Roberto C. Heros
Andrew S. Ferrell, R. Shane Tubbs, Leslie Acakpo-Satchivi, John P. Deveikis and Mark R. Harrigan
Foix-Alajouanine syndrome has become a well-known entity since its initial report in 1926. The traditional understanding of this clinical syndrome is as a progressive spinal cord venous thrombosis related to a spinal vascular lesion, resulting in necrotic myelopathy. However, spinal venous thrombosis is extremely rare and not a feature of any common spinal vascular syndrome. A translation and review of the original 42-page French report revealed 2 young men who had presented with progressive and unrelenting myelopathy ultimately leading to their deaths. Pathological analysis demonstrated endomesovasculitis of unknown origin, including vessel wall thickening without evidence of luminal narrowing, obliteration of cord vessels, or thrombosis. Foix and Alajouanine also excluded the presence of intramedullary arteriovenous malformations. At the time, dural arteriovenous fistulas (dAVFs) had not been described, and therefore this type of lesion was not specifically sought. In retrospect, it seems possible that both patients had progressive myelopathy due to Type I dAVFs. In the decades since that original report, numerous authors have included spinal cord venous thrombosis as a central feature of Foix-Alajouanine syndrome. The inclusion of thrombosis in the clinical picture of this syndrome is not only incorrect but may leave one with the impression of therapeutic futility, thus possibly preventing successful surgical or endovascular therapy.
Leslie Acakpo-Satchivi, R. Shane Tubbs, Audie L. Woolley, Cuong J. Bui, Peter Liechty, Yuki Hammers, John Wellons III, Jeffrey P. Blount and W. Jerry Oakes
R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, Robert J. Spinner, Erik H. Middlebrooks, William R. Stetler Jr., Leslie Acakpo-Satchivi, John C. Wellons III, Jeffrey P. Blount and W. Jerry Oakes
The suprascapular nerve may become entrapped as it travels deep to the suprascapular ligament, necessitating decompression. The present study was performed to verify the feasibility of a minimally invasive, endoscopically assisted technique for decompressing the suprascapular nerve in the supraspinous fossa.
The authors performed dissection and decompression of the suprascapular ligament using an endoscopically assisted technique via a 3-cm skin incision in 10 adult cadavers (20 sides). Measurements were also made of the depth from the skin to the suprascapular ligament.
A mean depth of 4 cm was necessary to reach the suprascapular ligament from the skin surface. With the authors' approach, no obvious injury occurred to the suprascapular or other vicinal neurovascular structures (such as the spinal accessory nerve and suprascapular vessels).
The results of this cadaveric study demonstrate that access to the suprascapular nerve can be obtained endoscopically via a small suprascapular incision. This approach obviates a large incision, entry into the glenohumeral joint, and reduces the risk of spinal accessory nerve injury in the posterior cervical triangle, or atrophy of the trapezius or supraspinatus muscles from a standard larger dissection. To the authors' knowledge an endoscopically assisted approach to decompressing the suprascapular nerve as it courses deep to the suprascapular ligament has not been reported previously.
Cuong J. Bui, R. Shane Tubbs, Gigi Pate, Traci Morgan, Douglas C. Barnhart, Leslie Acakpo-Satchivi, John C. Wellons III, W. Jerry Oakes and Jeffrey P. Blount
There is conflicting information in the literature regarding the increased risk of ventriculoperitoneal (VP) shunt infection after abdominal surgical procedures such as gastrostomy tube (GT) placement and Nissen fundoplication (NF) in the young patient. To further elucidate this potential association, the authors reviewed their institutional experience with such cases.
The authors retrospectively reviewed the records of all patients with shunted hydrocephalus who also underwent NF procedures and/or GT placements over a 9-year period.
During this 9-year period, 3065 cerebrospinal fluid (CSF) shunts were placed and 1630 NF procedures/GT placements were performed. Ninety-six patients were identified who received both a CSF shunt and NF procedures/GT placements. Seventy-nine patients had a functioning VP shunt (without recent [< 6 months] CSF infection or shunt revision) at the time of their abdominal procedure (NF procedure or GT placement). Of this latter cohort, there were 38 males and 41 females with a mean age of 6.4 months; 12.7% of these patients developed a shunt infection and 60% of these infections were due to Staphylococcus species.
