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Martin M. Mortazavi, R. Shane Tubbs, Maja Andrea Brockerhoff, Marios Loukas and W. Jerry Oakes

Few are familiar with the neurological contributions of the German pathologist Theodor Langhans. Even fewer are aware of his significant and early contributions to the study of what is now known as the Chiari I malformation. In at least 4 cases, Langhans described the association between tonsillar ectopia and syringomyelia. Moreover, this early pioneer speculated that there was a cause and effect with hindbrain herniation resulting in improper flow at the craniocervical junction and consequent development of syringomyelia. These cases were reported prior to Hans Chiari's descriptions, and Langhans' theory of impeded foramen magnum flow as a cause of syringomyelia was novel and preceded the current understanding of this mechanism by almost a century. The authors discuss the life of Langhans and translate excerpts from his 1881 work regarding tonsillar ectopia and syringomyelia.

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R. Shane Tubbs, Joshua Beckman, Robert P. Naftel, Joshua J. Chern, John C. Wellons III, Curtis J. Rozzelle, Jeffrey P. Blount and W. Jerry Oakes

Object

The diagnosis and treatment of Chiari malformation Type I (CM-I) has evolved over the last few decades. The authors present their surgical experience of over 2 decades of treating children with this form of hindbrain herniation.

Methods

The authors conducted a retrospective review of their institutional experience with the surgical treatment of the pediatric CM-I from 1989 to 2010.

Results

The 2 most common presentations were headache/neck pain (40%) and scoliosis (18%). Common associated diagnoses included neurofibromatosis Type 1 (5%) and idiopathic growth hormone deficiency (4.2%). Spine anomalies included scoliosis (18%), retroversion of the odontoid process (24%), Klippel-Feil anomaly (3%), and atlantooccipital fusion (8%). Approximately 3% of patients had a known family member with CM-I. Hydrocephalus was present in 48 patients (9.6%). Syringomyelia was present in 285 patients (57%), and at operation, 12% of patients with syringomyelia were found to have an arachnoid veil occluding the fourth ventricular outlet. Fifteen patients (3%) have undergone reoperation for continued symptoms or persistent large syringomyelia. The most likely symptoms and signs to resolve following surgery were Valsalva-induced headache and syringomyelia. The average hospital stay and “return to school” time were 3 and 12 days, respectively. The follow-up for this group ranged from 2 months to 15 years (mean 5 years). Complications occurred in 2.4% of cases; there was no mortality. No patient required acute return to the operating room, and no blood transfusions were performed.

Conclusions

The authors believe this to be the largest reported series of surgically treated pediatric CM-I patients and hope that their experience will be of use to others who treat this surgical entity.

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Martin M. Mortazavi, R. Shane Tubbs, Daniel Harmon and W. Jerry Oakes

Chronic emesis may result from a variety of causes. To the authors' knowledge, compression of the area postrema by regional vessels resulting in chronic emesis has not been reported.

The authors report on a child who presented with chronic medically intractable emesis and significant weight loss requiring jejunostomy feeding. Surgical exploration of the posterior cranial fossa found unilateral compression of the area postrema by the posterior inferior cerebellar artery. Microvascular decompression resulted in postoperative and long-term resolution of the patient's emesis.

Although apparently very rare, irritation of the area postrema from the posterior inferior cerebellar artery with resultant medically intractable chronic emesis may occur. Therefore, the clinician should be aware of this potential etiology when dealing with such patients.

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R. Shane Tubbs, Mohammadali M. Shoja, Marios Loukas, W. Jerry Oakes and Aaron Cohen-Gadol

William Henry Battle (1855–1936) practiced medicine in England > 1 century ago and is primarily remembered for his description of ecchymosis over the mastoid, which indicates fracture of the skull base. Although Mr. Battle made many contributions to medicine, almost nothing exists in the literature regarding his life and findings, especially in regard to head injury. The following is a review of Battle's background and his contributions to medicine, specifically his observations associated with basilar skull fractures.

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John C. Wellons III, Chevis N. Shannon, Abhaya V. Kulkarni, Tamara D. Simon, Jay Riva-Cambrin, William E. Whitehead, W. Jerry Oakes, James M. Drake, Thomas G. Luerssen, Marion L. Walker, John R. W. Kestle and for the Hydrocephalus Clinical Research Network

Object

The purpose of this study was to define the incidence of permanent shunt placement and infection in patients who have undergone the 2 most commonly performed temporizing procedures for posthemorrhagic hydrocephalus (PHH) of prematurity: ventriculosubgaleal (VSG) shunt placement and ventricular reservoir placement for intermittent tapping.

Methods

The 4 centers of the Hydrocephalus Clinical Research Network participated in a retrospective chart review of infants with PHH who underwent treatment at each institution between 2001 and 2006. Patients were included if they had received a diagnosis of Grade 3 or 4 intraventricular hemorrhage, weighed < 1500 g at birth, and had received surgical intervention. The authors determined the incidence of conversion from a temporizing device to a permanent shunt, the incidence of CSF infection during temporization, and the 6-month CSF infection rate after permanent shunt placement.

Results

Thirty-one (86%) of 36 patients who received VSG shunts and 61 (69%) of 88 patients who received ventricular reservoirs received permanent CSF diversion with a shunt (p = 0.05). Five patients (14%) in the VSG shunt group had CSF infections during temporization, compared with 11 patients (13%) in the ventricular reservoir group (p = 0.83). The 6-month incidence of permanent shunt infection in the VSG shunt group was 16% (5 of 31), compared with 12% (7 of 61) in the reservoir placement group (p = 0.65). For the first 6 months after permanent shunt placement, infants with no preceding temporizing procedure had an infection rate of 5% (1 of 20 infants) and those who had undergone a temporizing procedure had an infection rate of 13% (12 of 92; p = 0.45).

