx dimensions and curve magnitude.

Conclusions: Syrinx characteristics, but not tonsil position, were related to the presence of scoliosis in patients with CM-I, and there was an independent association of syrinx length and holocord syrinx with scoliosis. Further study is needed to evaluate the nature of the relationship between syrinx and scoliosis in patients with CM-I.
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http://dx.doi.org/10.3171/2019.5.PEDS18527DOI Listing
August 2019

Feed and Swaddle: An Alternative to Infant Sedation for Craniofacial Imaging.

Cleft Palate Craniofac J 2019 11 20;56(10):1373-1376. Epub 2019 Jun 20.

Oregon Health & Science University, Portland, OR, USA.

Objective: The gold standard for diagnosis of craniosynostosis is a clinical examination and motionless head computed tomography (CT). Computed tomography sedation is associated with increased cost, resource utilization, medical, and possible developmental risks. This study investigates whether a "feed and swaddle" protocol can be used to achieve diagnostic quality craniofacial imaging without the use of infant sedation.

Design: Prospective cohort study.

Setting: Tertiary academic medical center.

Patients: Ninety patients <18 months of age undergoing evaluation for craniosynostosis from 2012 to 2018.

Interventions: A feed and swaddle protocol.

Main Outcome Measures: Diagnostic level imaging without the use of infant sedation.

Results: Eighty-five (94%) achieved a diagnostic quality craniofacial CT scan using the "feed and swaddle" method. Mean patient age was 24.0 ± 10.0 weeks. Craniosynostosis was diagnosed in 74% of patients. Mean age of patients with successful completion of a CT scan was 23.7 ± 9.6 weeks, compared to 27.2 ± 17.1 weeks for unsuccessful completion. Mean weight for the successful group was 15.6 ± 2.9 pounds and 15.9 ± 2.5 pounds for the unsuccessful group. Mean travel distance was 59.2 ± 66.5 miles for successful patients and 66.5 ± 61.5 miles for unsuccessful patients. For the unsuccessful patients, there were no delays in surgical planning or scheduling.

Conclusion: The "feed and swaddle" protocol described here is an effective alternative to infant sedation for motionless craniofacial CT imaging.
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http://dx.doi.org/10.1177/1055665619857651DOI Listing
November 2019

Natural history of neuromodulation devices and therapies: a patient-centered survival analysis.

J Neurosurg 2019 Apr 19;132(5):1385-1391. Epub 2019 Apr 19.

Objective: Despite rapid development and expansion of neuromodulation technologies, knowledge about device and/or therapy durability remains limited. The aim of this study was to evaluate the long-term rate of hardware and therapeutic failure of implanted devices for several neuromodulation therapies.

Methods: The authors performed a retrospective analysis of patients' device and therapy survival data (Kaplan-Meier survival analysis) for deep brain stimulation (DBS), vagus nerve stimulation (VNS), and spinal cord stimulation (SCS) at a single institution (years 1994-2015).

Results: During the study period, 450 patients underwent DBS, 383 VNS, and 128 SCS. For DBS, the 5- and 10-year initial device survival was 87% and 73%, respectively, and therapy survival was 96% and 91%, respectively. For VNS, the 5- and 10-year initial device survival was 90% and 70%, respectively, and therapy survival was 99% and 97%, respectively. For SCS, the 5- and 10-year initial device survival was 50% and 34%, respectively, and therapy survival was 74% and 56%, respectively. The average initial device survival for DBS, VNS, and SCS was 14 years, 14 years, and 8 years while mean therapy survival was 18 years, 18 years, and 12.5 years, respectively.

Conclusions: The authors report, for the first time, comparative device and therapy survival rates out to 15 years for large cohorts of DBS, VNS, and SCS patients. Their results demonstrate higher device and therapy survival rates for DBS and VNS than for SCS. Hardware failures were more common among SCS patients, which may have played a role in the discontinuation of therapy. Higher therapy survival than device survival across all modalities indicates continued therapeutic benefit beyond initial device failures, which is important to emphasize when counseling patients.
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http://dx.doi.org/10.3171/2019.2.JNS182450DOI Listing
April 2019

Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary.

