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Osamu Akiyama, Ken Matsushima, Abuzer Gungor, Satoshi Matsuo, Dylan J. Goodrich, R. Shane Tubbs, Paul Klimo Jr., Aaron A. Cohen-Gadol, Hajime Arai and Albert L. Rhoton Jr.

OBJECTIVE

Approaches to the pulvinar remain challenging because of the depth of the target, surrounding critical neural structures, and complicated arterial and venous relationships. The purpose of this study was to compare the surgical approaches to different parts of the pulvinar and to examine the efficacy of the endoscope as an adjunct to the operating microscope in this area.

METHODS

The pulvinar was examined in 6 formalin-fixed human cadaveric heads through 5 approaches: 4 above and 1 below the tentorium. Each approach was performed using both the surgical microscope and 0° or 45° rigid endoscopes.

RESULTS

The pulvinar has a lateral ventricular and a medial cisternal surface that are separated by the fornix and the choroidal fissure, which wrap around the posterior surface of the pulvinar. The medial cisternal part of the pulvinar can be further divided into upper and lower parts. The superior parietal lobule approach is suitable for lesions in the upper ventricular and cisternal parts. Interhemispheric precuneus and posterior transcallosal approaches are suitable for lesions in the part of the pulvinar forming the anterior wall of the atrium and adjacent cisternal part. The posterior interhemispheric transtentorial approach is suitable for lesions in the lower cisternal part and the supracerebellar infratentorial approach is suitable for lesions in the inferior and medial cisternal parts.

The microscope provided satisfactory views of the ventricular and cisternal surfaces of the pulvinar and adjacent neural and vascular structures. The endoscope provided multi-angled and wider views of the pulvinar and adjacent structures.

CONCLUSIONS

A combination of endoscopic and microsurgical techniques allows optimal exposure of the pulvinar.

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Scott Boop, Mary Axente, Blakely Weatherford and Paul Klimo Jr.

OBJECTIVE

Research on pediatric abusive head trauma (AHT) has largely focused on clinical presentation and management. The authors sought to review a single-institution experience from a public health perspective to gain a better understanding of the local population affected, determine overall incidence and seasonal trends, and provide details on the initial hospitalization, including extent of injuries, neurosurgical interventions, and hospital charges.

METHODS

All cases of AHT involving patients who presented to Le Bonheur Children's Hospital (LBCH) from 2009 through 2014 were identified. AHT was defined as skull fracture or intracranial hemorrhage in a child under the age of 5 years with a suspicious mechanism or evidence of other intentional injuries, such as retinal hemorrhages, old or new fractures, or soft-tissue bruising. Injuries were categorized as Grade I (skull fracture only), Grade II (intracranial hemorrhage or edema not requiring surgical intervention), or Grade III (intracranial hemorrhage requiring intervention or death due to brain injury).

RESULTS

Two hundred thirteen AHT cases were identified. The demographics of the study population are similar to those reported in the literature: the majority of the patients involved were 6 months of age or younger (55%), male (61%), African American (47%), and publicly insured (82%). One hundred one neurosurgical procedures were performed in 58 children, with the most common being bur hole placement for treatment of subdural collections (25%) and decompressive hemicraniectomy (22%). The annual incidence rate rose from 2009 (19.6 cases per 100,000 in the population under 5 years of age) to 2014 (47.4 cases per 100,000) and showed seasonal peaks in January, July, and October (6-year average single-month incidence, respectively, 24.7, 21.7, and 24.7 per 100,000). The total hospital charges were $13,014,584, with a median cost of $27,939. Treatment costs for children who required surgical intervention (i.e., those with Grade III) were up to 10 times those of children with less severe injuries.

CONCLUSIONS

In the authors' local population, victims of AHT are overwhelmingly infants, are more often male than female, and are disproportionately from lower socioeconomic ranks. The incidence is increasing and initial hospitalization charges are substantial and variable. The authors introduce a simple 3-tiered injury classification scheme that adequately stratifies length of hospital stay and cost.

