Browse

You are looking at 1 - 9 of 9 items for

  • Refine by Access: all x
  • By Author: Jea, Andrew x
  • By Author: Chern, Joshua J. x
Clear All
Full access

Jonathan N. Sellin, William J. Steele III, Lauren Simpson, Wei X. Huff, Brandon C. Lane, Joshua J. Chern, Daniel H. Fulkerson, Christina M. Sayama, and Andrew Jea

OBJECTIVE

The Thoracolumbar Injury Classification and Severity Score (TLICS) system was developed to streamline injury assessment and guide surgical decision making. To the best of the authors' knowledge, external validation in the pediatric age group has not been undertaken prior to this report.

METHODS

This study evaluated the use of the TLICS in a large retrospective series of children and adolescents treated at 4 pediatric medical centers (Texas Children's Hospital, Children's Healthcare of Atlanta, Riley Children's Hospital, and Doernbecher Children's Hospital). A total of 147 patients treated for traumatic thoracic or lumbar spine trauma between February 1, 2002, and September 1, 2015, were included in this study. Clinical and radiographic data were evaluated. Injuries were classified using American Spinal Injury Association (ASIA) status, Denis classification, and TLICS.

RESULTS

A total of 102 patients (69%) were treated conservatively, and 45 patients (31%) were treated surgically. All patients but one in the conservative group were classified as ASIA E. In this group, 86/102 patients (84%) had Denis type compression injuries. The TLICS in the conservative group ranged from 1 to 10 (mean 1.6). Overall, 93% of patients matched TLICS conservative treatment recommendations (score ≤ 3). No patients crossed over to the surgical group in delayed fashion.

In the surgical group, 26/45 (58%) were ASIA E, whereas 19/45 (42%) had neurological deficits (ASIA A, B, C, or D). One of 45 (2%) patients was classified with Denis type compression injuries; 25/45 (56%) were classified with Denis type burst injuries; 14/45 (31%) were classified with Denis type seat belt injuries; and 5/45 (11%) were classified with Denis type fracture-dislocation injuries. The TLICS ranged from 2 to 10 (mean 6.4). Eighty-two percent of patients matched TLICS surgical treatment recommendations (score ≥ 5). No patients crossed over to the conservative management group. Eight patients (8/147, 5%) had a calculated TLICS of 4, which meant they were candidates for surgery or conservative therapy by TLICS criteria. Excluding these patients, the degree of agreement between TLICS and surgeon decision was deemed to be very good (κ = 0.878).

CONCLUSIONS

The TLICS results and recommendations matched treatment in 96% of conservative group cases. In the surgical group, TLICS recommendations matched treatment in 93% of cases. The TLICS recommendations and surgeon decision making displayed very good concordance. The TLICS appears to be effective in the classification of thoracic and lumbar spine injuries and in guiding treatment in the pediatric age group.

Restricted access

Joshua J. Chern, Samir Sarda, Brian M. Howard, Andrew Jea, R. Shane Tubbs, Barunashish Brahma, David M. Wrubel, Andrew Reisner, and William Boydston

Object

Nonoperative blunt head trauma is a common reason for admission in a pediatric hospital. Adverse events, such as growing skull fracture, are rare, and the incidence of such morbidity is not known. As a result, optimal follow-up care is not clear.

Methods

Patients admitted after minor blunt head trauma between May 1, 2009, and April 30, 2013, were identified at a single institution. Demographic, socioeconomic, and clinical characteristics were retrieved from administrative and outpatient databases. Clinical events within the 180-day period following discharge were reviewed and analyzed. These events included emergency department (ED) visits, need for surgical procedures, clinic visits, and surveillance imaging utilization. Associations among these clinical events and potential contributing factors were analyzed using appropriate statistical methods.

Results

There were 937 admissions for minor blunt head trauma in the 4-year period. Patients who required surgical interventions during the index admission were excluded. The average age of the admitted patients was 5.53 years, and the average length of stay was 1.7 days; 15.7% of patients were admitted for concussion symptoms with negative imaging findings, and 26.4% of patients suffered a skull fracture without intracranial injury. Patients presented with subdural, subarachnoid, or intraventricular hemorrhage in 11.6%, 9.19%, and 0.53% of cases, respectively. After discharge, 672 patients returned for at least 1 follow-up clinic visit (71.7%), and surveillance imaging was obtained at the time of the visit in 343 instances.

