Jonathan N. Sellin, Aditya Vedantam, Thomas G. Luerssen and Andrew Jea
The complication profile of epidural triamcinolone acetonide use during lumbar decompression surgery is not known. However, isolated reports of increased risk of delayed CSF leakage with the use of triamcinolone acetonide in adult spinal surgery patients have been published. The purpose of this study was to determine the safety of epidural triamcinolone acetonide use in conjunction with lumbar decompression surgery in pediatric patients.
The medical records of all patients who underwent lumbar decompression surgery with or without discectomy between July 1, 2007, and July 31, 2015, were retrospectively reviewed.
During the study period, 58 patients underwent 59 spine procedures at Texas Children's Hospital. There were 33 female and 25 male patients. The mean age at surgery was 16.5 years (range 12–24 years). Patients were followed for an average of 38.2 months (range 4–97 months). Triamcinolone acetonide was used in 28 (of 35 total) cases of discectomy; there were no cases of delayed symptomatic CSF leaks (0%) in the minimally invasive and open discectomies. On the other hand, triamcinolone acetonide was used in 14 (of 24 total) cases of multilevel laminectomy, among which there were 10 delayed CSF leaks (71.4%) requiring treatment. The use of triamcinolone acetonide in patients who underwent multilevel laminectomy was significantly associated with an increased risk of delayed CSF leaks or pseudomeningoceles (Fisher's exact test, p < 0.001).
There was an unacceptable incidence of delayed postoperative CSF leaks when epidural triamcinolone acetonide was used in patients who underwent multilevel laminectomy.
Jonathan N. Sellin, Jacob Cherian, James M. Barry, Sheila L. Ryan, Thomas G. Luerssen and Andrew Jea
It is common to evaluate children with suspected CSF shunt malfunctions using CT of the head or, more recently, “quick brain” MRI. However, the reliability of using ventricular behavior, as assessed on cranial imaging during previous presentations with shunt obstructions, is not well defined. The authors conducted a study to determine if CT or MRI of ventricular morphology added useful clinical information in the evaluation of shunt malfunctions.
A retrospective chart review of children operated on at Texas Children's Hospital from February 20, 2011, to June 18, 2013, for shunt obstruction was conducted. Inclusion criteria involved age 3 years or older in patients who had undergone two or more shunt revisions for intraoperatively confirmed obstructions. Patients with shunt infection but without shunt obstruction and patients with fourth ventricular shunt failure were excluded from the study. Preoperative CT or MRI results were dichotomized into two distinct categories, as determined by a radiologist's report: either dilation of the ventricular system in comparison with prior scans at points the shunt was deemed functional, or no dilation of the ventricular system in comparison such scans. Determination of the presence of shunt obstruction was assessed by findings documented by the surgeon in the operative report. Each case was then analyzed to see if the patient has a reliable pattern of ventricular dilation, or no dilation, at times of shunt obstruction.
Forty-two patients (25 males and 17 females) were included in the study. There were a total of 117 patient encounters analyzed and an average of 2.79 encounters per patient. The mean age at shunt failure presentation was 10.8 years (range 3–23 years). In 4 encounters, patients presented with a CSF leak or pseudomeningocele. Twenty-seven patients (64%) consistently demonstrated dilation of the ventricular system during episodes of shunt obstruction. Four patients (10%) consistently demonstrated no dilation during episodes of shunt obstruction. Eleven patients (26%) demonstrated inconsistent changes in ventricular size at times of shunt obstruction. In those first patient encounters with shunt obstruction presenting with ventricular dilation, 92% (49 of 53) of subsequent encounters demonstrated ventricular dilation with shunt obstruction presentations.
Historical CT or MRI data regarding ventricular morphology patterns seen during prior examinations of shunt obstructions may inform a clinician's judgment of shunt obstruction on subsequent presentations, but they are not conclusive. In the present series, the authors found that changes in the morphology of a given patient's ventricular system when shunt obstruction occurs were often consistent and predictable, but not always. It remains imperative, however, that cranial images obtained to rule out shunt malfunction be compared with prior studies.