Browse

You are looking at 101 - 107 of 107 items for

  • By Author: Wellons, John C. x
Clear All
Restricted access

Matthew D. Smyth, Jason T. Banks, R. Shane Tubbs, John C. Wellons III and W. Jerry Oakes

Object. The authors performed a study to evaluate the efficacy of a regimen of scheduled minor analgesic medications in managing postoperative pain in children undergoing intracranial procedures.

Methods. Postoperative pain scores were analyzed in two groups of children who underwent decompressive surgery for Chiari malformation: Group A underwent a scheduled regimen of minor oral analgesic medications (standing doses of acetaminophen [10 mg/kg] and ibuprofen [10 mg/kg] alternating every 2 hours) and Group B received analgesic medication when requested.

Fifty children underwent a standard occipital craniectomy (25 in each group). The pain scores were significantly lower in Group A during most of the postoperative period. Length of stay (LOS) was shorter (2.2 compared with 2.8 days), and narcotic and antiemetic requirements were also lower in Group A patients than in Group B patients. Patients with spinal cord syringes exhibited a similar postoperative status to those without, and similar improvements in pain scores with scheduled minor analgesic medications were also evident.

Conclusions. A regimen of minor analgesic therapy, given in alternating doses every 2 hours immediately after craniotomy and throughout hospitalization, significantly reduced postoperative pain scores and LOS in children in whom suboccipital craniotomy was performed. Narcotic and antiemetic requirements were also decreased in association with this regimen. Application of this postoperative analgesia protocol may benefit children and adults in whom various similar neurosurgical procedures are required.

Restricted access

R. Shane Tubbs, John C. Wellons III, Bermans J. Iskandar and W. Jerry Oakes

Object. Historically, cutaneous stigmata representative of occult spinal dysraphism (OSD) have included lumbar hemangiomas. Frequently, this skin change is found in conjunction with other cutaneous alterations such as dermal sinus tracts and subcutaneous lipomas. Debate has recently surrounded the question of whether these skin changes in isolation might indicate underlying spinal disease. The authors reviewed their experience in their most recent 120 cases in which OSD was diagnosed.

Methods. The authors retrospectively reviewed records obtained in 120 patients with OSD. They found that many of the patients reviewed harbored only a flat capillary hemangioma as an indicator of OSD. In 21 patients (17.5%) with only midline lumbosacral flat capillary hemangiomas, underlying OSD was present. No single variety of OSD had a higher incidence of association with this single cutaneous stigma.

Conclusions. Based on their experience, the authors recommend magnetic resonance (MR) imaging evaluation in cases involving this skin lesion in isolation to discern the potential for surgically significant spinal cord anomalies. Prospective studies are now needed to examine MR images obtained in all children with this lesion in the midline lumbosacral spine and assess for OSD.

Restricted access

Joseph H. Piatt Jr.

Restricted access

R. Shane Tubbs, Matthew D. Smyth, John C. Wellons III, Jeffrey P. Blount, Paul A. Grabb and W. Jerry Oakes

Object. To the best of the authors' knowledge, no quantitative analysis of the atlantoaxial interlaminar distance in flexion (ILD) in children exists in the medical literature. In this study they sought to determine the age-matched relationship between the posterior elements of the atlas and axis in children in cervical spine flexion, to be used as an adjunct to the atlantodental interval in common clinical use.

Methods. Lateral radiographs of the cervical spine in full flexion were analyzed in 74 children. The atlantoaxial ILD was defined as the distance between a midpoint of the anterior cortices of the atlantal and axial posterior arches.

The mean ILD for the entire group was 19 mm (range 8–30 mm). No significant difference was seen between male and female patients (p = 0.084). When stratified by age, the mean ILD was 12.3 ± 3 mm (15 cases) in children age 3 years or younger and 20.5 ± 4.7 mm (59 cases) in children age older than 3 years. Further stratification of the groups yielded a mean ILD of 10.4 ± 1.4 [eight cases]) in children age 1 to 2 years, and 14.4 ± 4.7 mm (seven cases) in children age 3 years. In children older than 3 years of age the mean ILD was consistently approximately 20 ± 5 mm regardless of age.