The number of adverse events was small and consisted of 34 ED visits and 3 surgeries. Some of the ED visits could have been prevented with better discharge instructions, but none of the surgery was preventable. Furthermore, the pattern of postinjury surveillance imaging utilization correlated with physician identity but not with injury severity. Because the number of adverse events was small, surveillance imaging could not be shown to positively influence outcomes.

Conclusions

Adverse events after nonoperative mild traumatic injury are rare. The routine use of postinjury surveillance imaging remains controversial, but these data suggest that such imaging does not effectively identify those who require operative intervention.

Restricted access

Steven W. Hwang, Loyola V. Gressot, Joshua J. Chern, Katherine Relyea, and Andrew Jea

Object

Occipitocervical stabilization in the pediatric age group remains a challenge because of the regional anatomy, poor occipital bone purchase, and, in some instances, significant thinning of the occipital bone. Multiple bicortical fixation points to the occipital bone may be required to increase construct rigidity. The authors evaluated the complications of bicortical occipital screw placement in children with occipital fusion constructs.

Methods

The records of 20 consecutive pediatric patients who had undergone occipitocervical fusion between September 1, 2007, and November 30, 2010, at Texas Children's Hospital were reviewed.

Results

The patients consisted of 10 girls and 10 boys, ranging in age from 10 months to 16 years (mean ± SD, 7.7 ± 5.1 years). Two patients were lost to follow-up, 2 died for reasons unrelated to the surgery, and the remaining patients had at least 3 months of follow-up (mean 14 ± 11.8 months) with evaluation via dynamic radiography and CT. Four patients experienced 8 complications: 2 CSF leaks, 2 vigorous venous bleedings, worsening of quadriparesis, wound infection, radiographic pseudarthrosis, and transient dysphagia. Among 114 screws, there were 2 cases of intraoperative dural venous sinus injury and 2 cases of intraoperative CSF leakage, without clinical sequelae from these complications. Only 1 case of radiographic pseudarthrosis was identified in a patient with skeletal dysplasia and a prior failed C1–2 posterior arthrodesis. There were no difficulties with wound healing because of prominent occipital instrumentation, and there was only 1 wound infection.

Conclusions

Data in this report confirm that including bicortical occipital screw placement in occipitocervical constructs in children may result in a high fusion rate but at the cost of a notable complication rate.

Restricted access

Joshua J. Chern, R. Shane Tubbs, Akash J. Patel, Amber S. Gordon, S. Kathleen Bandt, Matthew D. Smyth, Andrew Jea, and W. Jerry Oakes

Object

Tethered cord release for a tight filum terminale is a common pediatric operation associated with low morbidity and mortality rates. While almost all would agree that keeping patients lying flat after the operation will prevent a CSF leak, the optimal period of doing so has not been determined. In this study, the authors examined whether a longer length of stay in the hospital for the sole purpose of maintaining patients flat correlates with a decreased rate of CSF leakage.

Methods

Intraoperative and postoperative data were retrospectively collected in 222 cases of simple tethered cord release at 3 large children's hospitals. Risk factors for postoperative CSF leakage were identified.

Results

Thirty-eight patients were maintained lying flat for 24 hours, 86 for 48 hours, and 98 for 72 hours at the individual surgeon's discretion. A CSF leak occurred in 13 patients (5.9%) and pseudomeningocele developed in 9 patients (4.1%). In the univariate analysis, operating time, use of the microscope, use of dural sealant, and duration of remaining flat after surgery failed to correlate with the occurrence of complications.

Conclusions

A longer hospital stay for maintaining patients flat after a simple tethered cord release appears not to prevent CSF leakage. However, a larger patient cohort will be needed to detect small differences in complication rates.

Restricted access

Akash J. Patel, Jacob Cherian, Daniel H. Fulkerson, Benjamin D. Fox, Joshua J. Chern, William E. Whitehead, Daniel J. Curry, Thomas G. Luerssen, and Andrew Jea

Object

Translaminar screw (TLS) fixation can be used safely and efficaciously for upper cervical fusion in children. No published studies have evaluated this technique in the thoracic spine of the pediatric population, and thus the authors undertook such an analysis.