Pediatr Crit Care Med 2019 03;20(3):280-289

Herman and Faye Sarkowsky Endowed Chair, Head, Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, WA.

Objectives: The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients.

Methods And Main Results: This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, nine are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, three are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The purpose of publishing the algorithm as a separate document is to provide guidance for clinicians while maintaining a clear distinction between what is evidence based and what is consensus based. This approach allows, and is intended to encourage, continued creativity in treatment and research where evidence is lacking. Additionally, it allows for the use of the evidence-based recommendations as the foundation for other pathways, protocols, or algorithms specific to different organizations or environments. The complete guideline document and supplemental appendices are available electronically from this journal. These documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology.

Conclusions: New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.
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http://dx.doi.org/10.1097/PCC.0000000000001736DOI Listing
March 2019

Management of Pediatric Severe Traumatic Brain Injury: 2019 Consensus and Guidelines-Based Algorithm for First and Second Tier Therapies.

Pediatr Crit Care Med 2019 03;20(3):269-279

Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, WA.

Objectives: To produce a treatment algorithm for the ICU management of infants, children, and adolescents with severe traumatic brain injury.

Data Sources: Studies included in the 2019 Guidelines for the Management of Pediatric Severe Traumatic Brain Injury (Glasgow Coma Scale score ≤ 8), consensus when evidence was insufficient to formulate a fully evidence-based approach, and selected protocols from included studies.

Data Synthesis: Baseline care germane to all pediatric patients with severe traumatic brain injury along with two tiers of therapy were formulated. An approach to emergent management of the crisis scenario of cerebral herniation was also included. The first tier of therapy focuses on three therapeutic targets, namely preventing and/or treating intracranial hypertension, optimizing cerebral perfusion pressure, and optimizing partial pressure of brain tissue oxygen (when monitored). The second tier of therapy focuses on decompressive craniectomy surgery, barbiturate infusion, late application of hypothermia, induced hyperventilation, and hyperosmolar therapies.

Conclusions: This article provides an algorithm of clinical practice for the bedside practitioner based on the available evidence, treatment protocols described in the articles included in the 2019 guidelines, and consensus that reflects a logical approach to mitigate intracranial hypertension, optimize cerebral perfusion, and improve outcomes in the setting of pediatric severe traumatic brain injury.
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http://dx.doi.org/10.1097/PCC.0000000000001737DOI Listing
March 2019

Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary.

Neurosurgery 2019 06;84(6):1169-1178

Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, Washington.

The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients. This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, 9 are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, 3 are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The complete guideline document and supplemental appendices are available electronically (https://doi.org/10.1097/PCC.0000000000001735). The online documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology. New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.
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http://dx.doi.org/10.1093/neuros/nyz051DOI Listing
June 2019

Clinical outcomes following prenatal diagnosis of asymmetric ventriculomegaly, interhemispheric cyst, and callosal dysgenesis (AVID).

Prenat Diagn 2019 01 21;39(1):26-32. Epub 2018 Dec 21.

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

Objectives: When identified prenatally, the imaging triad of asymmetric ventriculomegaly, interhemispheric cyst, and dysgenesis of the corpus callosum (AVID) can indicate a more serious congenital brain anomaly. In this follow-up series of 15 fetuses, we present the neurodevelopmental outcomes of a single institution cohort of children diagnosed prenatally with AVID.

Methods: Our fetal ultrasound database was queried for cases of AVID between 2000 and 2016. All available fetal MR imaging studies were reviewed for the presence of (a) interhemispheric cysts or ventricular diverticula and (b) dysgenesis or agenesis of the corpus callosum. Clinical records were reviewed for perinatal management, postnatal surgical management, and neurodevelopmental outcomes.

Results: Fifteen prenatal cases of AVID were identified. Twelve were live-born and three pregnancies were terminated. Of the 12 patients, 11 underwent neurosurgical intervention. Of the eight patients surviving past infancy, seven of eight have moderate to severe neurodevelopmental delays or disabilities, encompassing both motor and language skills, and all have variable visual abnormalities.