Based on this study, an NF procedure/GT placement in a child with a VP shunt appears to carry approximately the same risk of shunt infection as a shunt placement operation. Moreover, the microbiology observed in these patients with infection did not differ significantly from the usual microorganisms responsible for VP shunt infections in infants/neonates. Finally, but not conclusively, an open NF procedure/GT placement may carry a higher infection risk than a laparoscopic-assisted NF procedure/GT placement.
Jeffrey P. Blount, R. Shane Tubbs, John C. Wellons III, Leslie Acakpo-Satchivi, David Bauer and W. Jerry Oakes
✓ In certain highly selected circumstances, division of a distally nonfunctional or dysfunctional cord can be a means of definitive untethering that spares and protects more rostral neurological function and results in definitive untethering. The authors reviewed their institutional experience with such cases and evaluated the limited literature. Based on their experience, treatment can be effective in carefully selected patients who undergo spinal cord transection, and the rate of repetitive tethered spinal cord can be decreased. Although uncommon, spinal cord transection appears to be an effective therapy in carefully selected patents with symptoms of repetitive cord tethering.
R. Shane Tubbs, Marios Loukas, Robert G. Louis Jr., Mohammadali M. Shoja, Leslie Acakpo-Satchivi, Jeffrey P. Blount, E. George Salter, W. Jerry Oakes and John C. Wellons III
The superior and inferior sagittal sinuses have been well studied. Interestingly, other venous structures within the falx cerebri have received scant attention in the medical literature. The present study was performed to elucidate the presence and anatomy of these midline structures.
The authors examined 27 adult latex- or ink-injected cadaveric specimens to observe the morphological features of the sinuses within the falx cerebri (excluding the inferior and superior sagittal sinuses).
All specimens were found to have an extensive network of small tributaries within the falx cerebri that were primarily concentrated in its posterior one third. In this posterior segment, these structures were usually more pronounced in the inferior two thirds. The portion of the falx cerebri not containing significant falcine venous sinus was termed a “safe area.” These vascular channels ranged in size from 0.5 mm to 1.1 cm (mean 0.6 mm); 100% of these vessels communicated with the inferior sagittal sinus. Classification of the structures was then performed based on communication of the falcine venous sinus with the superior sagittal sinus. Type I falcine sinuses had no communication with the superior sagittal sinus, Type II falcine sinuses had limited communication with the superior sagittal sinus, and Type III falcine sinuses had significant communication with the superior sagittal sinus. Seventeen (63%) of 27 specimens communicated with the superior sagittal sinus (Types II and III). Further subdivision revealed 10 Type I, seven Type II, and 10 Type III falcine venous plexuses.
There are other venous sinuses in the falx cerebri in addition to the superior and inferior sagittal sinuses. Neurosurgical procedures that necessitate incising or puncturing the falx cerebri can be done more safely via a described safe area. Given that the majority of specimens in the authors' study were found to have a plexiform venous morphology within the falx cerebri, they propose that these channels be referred to as the falcine venous plexus and not sinus. The falcine venous plexus should be taken into consideration by the neurosurgeon.
Cuong J. Bui, R. Shane Tubbs, Chevis N. Shannon, Leslie Acakpo-Satchivi, John C. Wellons III, Jeffrey P. Blount and W. Jerry Oakes
There is scant literature regarding the long-term outcome in patients with cranial vault encephaloceles, and what literature there is may underestimate long-term deficits. The goal of this study was to address this lack of information.
The authors performed a retrospective chart review of cranial vault encephaloceles performed at our institution between 1989 and 2003. Fifty-two total patients were identified and 44 of these cases were reviewed. Additionally, 34 of the 44 patients were contacted and given an outcome survey (Hydrocephalus Outcome Questionnarie [HOQ]) to evaluate physical, emotional, cognitive, and overall health outcomes.
