External hydrocephalus has been associated with subdural hematomas in infancy, and the hematomas have been noted to be secondary to minor trauma or have even been described as spontaneous. The author reports the case of an infant with external hydrocephalus who developed retinal as well as subdural hemorrhages after sustaining a minor head injury. Although retinal hemorrhage in infancy has been considered virtually pathognomonic of child abuse, in the setting of external hydrocephalus a more cautious interpretation may be appropriate.
Joseph H. Piatt Jr.
A rule for identifying patients with traumatic brain injury (TBI) who are at exceptionally low risk of cervical spine injury might be clinically useful. The goal in this study was to research case records to determine whether such a rule would be practicable.
The Pennsylvania Trauma Outcomes Study database was used to find patients with TBI in whom Glasgow Coma Scale (GCS) scores at admission were 8 or less. Cases of cervical spine injury were identified from diagnostic codes. Associations between these injuries and a variety of clinical variables were tested using chi-square analysis. The probability of a cervical spine injury in these patients was modeled by logistic regression. Decision tree models were constructed and statistical determinants of overlooked cervical spine injury were examined.
The prevalence of cervical spine injury among 41,142 cases of TBI was 8%. The mechanism of injury, presence of thoracolumbosacral (TLS) spinal, limb and/or facial fracture, patient age, GCS score at admission, and the presence of hypotension were all factors associated with cervical spine injury. These were incorporated into the following logistic regression model: probability of cervical spine injury = 1/(1 + exp[4.030 − 0.417*mechanism − 0.264*age − 0.678*TLS − 0.299*limb + 0.218*GCS score − 0.231*hypotension − 0.157*facial]).
This model yielded a rule for clearance of 28% of cases, with a negative predictive value (NPV) of 97%. Decision tree analysis yielded an easily stated rule for clearance of 24% of cases, with an NPV of 98.2%. The prevalence of overlooked cervical spine injury among all patients with severe TBI was 0.3%; the prevalence of overlooked cervical spine injury among patients in whom it was later diagnosed was 3.9%. Overlooked cervical spine injury was less common among patients with associated TLS fractures (odds ratio 0.453, 95% confidence interval 0.245–0.837).
No acceptable rule for relaxation of vigilance in the search for cervical spine injury among patients with severe TBI has been identified. Levels of provider vigilance and consequent rates of overlooked cervical spine injury can be affected by environmental cues and presumably by other behavioral and organizational factors.
Joseph H. Piatt Jr.
Intracranial abscess is a very infrequent complication of sinusitis among children. Case series, mostly small and focusing on surgical treatment, have appeared in the literature, but there has been no study on the epidemiology of this condition, nor has there been any large-scale study on the intensity of therapy or outcomes.
Data were drawn from the Kids' Inpatient Databases for 1997, 2000, 2003, and 2006 and the National Inpatient Sample for 2001. Cases were defined by the conjunction between the diagnostic codes for intracranial abscess and those for acute or chronic sinusitis or mastoiditis.
Eight hundred forty-seven hospital admissions were captured. Over the 10 years of the study, admission rates ranged between 2.74 and 4.38 per million children per year. Boys were affected much more commonly than girls. Black children were affected out of proportion to their presence in the population. The overall incidence seemed to peak in early adolescence. Sinogenic cases had a marked seasonal pattern peaking in winter, but no seasonal variation was seen for otogenic cases. Asthma comorbidity was more prevalent among sinogenic cases. The mortality rate was 2%, and death occurred only among sinogenic cases. Moreover, sinogenic cases tended to require more intensive therapy, as measured by the number of procedures, and there was a trend toward less favorable discharge dispositions. Older patients and black patients were less likely to be discharged directly to home. At least a quarter of the cases were managed without neurosurgical intervention. White patients were treated without neurosurgery more often than others.
Analysis of administrative data sets has yielded a descriptive picture of intracranial abscess complicating sinusitis among children, but the very low incidence of this condition impedes prospective clinical research directed at practical management issues.
Spencer E. Barton, Jeffrey W. Campbell and Joseph H. Piatt Jr.
The authors define and examine the properties of 2 new, practice-based quality measures for the management of hydrocephalus.