Conclusions. Rapid, safe, and accurate diagnosis of the cervical spine is essential in critical care. Knowledge of the distance between the posterior elements of the atlas and axis in flexion should enhance the clinicians' (those who clear cervical spines) ability to diagnose accurately atlantoaxial instability on lateral radiographs obtained in flexion.

Restricted access

R. Shane Tubbs, John C. Wellons III, Jeffrey P. Blount, Paul A. Grabb and W. Jerry Oakes

Object. The quantitative analysis of odontoid process angulation has had scant attention in the Chiari I malformation population. In this study the authors sought to elucidate the correlation between posterior angulation of the odontoid process and patients with Chiari I malformation.

Methods. Magnetic resonance images of the craniocervical junction obtained in 100 children with Chiari I malformation and in 50 children with normal intracranial anatomy (controls) were analyzed. Specific attention was focused on measuring the degree of angulation of the odontoid process and assigning a score to the various degrees. Postoperative outcome following posterior cranial fossa decompression was then correlated to grades of angulation. Other measurements included midsagittal lengths of the foramen magnum and basiocciput, the authors' institutions' previously documented pB—C2 line (a line drawn perpendicular to one drawn between the basion and the posterior aspect of the C-2 body), level of the obex from a midpoint of the McRae line, and the extent of tonsillar herniation.

Higher grades of odontoid angulation (retroflexion) were found to be more frequently associated with syringomyelia and particularly holocord syringes. Higher grades of angulation were more common in female patients and were often found to have obices that were caudally displaced greater than three standard deviations below normal.

Conclusions. These results not only confirm prior reports of an increased incidence of a retroflexed odontoid process in Chiari I malformation but quantitatively define grades of inclination. Grades of angulation were not found to correlate with postoperative outcome. It is the authors' hopes that these data add to our current limited understanding of the mechanisms involved in hindbrain herniation.

Restricted access

R. Shane Tubbs, John C. Wellons III, Jason Banks, Jeffrey P. Blount and W. Jerry Oakes

Object. The medial tubercles of the atlas serve as the attachments of the transverse ligament and provide an important anchoring site for which no discussion of their fine anatomy is published in the literature. In this study the authors examine this anatomy along with its osseous relationships.

Methods. One hundred dry cadaveric atlantal tubercles were assessed for size and relationship to nearby anatomical osseous structures. In addition, eight cadaveric specimens were evaluated for their anatomy in this area.

All specimens exhibited atlantal tubercles for the attachment of the transverse portion of the cruciate ligament of the atlas. Right-sided tubercles tended to be of a larger caliber. Overall, right-sided vertical distances between these tubercles and the superior articular facets and inferior articular facets were greater, although distances from each tubercle to the lateral margin of the dental facets anteriorly were found to be constant, as were intertubercular distances. The mean angle formed between both tubercles and the dental facet was 75°.

Conclusions. The data derived in this study should be useful to the clinician for whom the craniocervical junction is a vital anatomical area.

Restricted access

R. Shane Tubbs, John C. Wellons III, Jeffrey P. Blount and W. Jerry Oakes

✓ The authors describe the use of autogenetic posterior atlantooccipital (PAO) membrane for duraplasty following after posterior cranial fossa surgery. The PAO membrane is routinely exposed for procedures of the posterior cranial fossa and merely needs to be dissected free of the underlying dura mater. Recently this membrane was obtained in several pediatric patients following procedures of the posterior cranial fossa such as duraplasty in case of Chiari I malformation. No postoperative complications were found at 6-month follow-up examination. The advantages of this intervention include less manipulation of muscle and fascia than that involved in other procedures and, therefore, seemingly less postoperative pain and the negation of issues inherent with foreign-body graft sources. The authors believe this structure to be of use as a dural substitute in small dural openings of the posterior cranial fossa.