Methods

The upper thoracic spines (T1–4) of 130 patients, consisting of 70 boys and 60 girls, were studied using CT scans. Laminar height and thickness, screw length, and screw angle were measured. Exclusion criteria included the following: patients older than 18 years of age, trauma or congenital abnormalities of the thoracic spine, or absent demographic information or imaging studies through T-4. Statistical analysis was performed using paired or unpaired Student t-tests (p < 0.05) and linear regression analysis.

Results

The mean laminar heights for T-1, T-2, T-3, and T-4 were as follows: 12.3 ± 3.4, 13.0 ± 3.5, 13.4 ± 3.8, and 14.7 ± 4.1 mm, respectively. The mean laminar widths were 6.5 ± 1.3, 6.6 ± 1.3, 6.6 ± 1.3, and 6.6 ± 1.4 mm, respectively. The mean screw lengths were 29.9 ± 4.1, 25.2 ± 3.5, 22.7 ± 3.2, and 21.6 ± 3.1 mm, respectively. The mean screw angles were 47° ± 4°, 48° ± 4°, 51° ± 4°, and 53° ± 5°, respectively. There were no significant differences between the right and left sides. However, significant differences were found when comparing patients younger than 8 years with those who were 8 years or older, and when comparing boys and girls.

Conclusions

Careful preoperative thin-cut CT with sagittal reconstruction is mandatory to determine if the placement of TLSs is feasible in the pediatric population. Based on CT analysis, the insertion of TLSs in the pediatric thoracic spine is possible in all patients older than 8 years and in many patients younger than 8 years. Boys could accept longer screws in the upper thoracic spine compared with girls.

Restricted access

Joshua J. Chern, Akash J. Patel, Andrew Jea, Daniel J. Curry, and Youssef G. Comair

Object

Focal cortical dysplasia (FCD) is an important cause of intractable epilepsy and is at times treatable by resection. The now widespread use of MR imaging and recent advancement of functional imaging have increased the number of patients undergoing surgical treatment for FCD. The objective of this review is to critically examine and to provide a summary of surgical series on FCD published since 2000.

Methods

Studies concerning surgery for FCD were identified from MEDLINE and references of selected articles and book chapters. Data from these included studies were summarized and analyzed to identify factors correlated with seizure outcome.

Results

Sixteen studies were identified, and 469 patients met our selection criteria. Seizure-free outcome at 1-year postoperatively was achieved in 59.7% of the patients. Children and adults were equally likely to benefit from the surgery. Complete resection (OR 13.7, 95% CI 6.68–28.1; p < 0.0001) and temporal location (OR 2.15, 95% CI 1.26–3.69; p = 0.0073) were two positive prognostic indicators of seizure-free outcome. Utilization of invasive monitoring did not affect the chance of seizure remission, but firm conclusions could not be drawn because patients were not randomized.

Conclusions

The advancement of modern imaging has transformed the process of surgical candidate selection for partial epilepsy due to FCD. Patients from recent surgical series were more homogeneous in their clinical presentations and might represent FCD as an independent pathological entity. This likely explained the improved surgical outcome for this group of patients. These reports also documented the increased utilization of functional imaging, but their efficacy needs to be verified with further studies.

Restricted access

Joshua J. Chern, Charles G. Macias, Andrew Jea, Daniel J. Curry, Thomas G. Luerssen, and William E. Whitehead

Object

Patients with CSF shunts often present to the emergency department (ED) with suspected shunt malfunction. Timely assessment and treatment are important factors affecting patient outcomes. A protocol was implemented at a tertiary children's hospital ED to expedite the care of these patients. This study evaluated the effectiveness of this protocol.

Methods

The protocol assigned all patients with CSF shunts into 1 of 3 pathways. If a patient presented with altered mental status, the Cushing triad, acute focal neurological deficit, ongoing seizure activity, or severe dehydration due to emesis, an ED physician was immediately notified (emergency pathway). If a patient presented with emesis, headache, increasing frequency of seizure, or parental concern for shunt malfunction, the patient entered the expedited pathway, and imaging studies were ordered prior to physician evaluation. All other patients entered the default pathway, in which a physician would evaluate the patient before deciding on further workup. Outcomes of interest included measures of timeliness in the ED and clinical outcomes. Comparisons were made between preprotocol and protocol periods and among the 3 pathways.