Conclusion: In our cohort of 15 prenatally diagnosed fetuses with AVID, eight survived past infancy and all have neurodevelopmental disabilities, including motor and language deficits, a wide range of visual defects, craniofacial abnormalities, and medical comorbidities.
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http://dx.doi.org/10.1002/pd.5393DOI Listing
January 2019

Complications following pediatric cranioplasty after decompressive craniectomy: a multicenter retrospective study.

J Neurosurg Pediatr 2018 09 8;22(3):225-232. Epub 2018 Jun 8.

17Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.

OBJECTIVE In children, the repair of skull defects arising from decompressive craniectomy presents a unique set of challenges. Single-center studies have identified different risk factors for the common complications of cranioplasty resorption and infection. The goal of the present study was to determine the risk factors for bone resorption and infection after pediatric cranioplasty. METHODS The authors conducted a multicenter retrospective case study that included all patients who underwent cranioplasty to correct a skull defect arising from a decompressive craniectomy at 13 centers between 2000 and 2011 and were less than 19 years old at the time of cranioplasty. Prior systematic review of the literature along with expert opinion guided the selection of variables to be collected. These included: indication for craniectomy; history of abusive head trauma; method of bone storage; method of bone fixation; use of drains; size of bone graft; presence of other implants, including ventriculoperitoneal (VP) shunt; presence of fluid collections; age at craniectomy; and time between craniectomy and cranioplasty. RESULTS A total of 359 patients met the inclusion criteria. The patients' mean age was 8.4 years, and 51.5% were female. Thirty-eight cases (10.5%) were complicated by infection. In multivariate analysis, presence of a cranial implant (primarily VP shunt) (OR 2.41, 95% CI 1.17-4.98), presence of gastrostomy (OR 2.44, 95% CI 1.03-5.79), and ventilator dependence (OR 8.45, 95% CI 1.10-65.08) were significant risk factors for cranioplasty infection. No other variable was associated with infection. Of the 240 patients who underwent a cranioplasty with bone graft, 21.7% showed bone resorption significant enough to warrant repeat surgical intervention. The most important predictor of cranioplasty bone resorption was age at the time of cranioplasty. For every month of increased age the risk of bone flap resorption decreased by 1% (OR 0.99, 95% CI 0.98-0.99, p < 0.001). Other risk factors for resorption in multivariate models were the use of external ventricular drains and lumbar shunts. CONCLUSIONS This is the largest study of pediatric cranioplasty outcomes performed to date. Analysis included variables found to be significant in previous retrospective reports. Presence of a cranial implant such as VP shunt is the most significant risk factor for cranioplasty infection, whereas younger age at cranioplasty is the dominant risk factor for bone resorption.
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http://dx.doi.org/10.3171/2018.3.PEDS17234DOI Listing
September 2018

Incidence of symptomatic tethered spinal cord in pediatric patients presenting with neurofibromatosis types 1 and 2.

J Neurosurg Pediatr 2018 05 23;21(5):456-459. Epub 2018 Feb 23.

OBJECTIVE The relationship between a tethered cord (TC) and neurofibromatosis type 1 (NF1) and NF2 is not known. The purpose of this study was to define the incidence of TC in pediatric neurosurgical patients who present with NF. METHODS The authors performed a single-institution (tertiary care pediatric hospital) 10-year retrospective analysis of patients who were diagnosed with or who underwent surgery for a TC and/or NF. Clinical and radiological characteristics were analyzed, as was histopathology. RESULTS A total of 424 patients underwent surgery for a TC during the study period, and 67 patients with NF were seen in the pediatric neurosurgery clinic. Of these 67 patients, 9 (13%) were diagnosed with a TC, and filum lysis surgery was recommended. Among the 9 patients with NF recommended for TC-release surgery, 4 (44%) were female, the mean age was 8 years (range 4-14 years), the conus position ranged from L1-2 to L-3, and 3 (33%) had a filum lipoma, defined as high signal intensity on T1-weighted MR images. All 9 of these patients presented with neuromotor, skeletal, voiding, and/or pain-related symptoms. Histopathological examination consistently revealed dense fibroconnective tissue and blood vessels. CONCLUSIONS Despite the lack of any known pathophysiological relationship between NF and TC, the incidence of a symptomatic TC in patients with NF1 and NF2 who presented for any reason to this tertiary care pediatric neurosurgery clinic was 13%. Counseling patients and families regarding TC symptomatology might be indicated in this patient population.
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http://dx.doi.org/10.3171/2017.12.PEDS17306DOI Listing
May 2018