The Surgical Activity Rate (SAR) is defined as the number of definitive operations for the treatment of hydrocephalus performed in a neurosurgical practice over the course of a year, divided by the number of patients with hydrocephalus seen in follow-up during that year. The Revision Quotient (RQ) is defined as the number of definitive revision operations performed in a neurosurgical practice in the course of a year, divided by the number of definitive initial operations during that year for patients with newly diagnosed hydrocephalus. Using published actuarial shunt survival data, the authors conducted Monte Carlo simulations of a pediatric neurosurgical practice to illustrate the properties and interpretations of the SAR and RQ. They used data from the Kids' Inpatient Database (KID) for 2009 to calculate RQs for hospitals accounting for more than 10 admissions coded for initial CSF shunt insertions.
During the initial growth phase of a simulated neurosurgical practice, the SAR approached its steady-state value much earlier than the RQ. Both measures were sensitive to doubling or halving of monthly failure rates. In the 2009 KID, 117 hospitals reported more than 10 initial shunt insertions. The weighted mean (± standard deviation) RQ for these hospitals was 1.79 ± 0.69. Among hospitals performing 50 or more initial shunt insertions, the RQ ranged between 0.71 and 3.65.
The SAR and RQ have attractive qualitative features as practice-based quality measures. The RQ, at least, exhibits clinically meaningful interhospital variation as applied to CSF shunt surgery. The SAR and RQ merit prospective field-testing as measures of quality in the management of childhood hydrocephalus.
Samir Sarda, Mike K. Moore and Joshua J. Chern
Joseph H. Piatt Jr.
In the US, race and economic status have pervasive associations with mechanisms of injury, severity of injury, management, and outcomes of trauma. The goal of the current study was to examine these relationships on a large scale in the setting of pediatric spinal injury.
Admissions for spinal fracture without or with spinal cord injury (SCI), spinal dislocation, and SCI without radiographic abnormality were identified in the Kids’ Inpatient Database (KID) and the National Trauma Data Bank (NTDB) registry for 2009. Patients ranged in age from birth up to 21 years. Data from the KID were used to estimate nationwide annual incidences. Data from the NTDB were used to describe patterns of injury in relation to age, race, and payor, with corroboration from the KID. Multiple logistic regression was used to model rates of mortality and spinal fusion.
In 2009, the estimated incidence of hospital admission for spinal injury in the US was 170 per 1 million in the population under 21 years of age. The incidence of SCI was 24 per 1 million. Incidences varied regionally. Adolescents predominated. Patterns of injury varied by age, race, and payor. Black patients were more severely injured than patients of other races as measured by Injury Severity Scale scores. Among black patients with spinal injury in the NTDB, 23.9% suffered firearm injuries; only 1% of white patients suffered firearm injuries. The overall mortality rate in the NTDB was 3.9%. In a multivariate analysis that included a large panel of clinical and nonclinical factors, black race retained significance as a predictor of mortality (p = 0.006; adjusted OR 1.571 [1.141–2.163]). Rates of spinal fusion were associated with race and payor in the NTDB data and with payor in the KID: patients with better insurance underwent spinal fusion at higher rates.
The epidemiology of pediatric spinal injury in the US cannot be understood apart from considerations of race and economic status.
Joseph H. Piatt Jr.
The natural history and management of myelomeningocele (MM) in children is fairly well understood. There is a deficiency of knowledge regarding the care of adults, however, even though there are now more adults than children living with MM. The purpose of this study was to characterize the hospital care of adults with MM and hydrocephalus on a nationwide population base. Adults with other forms of spina bifida (SB) were studied for contrast.
The Nationwide Inpatient Sample for the years 2001, 2004, 2007, and 2010 was queried for admissions with diagnostic ICD-9-CM codes for MM with hydrocephalus and for other forms of SB.
There were 4657 admissions of patients with MM and 12,369 admissions of patients with SB in the sample. Nationwide rates of admission increased steadily for both MM and SB patients throughout the study period. Hospital charges increased faster than the health care component of the Consumer Price Index. Patients with MM were younger than patients with SB, but annual admissions of MM patients older than 40 years increased significantly during the study period. With respect to hospital death and discharge home, outcomes of surgery for hydrocephalus were superior at high-volume hospitals. Patients with MM and SB were admitted to the hospital more frequently than the general population for surgery to treat degenerative spine disease.
Patients with MM and SB continue to require neurosurgical attention in adulthood, and the demand for services for older patients with MM is increasing. Management of hydrocephalus at high-volume centers is advantageous for this population. Patients with MM or SB may experience high rates of degenerative spine disease.