Results

The total time to complete both ED physician evaluation and to initiate imaging studies was significantly shorter in the protocol period than in the preprotocol period (104 vs 147 minutes). Similar time saving over the 2 processes was demonstrated comparing expedited and default pathways during the protocol period (95 vs 134 minutes, a 29% difference). Clinically, more patients underwent surgery in the expedited pathway than the default pathway (36% vs 17%), and patients in the expedited pathway had a shorter hospital stay (3.4 ± 0.9 days vs 5.7 ± 4.0 days; p = 0.02).

Conclusions

An ED-based protocol helped identify patients at risk for shunt failure early in the triage process and shortened the assessment process prior to neurosurgical intervention. Improving the timeliness of care for patients with shunt failure is important because morbidity and mortality associated with shunt failure are time dependent.

Restricted access

Joshua J. Chern, Katherine Relyea, Jane C. Edmond, William E. Whitehead, Daniel J. Curry, Thomas G. Luerssen, and Andrew Jea

Selective downward gaze paralysis has not previously been described as a complication after posterior fossa operations in children. The authors found downgaze palsy to be a transient complication after resection of large pediatric posterior fossa midline tumors reaching the aqueduct of Sylvius. They reviewed the cases of 2 children with large posterior fossa midline tumors who underwent resection via an inferior transventricular approach. They developed a hypothetical scheme to account for downward gaze paralysis based on anatomy and insight gained from experimental studies.

The authors describe potential risk factors for developing transient selective downward gaze paralysis with the hope of making more pediatric neurosurgeons aware of this complication following removal of lesions around the mesencephalic periaqueductal gray matter. Recognition and understanding of downward gaze palsy after posterior fossa surgery should improve preoperative counseling and promote postoperative family coping.

Restricted access

Joshua J. Chern, Roukoz B. Chamoun, William E. Whitehead, Daniel J. Curry, Thomas G. Luerssen, and Andrew Jea

Object

The management of upper cervical spinal instability in children continues to represent a technical challenge. Traditionally, a number of wiring techniques followed by halo orthosis have been applied; however, they have been associated with a high rate of nonunion and poor tolerance for the halo. Alternatively, C1–2 transarticular screws and C-2 pars/pedicle screws allow more rigid fixation, but their placement is technically demanding and associated with vertebral artery injuries. Recently, C-2 translaminar screws have been added to the armamentarium of the pediatric spine surgeon as a technically simple and biomechanically efficient means of fixation. However, the use of subaxial translaminar screws have not been described in the general pediatric population. There are no published data that describe the anatomical considerations and potential limitations of this technique in the pediatric population.

Methods

The cervical vertebrae of 69 pediatric patients were studied on CT scans. Laminar height and thickness were measured. Statistical analysis was performed using unpaired Student t-tests (p < 0.05) and linear regression analysis.

Results

The mean laminar heights at C-2, C-3, C-4, C-5, C-6, and C-7, respectively, were 9.76 ± 2.22 mm, 8.22 ± 2.24 mm, 8.09 ± 2.38 mm, 8.51 ± 2.34 mm, 9.30 ± 2.54 mm, and 11.65 ± 2.65 mm. Mean laminar thickness at C-2, C-3, C-4, C-5, C-6, and C-7, respectively, were 5.07 ± 1.07 mm, 2.67 ± 0.79 mm, 2.18 ± 0.73 mm, 2.04 ± 0.60 mm, 2.52 ± 0.66 mm, and 3.84 ± 0.96 mm. In 50.7% of C-2 laminae, the anatomy could accept at least 1 translaminar screw (laminar thickness ≥ 4 mm).

Conclusions

Overall, the anatomy in 30.4% of patients younger than 16 years old could accept bilateral C-2 translaminar screws. However, the anatomy of the subaxial cervical spine only rarely could accept translaminar screws. This study establishes anatomical guidelines to allow for accurate and safe screw selection and insertion. Preoperative planning with thin-cut CT and sagittal reconstruction is essential for safe screw placement using this technique.