Editorial. Prone to error, or enlightenment?

Authors:
Nathan R Selden

J Neurosurg Pediatr 2018 01 27;21(1):1-3. Epub 2017 Oct 27.

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http://dx.doi.org/10.3171/2017.3.PEDS17126DOI Listing
January 2018

Assessment of the Interrater Reliability of the Congress of Neurological Surgeons Microanastomosis Assessment Scale.

Oper Neurosurg (Hagerstown) 2017 02;13(1):108-112

Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.

Background: The potential for simulation-based learning in neurosurgical training has led the Congress of Neurosurgical Surgeons to develop a series of simulation modules. The Northwestern Objective Microanastomosis Assessment Tool (NOMAT) was created as the corresponding assessment tool for the Congress of Neurosurgical Surgeons Microanastomosis Module. The face and construct validity of the NOMAT have been previously established.

Objective: To further validate the NOMAT by determining its interrater reliability (IRR) between raters of varying levels of microsurgical expertise.

Methods: The NOMAT was used to assess residents' performance in a microanastomosis simulation module in 2 settings: Northwestern University and the Society of Neurological Surgeons 2014 Boot Camp at the University of Indiana. At Northwestern University, participants were scored by 2 experienced microsurgeons. At the University of Indiana, participants were scored by 2 postdoctoral fellows and an experienced microsurgeon. The IRR of NOMAT was estimated by computing the intraclass correlation coefficient using SPSS v22.0 (IBM, Armonk, New York).

Results: A total of 75 residents were assessed. At Northwestern University, 21 residents each performed microanastomosis on 2 model vessels of different sizes, one 3 mm and one 1 mm. At the University of Indiana, 54 residents performed a single microanastomosis procedure on 3-mm vessels. The intraclass correlation coefficient of the total NOMAT scores was 0.88 at Northwestern University and 0.78 at the University of Indiana.

Conclusion: This study indicates high IRR for the NOMAT. These results suggest that the use of raters with varying levels of expertise does not compromise the precision or validity of the scale. This allows for a wider adoption of the scale and, hence, a greater potential educational impact.
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http://dx.doi.org/10.1227/NEU.0000000000001403DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6312083PMC
February 2017

The Effect and Use of Milestones in the Assessment of Neurological Surgery Residents and Residency Programs.

J Surg Educ 2018 Jan - Feb;75(1):147-155. Epub 2017 Jun 22.

Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon.

Objectives: The purpose of this study was to determine the effect of the Accreditation Council for Graduate Medical Education Milestones on the assessment of neurological surgery residents. The authors sought to determine the feasibility, acceptability, and utility of this new framework in making judgments of progressive competence, its implementation within programs, and the influence on curricula. Residents were also surveyed to elicit the effect of Milestones on their educational experience and professional development.

Design, Setting, And Participants: In 2015, program leadership and residents from 21 neurological surgery residency programs participated in an online survey and telephone interview in which they reflected on their experiences with the Milestones. Survey data were analyzed using descriptive statistics. Interview transcripts were analyzed using grounded theory.