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Garrett T. Venable, Nicholas B. Rossi, G. Morgan Jones, Nickalus R. Khan, Zachary S. Smalley, Mallory L. Roberts and Paul Klimo Jr.

OBJECTIVE

Shunt surgery consumes a large amount of pediatric neurosurgical health care resources. Although many studies have sought to identify risk factors for shunt failure, there is no consensus within the literature on variables that are predictive or protective. In this era of “quality outcome measures,” some authors have proposed various metrics to assess quality outcomes for shunt surgery. In this paper, the Preventable Shunt Revision Rate (PSRR) is proposed as a novel quality metric.

METHODS

An institutional shunt database was queried to identify all shunt surgeries performed from January 1, 2010, to December 31, 2014, at Le Bonheur Children's Hospital. Patients' records were reviewed for 90 days following each “index” shunt surgery to identify those patients who required a return to the operating room. Clinical, demographic, and radiological factors were reviewed for each index operation, and each failure was analyzed for potentially preventable causes.

RESULTS

During the study period, there were 927 de novo or revision shunt operations in 525 patients. A return to the operating room occurred 202 times within 90 days of shunt surgery in 927 index surgeries (21.8%). In 67 cases (33% of failures), the revision surgery was due to potentially preventable causes, defined as inaccurate proximal or distal catheter placement, infection, or inadequately secured or assembled shunt apparatus. Comparing cases in which failure was due to preventable causes and those in which it was due to nonpreventable causes showed that in cases in which failure was due to preventable causes, the patients were significantly younger (median 3.1 vs 6.7 years, p = 0.01) and the failure was more likely to occur within 30 days of the index surgery (80.6% vs 64.4% of cases, p = 0.02). The most common causes of preventable shunt failure were inaccurate proximal catheter placement (33 [49.3%] of 67 cases) and infection (28 [41.8%] of 67 cases). No variables were found to be predictive of preventable shunt failure with multivariate logistic regression.

CONCLUSIONS

With economic and governmental pressures to identify and implement “quality measures” for shunt surgery, pediatric neurosurgeons and hospital administrators must be careful to avoid linking all shunt revisions with “poor” or less-than-optimal quality care. To date, many of the purported risk factors for shunt failure and causes of shunt revision surgery are beyond the influence and control of the surgeon. We propose the PSRR as a specific, meaningful, measurable, and—hopefully—modifiable quality metric for shunt surgery in children.

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Michael DeCuypere, Michael S. Muhlbauer, Frederick A. Boop and Paul Klimo Jr.

OBJECTIVE

Penetrating brain injury in civilians is much less common than blunt brain injury but is more severe overall. Gunshot wounds (GSWs) cause high morbidity and mortality related to penetrating brain injury; however, there are few reports on the management and outcome of intracranial GSWs in children. The goals of this study were to identify clinical and radiological factors predictive for death in children and to externally validate a recently proposed pediatric prognostic scale.

METHODS

The authors conducted a retrospective review of penetrating, isolated GSWs sustained in children whose ages ranged from birth to 18 years and who were treated at 2 major metropolitan Level 1 trauma centers from 1996 through 2013. Several standard clinical, laboratory, and radiological factors were analyzed for their ability to predict death in these patients. The authors then applied the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a scoring algorithm that was designed to provide rapid prognostic information for emergency management decisions. The scale's sensitivity, specificity, and positive and negative predictability were determined, with death as the primary outcome.

RESULTS

Seventy-one children (57 male, 14 female) had a mean age of 14 years (range 19 months to 18 years). Overall mortality among these children was 47.9%, with 81% of survivors attaining a favorable clinical outcome (Glasgow Outcome Scale score ≥ 4). A number of predictors of mortality were identified (all p < 0.05): 1) bilateral fixed pupils; 2) deep nuclear injury; 3) transventricular projectile trajectory; 4) bihemispheric injury; 5) injury to ≥ 3 lobes; 6) systolic blood pressure < 100 mm Hg; 7) anemia (hematocrit < 30%); 8) Glasgow Coma Scale score ≤ 5; and 9) a blood base deficit < −5 mEq/L. Patient age, when converted to a categorical variable (0–9 or 10–18 years), was not predictive. Based on data from the 71 patients in this study, the positive predictive value of the St. Louis scale in predicting death (score ≥ 5) was 78%.