The mean age for patients in this cohort was 9.6 years (range 4–17 years) and the mean follow-up time was 9.2 years. There was an equal sex distribution and there were no deaths. Hydrocephalus was found in 60% of occipital and 14% of frontal encephaloceles, and epilepsy was confirmed in 17% of occipital and 7% of frontal lesions. Outcome assessments performed using the HOQ showed that 50% of the patients with occipital encephaloceles had overall HOQ health scores of 0.5 or less and 55% had HOQ cognitive scores of 0.3 or less, compared with 0% of patients in both categories who had frontal encephaloceles. It was also found that the presence of hydrocephalus and epilepsy independently and significantly lowered the overall health scores.
Occipital encephaloceles carry a worse prognosis than frontal encephaloceles, with higher rates of hydrocephalus and seizure. Based on this study, the presence of hydrocephalus and epilepsy are significant additive adverse prognostic factors. Approximately half of the patients with occipital encephaloceles will be severely debilitated and will probably be unable to live and function independently in society. These data may be useful to clinicians in counseling patients and predicting long-term outcome following repair of cranial vault encephaloceles.
R. Shane Tubbs, Charles Law, Drew Davis, Mohammadali M. Shoja, Leslie Acakpo-Satchivi, John C. Wellons III, Jeffrey P. Blount and W. Jerry Oakes
Postoperative epidural morphine is commonly used to control pain in children following dorsal rhizotomy for spasticity. The authors report their experience in using a regimen of scheduled minor analgesic drugs to manage postoperative pain, with the goal of avoiding opiate use following a spinal intradural procedure.
Postoperative pain scores were analyzed in a group of 22 children who underwent a partial dorsal rhizotomy. According to a preestablished standard regimen for postoperative pain control after dorsal rhizotomy, in each patient an intraoperative epidural catheter was placed for the potential infusion of postoperative morphine. Additionally, this cohort underwent a scheduled regimen of acetaminophen (10 mg/kg) and ibuprofen (10 mg/kg), alternating every 2 hours. For comparison, a retrospective chart review was performed in 20 patients with rhizotomies completed prior to the use of this oral analgesic protocol.
Only one patient received a postoperative dose of morphine epidurally. None of the remaining patients required postoperative epidural morphine for pain control. Pain scores were significantly lower in this group compared with a retrospective review of patients treated according to the standard regimen. Length of hospital stay was shorter in these patients and antiemetic requirements were lower.
A regimen of minor analgesic therapy, when given in alternating doses every 2 hours immediately after partial dorsal rhizotomy for spasticity and throughout hospitalization, significantly reduced postoperative pain scores, hospitalization, and antiemetic requirements in these patients.
R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, Leslie Acakpo-Satchivi, John C. Wellons III, Jeffrey P. Blount and W. Jerry Oakes
Facial nerve injury with resultant facial muscle paralysis is disfiguring and disabling. Reanimation of the facial nerve has been performed using different regional nerves. The nerve to the mylohyoid has not been previously explored as a donor nerve for facial nerve reanimation procedures.
Five fresh adult human cadavers (10 sides) were dissected to identify an additional nerve donor candidate for facial nerve neurotization. Using a curvilinear cervicofacial skin incision, the nerve to the mylohyoid and facial nerve were identified. The nerve to the mylohyoid was transected at its point of entrance into the anterior belly of the digastric muscle. Measurements were made of the length and diameter of the nerve to the mylohyoid, and this nerve was repositioned superiorly to the various temporofacial and cervicofacial parts of the extracranial branches of the facial nerve.
All specimens had a nerve to the mylohyoid. The mean length of this nerve available inferior to the mandible was 5.5 cm and the mean diameter was 1 mm. In all specimens, the nerve to the mylohyoid reached the facial nerve stem and the temporofacial and cervicofacial trunks without tension. No gross evidence of injury to surrounding neurovascular structures was identified.
To the authors' knowledge, the use of the nerve to the mylohyoid for facial nerve reanimation has not been explored previously. Based on the results of this cadaveric study, the use of the nerve to the mylohyoid may be considered for facial nerve reanimation procedures.