Results: Response themes were categorized into 2 groups: outcomes of the Milestones implementation process, and facilitators and barriers. Because of Milestones implementation, participants reported changes to the quality of the assessment process, including the ability to identify struggling residents earlier and design individualized improvement plans. Some programs revised their curricula based on training gaps identified using the Milestones. Barriers to implementation included limitations to the adoption of a developmental progression model in the context of rotation block schedules and misalignment between progression targets and clinical experience. The shift from time-based to competency-based evaluation presented an ongoing adjustment for many programs. Organized preparation before clinical competency committee meetings and diverse clinical competency committee composition led to more productive meetings and perceived improvement in promotion decisions.

Conclusions: The results of this study can be used by program leadership to help guide further implementation of the Milestones and program improvement. These results also help to guide the evolution of Milestones language and their implementation across specialties.
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http://dx.doi.org/10.1016/j.jsurg.2017.06.001DOI Listing
November 2018

A microcontroller-based simulation of dural venous sinus injury for neurosurgical training.

J Neurosurg 2018 05 2;128(5):1553-1559. Epub 2017 Jun 2.

1Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and.

OBJECTIVE Surgical simulation has the potential to supplement and enhance traditional resident training. However, the high cost of equipment and limited number of available scenarios have inhibited wider integration of simulation in neurosurgical education. In this study the authors provide initial validation of a novel, low-cost simulation platform that recreates the stress of surgery using a combination of hands-on, model-based, and computer elements. Trainee skill was quantified using multiple time and performance measures. The simulation was initially validated using trainees at the start of their intern year. METHODS The simulation recreates intraoperative superior sagittal sinus injury complicated by air embolism. The simulator model consists of 2 components: a reusable base and a disposable craniotomy pack. The simulator software is flexible and modular to allow adjustments in difficulty or the creation of entirely new clinical scenarios. The reusable simulator base incorporates a powerful microcomputer and multiple sensors and actuators to provide continuous feedback to the software controller, which in turn adjusts both the screen output and physical elements of the model. The disposable craniotomy pack incorporates 3D-printed sections of model skull and brain, as well as artificial dura that incorporates a model sagittal sinus. RESULTS Twelve participants at the 2015 Western Region Society of Neurological Surgeons postgraduate year 1 resident course ("boot camp") provided informed consent and enrolled in a study testing the prototype device. Each trainee was required to successfully create a bilateral parasagittal craniotomy, repair a dural sinus tear, and recognize and correct an air embolus. Participant stress was measured using a heart rate wrist monitor. After participation, each resident completed a 13-question categorical survey. CONCLUSIONS All trainee participants experienced tachycardia during the simulation, although the point in the simulation at which they experienced tachycardia varied. Survey results indicated that participants agreed the simulation was realistic, created stress, and was a useful tool in training neurosurgical residents. This simulator represents a novel, low-cost approach for hands-on training that effectively teaches and tests residents without risk of patient injury.
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http://dx.doi.org/10.3171/2016.12.JNS162165DOI Listing
May 2018

QuickBrain MRI for the detection of acute pediatric traumatic brain injury.

J Neurosurg Pediatr 2017 Feb 25;19(2):259-264. Epub 2016 Nov 25.

Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine.

OBJECTIVE The current gold-standard imaging modality for pediatric traumatic brain injury (TBI) is CT, but it confers risks associated with ionizing radiation. QuickBrain MRI (qbMRI) is a rapid brain MRI protocol that has been studied in the setting of hydrocephalus, but its ability to detect traumatic injuries is unknown. METHODS The authors performed a retrospective cohort study of pediatric patients with TBI who were undergoing evaluation at a single Level I trauma center between February 2010 and December 2013. Patients who underwent CT imaging of the head and qbMRI during their acute hospitalization were included. Images were reviewed independently by 2 neuroradiology fellows blinded to patient identifiers. Image review consisted of identifying traumatic mass lesions and their intracranial compartment and the presence or absence of midline shift. CT imaging was used as the reference against which qbMRI was measured. RESULTS A total of 54 patients met the inclusion criteria; the median patient age was 3.24 years, 65% were male, and 74% were noted to have a Glasgow Coma Scale score of 14 or greater. The sensitivity and specificity of qbMRI to detect any lesion were 85% (95% CI 73%-93%) and 100% (95% CI 61%-100%), respectively; the sensitivity increased to 100% (95% CI 89%-100%) for clinically important TBIs as previously defined. The mean interval between CT and qbMRI was 27.5 hours, and approximately half of the images were obtained within 12 hours. CONCLUSIONS In this retrospective pilot study, qbMRI demonstrated reasonable sensitivity and specificity for detecting a lesion or injury seen with neuroimaging (radiographic TBI) and clinically important acute pediatric TBI.
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http://dx.doi.org/10.3171/2016.7.PEDS16204DOI Listing
February 2017