CONCLUSIONS

This series of pediatric cranial GSWs underscores the importance of the initial clinical exam and CT studies along with adequate resuscitation to make the appropriate management decision(s). Based on our population, the St. Louis Scale seems to be more useful as a predictor of who will survive than who will succumb to their injury.

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Abhaya V. Kulkarni

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Paul Klimo Jr., L. Madison Michael II, Garrett T. Venable and Douglas R. Taylor

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Kyle A. Smith and Morgan B. Glusman

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Nicholas B. Rossi, Nickalus R. Khan, Tamekia L. Jones, Jacob Lepard, Joseph H. McAbee and Paul Klimo Jr.

OBJECT

Ventricular shunts for pediatric hydrocephalus continue to be plagued with high failure rates. Reported risk factors for shunt failure are inconsistent and controversial. The raw or global shunt revision rate has been the foundation of several proposed quality metrics. The authors undertook this study to determine risk factors for shunt revision within their own patient population.

METHODS

In this single-center retrospective cohort study, a database was created of all ventricular shunt operations performed at the authors’ institution from January 1, 2010, through December 2013. For each index shunt surgery, demographic, clinical, and procedural variables were assembled. An “index surgery” was defined as implantation of a new shunt or the revision or augmentation of an existing shunt system. Bivariate analyses were first performed to evaluate individual effects of each independent variable on shunt failure at 90 days and at 180 days. A final multivariate model was chosen for each outcome by using a backward model selection approach.

RESULTS

There were 466 patients in the study accounting for 739 unique (“index”) operations, for an average of 1.59 procedures per patient. The median age for the cohort at the time of the first shunt surgery was 5 years (range 0–35.7 years), with 53.9% males. The 90- and 180-day shunt failure rates were 24.1% and 29.9%, respectively. The authors found no variable—demographic, clinical, or procedural—that predicted shunt failure within 90 or 180 days.

CONCLUSIONS

In this study, none of the risk factors that were examined were statistically significant in determining shunt failure within 90 or 180 days. Given the negative findings and the fact that all other risk factors for shunt failure that have been proposed in the literature thus far are beyond the control of the surgeon (i.e., nonmodifiable), the use of an institution’s or individual’s global shunt revision rate remains questionable and needs further evaluation before being accepted as a quality metric.

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Garrett T. Venable, Brandon A. Shepherd, Christopher M. Loftis, S. Gray McClatchy, Mallory L. Roberts, Meghan E. Fillinger, James B. Tansey and Paul Klimo Jr.

OBJECT

Bradford’s law describes the scatter of citations for a given subject or field. It can be used to identify the most highly cited journals for a field or subject. The objective of this study was to use currently accepted formulations of Bradford’s law to identify core journals of neurosurgery and neurosurgical subspecialties.

METHODS

All original research publications from 2009 to 2013 were analyzed for the top 25 North American academic neurosurgeons from each subspecialty. The top 25 were chosen from a ranked career h-index list identified from previous studies. Egghe’s formulation and the verbal formulation of Bradford’s law were applied to create specific citation density zones and identify the core journals for each subspecialty. The databases were then combined to identify the core journals for all of academic neurosurgery.

RESULTS

Using Bradford’s verbal law with 4 zone models, the authors were able to identify the core journals of neurosurgery and its subspecialties. The journals found in the most highly cited first zone are presented here as the core journals. For neurosurgery as a whole, the core included the following journals: Journal of Neurosurgery, Neurosurgery, Spine, Stroke, Neurology, American Journal of Neuroradiology, International Journal of Radiation Oncology Biology Physics, and New England Journal of Medicine. The core journals for each subspecialty are presented in the manuscript.

CONCLUSIONS

Bradford’s law can be used to identify the core journals of neurosurgery and its subspecialties. The core journals vary for each neurosurgical subspecialty, but Journal of Neurosurgery and Neurosurgery are among the core journals for each neurosurgical subspecialty.