Conclusions

The use of intermittent tapping of ventricular reservoirs in this population appears to lead to a lower incidence of permanent shunt placement than the use of VSG shunts. The incidence of infection during temporization and for the initial 6 months after conversion appears comparable for both groups. The apparent difference identified in this pilot study requires confirmation in a more rigorous study.

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, Ghaffar Shokouhi, John C. Wellons III, W. Jerry Oakes and Aaron A. Cohen-Gadol

Object

Various donor nerves, including the ipsilateral long thoracic nerve (LTN), have been used for brachial plexus neurotization procedures. Neurotization to proximal branches of the brachial plexus using the contralateral long thoracic nerve (LTN) has, to the authors' knowledge, not been previously explored.

Methods

In an attempt to identify an additional nerve donor candidate for proximal brachial plexus neurotization, the authors dissected the LTN in 8 adult human cadavers. The nerve was transected at its distal termination and then passed deep to the clavicle and axillary neurovascular bundle. This passed segment of nerve was then tunneled subcutaneously and contralaterally across the neck to a supra- and infraclavicular exposure of the suprascapular and musculocutaneous nerves. Measurements were made of the length and diameter of the LTN.

Results

All specimens were found to have a LTN that could be brought to the aforementioned contralateral nerves. Neural connections remained tension free with left and right neck rotation of ~ 45°. The mean length of the LTN was 22 cm with a range of 18–27 cm. The overall mean diameter of this nerve was 3.0 mm. No gross evidence of injury to surrounding neurovascular structures was identified in any specimen.

Conclusions

Based on the results of this cadaveric study, the use of the contralateral LTN may be considered for neurotization of the proximal musculocutaneous and suprascapular nerves.

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, Mohammad Ardalan and W. Jerry Oakes

The 11th century was culturally and medicinally one of the most exciting periods in the history of Islam. Medicine of this day was influenced by the Greeks, Indians, Persians, Coptics, and Syriacs. One of the most prolific writers of this period was Ibn Jazlah, who resided in Baghdad in the district of Karkh. Ibn Jazlah made many important observations regarding diseases of the brain and spinal cord. These contributions and a review of the life and times of this early Muslim physician are presented.

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, Mohammad R. Ardalan, Nihal Apaydin, Candice Myers, Ghaffar Shokouhi and W. Jerry Oakes

Object

The intradural contributions of the C-4 nerve rootlets have not been previously evaluated for their connections to the brachial plexus. The authors undertook a cadaveric study to evaluate the C-4 contributions to the upper trunk of the brachial plexus.

Methods

The posterior cervical triangles from 60 adult cadavers were dissected. All specimens that were found to have extradural C-4 contributions to the upper trunk of the brachial plexus were excluded from further study. In specimens found to have no extradural C-4 contributions to the brachial plexus a C1–T1 laminectomy was performed. Observations were made of any neural communications between adjacent spinal rootlets, specifically between C-4 and C-5.

Results

Nine (15%) of the 60 sides were found to have extradural C-4 contributions to the upper trunk of the brachial plexus. These sides were excluded from further study. No specimen was found to have a postfixed brachial plexus. Of the remaining 51 sides, 11 (21.6%) were found to have intradural neural connections between C-4 and C-5 dorsal rootlets and 1 (1.96%) had a connection between the ventral roots of C-4 and C-5. Communications between these 2 adjacent dorsal cervical cord levels were of 3 types. Type I was a vertical communication between the more horizontally traveling dorsal roots. Type II was a forked communication between adjacent C-4 and C-5 dorsal rootlets. The Type III designation was applied to connections between ventral rootlets. Although communications were slightly more frequent on left sides, this did not reach statistical significance.

Conclusions

In ~ 20% of normally composed brachial plexuses (those with extradural contributions from only C5–T1) we found intradural C4–5 neural connections. Such variations may lead to misinterpretation of spinal levels in pathological conditions of the spinal axis and should be considered in surgical procedures of this region, such as rhizotomy.

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R. Shane Tubbs, William A. Shaffer, Marios Loukas, Mohammadali M. Shoja and W. Jerry Oakes

Object

Injury of the facial nerve with resultant facial muscle paralysis may result in other significant complications such as corneal ulceration. To the authors' knowledge, neurotization to the facial nerve using the long thoracic nerve (LTN), a nerve used previously for neurotization to other branches of the brachial plexus, has not been explored previously.

Methods

In an attempt to identify an additional nerve donor candidate for facial nerve neurotization, 8 adult human cadavers (16 sides) underwent dissection of the LTN, which was passed deep to the clavicle and axillary neurovascular bundle. The facial nerve was localized from the stylomastoid foramen onto the face, and the distal cut end of the previously dissected LTN was tunneled to this location. Measurements were made of the length and diameter of the LTN. Long thoracic nerve innervation to the first and second digitations of the serratus anterior was maintained on all sides.

Results

All specimens were found to have an LTN with more than enough length to be tunneled superiorly, tension-free to the extracranial facial nerve. Connections remained tensionless with left and right head rotation of up to 45°. The mean length of this part of the LTN was 18 cm with a range of 15–22 cm. The overall mean diameter of this nerve was 2.5 mm. No evidence of injury to the surrounding neurovascular structures was identified on gross examination.

Conclusions

To the authors' knowledge, the LTN has not been previously examined as a donor nerve for facial nerve reanimation procedures. Based on the results of this cadaveric study, the use of the LTN may be considered for such surgical maneuvers.

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W. Jerry Oakes