Implementation of a Tranexamic Acid Protocol to Reduce Blood Loss During Cranial Vault Remodeling for Craniosynostosis.

J Craniofac Surg 2016 Sep;27(6):1527-31

*Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery †Department of Anesthesiology and Perioperative Medicine ‡Division of Plastic Surgery, Department of Surgery, Oregon Health & Science University §Department of Surgery, Oregon Health & Science University ||Department of Neurological Surgery ¶Division of Pediatric Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR.

Objective: Pediatric cranial vault remodeling for repair of craniosynostosis is associated with significant blood loss and transfusion requirements. Beginning in 2011, the authors evaluated the impact tranexamic acid (TXA) on blood loss and blood product transfusion for children less than 15 months of age undergoing primary surgical repair of nonsyndromic single suture craniosynostosis.

Methods: Following institutional review board approval, the authors performed a retrospective study of all children undergoing surgical correction of craniosynostosis at Oregon Health & Science University from 2005 to 2015. All available records were reviewed, and patient data were collected from the time of preoperative evaluation until discharge, comparing patient and clinical variables before and after the implementation of perioperative TXA.

Results: Of a total of 259 patients with craniosynostosis, 187 had nonsyndromic single-suture involvement; 69 of these patients (36.9%) received TXA. A single surgical team (AAK and NRS) performed all operations. Median age at the time of surgery was 8.1 months (interquartile range [IQR] of 6.0-9.8 months). The TXA group had a significant reduction in estimated intraoperative blood loss (26 mL/kg versus 36 mL/kg, P <0.001), cell saver volume transfused 6 mL/kg versus 10 mL/kg, P <0.001), red cell transfusion volume (32 mL/kg versus 42 mL/kg, P <0.001), exposure to plasma transfusion (0% versus 24% P <0.001), exposure to cryoprecipitate transfusion (0% versus 16%, P <0.001), and exposure to platelet transfusion (0% versus 7.6% P = 0.03). Despite reduced red cell transfusion, the TXA-treated patients exhibited similar postoperative hematocrits (30.4 versus 30.3 P = 0.906) to those not treated with TXA. Use of TXA was associated with reduced length of stay (4 days IQR 3-4 versus 4 days IQR 4-5, P <0.001) and reduced postoperative output from surgically placed drains (181 mL versus 311 mL P <0.001). There was no difference in postoperative complications between groups and no deaths in either group.

Conclusions: The introduction of TXA for nonsyndromic single-suture synostosis repair at our institution has significantly reduced blood loss and blood product and plasma transfusion during and following primary cranial vault remodeling for single suture craniosynostosis. Postoperative hematocrit was similar in the TXA-treated and untreated groups despite reduced red cell transfusion in the treated group. In addition, TXA use in this population has eliminated the need for plasma transfusion, and is associated with a shorter hospital stay. No difference in postoperative complications was observed. Our data provide support for further investigation of TXA treatment to improve clinical outcomes in children undergoing pediatric cranial vault remodeling.
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http://dx.doi.org/10.1097/SCS.0000000000002835DOI Listing
September 2016

IGF1R as a Key Target in High Risk, Metastatic Medulloblastoma.

Sci Rep 2016 06 3;6:27012. Epub 2016 Jun 3.

Children's Cancer Therapy Development Institute, Beaverton, OR USA.

Risk or presence of metastasis in medulloblastoma causes substantial treatment-related morbidity and overall mortality. Through the comparison of cytokines and growth factors in the cerebrospinal fluid (CSF) of metastatic medulloblastoma patients with factors also in conditioned media of metastatic MYC amplified medulloblastoma or leptomeningeal cells, we were led to explore the bioactivity of IGF1 in medulloblastoma by elevated CSF levels of IGF1, IGF-sequestering IGFBP3, IGFBP3-cleaving proteases (MMP and tPA), and protease modulators (TIMP1 and PAI-1). IGF1 led not only to receptor phosphorylation but also accelerated migration/adhesion in MYC amplified medulloblastoma cells in the context of appropriate matrix or meningothelial cells. Clinical correlation suggests a peri-/sub-meningothelial source of IGF-liberating proteases that could facilitate leptomeningeal metastasis. In parallel, studies of key factors responsible for cell autonomous growth in MYC amplified medulloblastoma prioritized IGF1R inhibitors. Together, our studies identify IGF1R as a high value target for clinical trials in high risk medulloblastoma.
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http://dx.doi.org/10.1038/srep27012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4891740PMC
June 2016

Mentorship: service, education, progress. The 2015 CNS Presidential Address.

Authors:
Nathan R Selden

J Neurosurg 2017 Jan 6;126(1):158-164. Epub 2016 May 6.

Department of Neurological Surgery, School of Medicine, Oregon Health & Science University, Portland, Oregon.

The theme of the 65th Annual Meeting of the Congress of Neurological Surgeons and the title of this presidential address focus on mentorship as a valuable service owed to the profession of neurological surgery by its members, a crucial tool for the education of new neurosurgeons, and a fundamental contributor to the progress of the specialty. The author explores the origin of the term "mentor" in Homeric tradition and the impact of mentorship on the historical legacy of neurological surgery. He outlines the role mentorship played in his own professional development, as well as the changing face of mentorship today due to increasing numbers of women in neurosurgery. Many surgeons perceive modern educational approaches as threats to the tradition of personal mentorship in medicine. The author argues that intentional educational methods, such as the Society of Neurological Surgeons (SNS) "matrix" curriculum, the Accreditation Council for Graduate Medical Education "milestones," and the SNS "boot camp" courses, each focus, enhance, and empower, but do not replace, personal mentorship. The author further describes the important role of mentorship in the definition, growth, and health of the specialty of neurological surgery and in the personal well-being and fulfillment of its practitioners.
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January 2017

Computed tomography-generated anthropometric measurements of orbital relationships in normal infants and children.

J Neurosurg Pediatr 2016 Aug 29;18(2):201-6. Epub 2016 Apr 29.

Division of Pediatric Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon.

OBJECTIVE The aim of this study was to develop soft-tissue and bony anthropometric orbital measurements in a normal pediatric population based upon CT scans. METHODS This was a retrospective stratified study of children with ages ranging from birth to 36 months. Head CT images for 204 children were available and obtained with 0.625-1-mm slice widths. Soft-tissue and bone windows were reviewed. Images were oriented in the Frankfort horizontal plane, and the intercanthal (IC), bony interorbital (IO), and bony lateral orbital (LO) distances were measured. Age group stratifications were 0-3, > 3-6, > 6-9, > 9-12, > 12-18, > 18-24, > 24-30, and > 30-36 months. Patients with known syndromes or craniofacial abnormalities were excluded. Statistical analysis included the mean, SD, SEM, 95% CI, and an evaluation of IO:LO ratio. RESULTS There was an average of 25.5 patients in each age group (range 25-27 patients). All soft-tissue and bony measurements consistently showed rapid increase from 0-6 months of age, which tapered after age > 12 months. The mean IC, bony IO, and bony LO distances started at 22.22 ± 1.13 mm, 14.16 ± 0.74 mm, and 65.56 ± 1.76 mm, and at 12 months were 27.74 ± 1.01 mm, 16.21 ± 0.75 mm, and 77.98 ± 1.57 mm, respectively. The bony LO position was equivalent to the lateral canthal position and measurements. The IC distance was approximately one-third the lateral canthal distance for all age groups. CONCLUSIONS This study established and reported normal anthropometric orbital measurements in a pediatric population using fine-cut craniofacial CT. These measurements are essential when evaluating children with craniofacial anomalies.
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http://dx.doi.org/10.3171/2016.2.PEDS15475DOI Listing
August 2016

Age at the Time of Surgery and Maintenance of Head Size in Nonsyndromic Sagittal Craniosynostosis.

Plast Reconstr Surg 2016 May;137(5):1557-1565

Portland, Ore.

Background: Repair of nonsyndromic sagittal craniosynostosis should durably improve intracranial volume and cranial index. The optimal timing of surgery is not known. The authors previously reported reoperation in patients aged younger than 6 months at primary repair.

Methods: Patients undergoing primary reconstruction for sagittal craniosynostosis before age 1 year between 2005 and 2013 at Oregon Health & Science University underwent retrospective computed tomographic determination of cranial index and intracranial volume preoperatively and 2 years postoperatively and head circumference measurements until age 6 years.

Results: Fifty-six patients undergoing operation before their first birthday were studied in two groups: those younger than 6 months [34 (61 percent)] and those aged 6 months or older at the time of operation. Head circumference percentile increased immediately after surgery but decreased at 1 and 2 years after surgery, significantly more so in patients younger than 6 months (p < 0.015 at 1 year; p < 0.011 at 2-year follow-up). Mean 2-year postoperative cranial index was significantly increased in both groups (p < 0.001), which did not differ preoperatively (younger than 6 months, 76.5; 6 months or older, 78.0) or 2 years postoperatively (younger than 6 months, 88.4; 6 months or older, 87.1; p = not significant). Intracranial volume increased in all patients from before surgery to 2 years postoperatively and was higher in the patients aged 6 months or older (p < 0.001).

Conclusion: Cranial reconstruction for nonsyndromic sagittal craniosynostosis improved cranial index equally in all patients but increased head circumference and intracranial volume significantly more in patients who underwent surgical reconstruction at age 6 months or older.

Clinical Question/level Of Evidence: Therapeutic, III.
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May 2016

A Reduction in Radiation Exposure During Pediatric Craniofacial Computed Tomography.

J Craniofac Surg 2016 Mar;27(2):331-3

*Division of Plastic and Reconstructive Surgery †Department of Surgery, Division of Pediatric Surgery ‡Department of Radiology §Department of Neurological Surgery, Oregon Health & Science University, Portland, OR.

Background: Radiation exposure during computed tomography (CT) evaluation in children is the subject of growing professional and public concern. The authors previously demonstrated an 18% reduction in effective radiation dose during craniofacial CT imaging using a modified head position ("exaggerated sniff"), without any compromise of image diagnostic quality. The current study reports additional reduction of radiation exposure using a commercially available iterative reconstruction CT technique.

Methods: This single-institution, retrospective cohort study compared the overall effective radiation dose received during elective pediatric craniofacial CT imaging. Patients imaged using the iterative reconstruction and exaggerated sniff protocol combined (January 2010 through December 2013) were compared with those undergoing imaging with the exaggerated sniff position alone, between October 2008 and January 2010.

Results: A total of 325 patients who underwent CT imaging with the exaggerated sniff position, decreased dose and iterative reconstruction protocol experienced an average effective radiation dose of 1.22 mSv (47% reduction), compared with 2.32 mSv for the sniff-position alone group. Age-matched reference patients not treated using either protocol received an average of 2.82 mSv. This represents a 56.7% average radiation dose reduction for combined sniff position and iterative reconstruction patients compared with reference patients and 47.4% reduction compared with the sniff-position alone group. Image quality of both bone and brain windows was equivalent.

Conclusions: Altering head position and use of iterative reconstruction technique with a reduced radiation protocol diminishes CT imaging-related effective radiation dose by approximately 50% in children undergoing elective cranial CT imaging for craniofacial disorders.
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http://dx.doi.org/10.1097/SCS.0000000000002374DOI Listing
March 2016