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George I. Jallo

otolaryngologists to access the frontal sinuses, and this craniotomy is essentially an enlarged bur hole that measures 12 mm in diameter. Although it is the most direct approach, this opening is limited in its exposure. Furthermore the closure must be completed with a bur hole titanium plate or cement. These repair techniques must be carefully selected in the setting of suppuration. As the authors clearly point out, the frontal sinus must be carefully identified on the preoperative studies prior to surgery, as this approach is not indicated if a frontal sinus is present. I

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Matthew J. McGirt, Shlomi Constantini and George I. Jallo

I ntramedullary spinal cord tumors are rare neoplasms that account for 6–8% of all central nervous system tumors but represent 20% of adult and 35% of pediatric spinal tumors. 2 , 4 Current treatment is aimed at radical or subtotal removal with adjuvant radiotherapy and/or chemotherapy, guided by histological results and tumor grade. 5 , 6 , 8 , 10 , 13–15 , 24 However, postoperative progressive spinal deformity, occurring in 16–100% of cases, often complicates functional outcome years after surgery. 7 , 12 , 21 , 22 , 28 It remains unclear which

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Harel Deutsch, George I. Jallo, Alina Faktorovich and Fred Epstein

between 1991 and 1999 for spinal intramedullary cavernoma were reviewed. All surgeries were performed by the senior author (F.E.). Two patients with cervicomedullary cavernomas were excluded from the series, and thus the study group consisted of 16 patients. There were six female and 10 male patients who ranged in age from 8 to 73 years (mean age 38.7 years). Symptoms present at the time of surgery are listed in Table 1 . The most common presenting symptom was a motor deficit. All patients underwent pre- and postoperative MR imaging studies. TABLE 1 Clinical

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Vivek A. Mehta, Chetan Bettegowda, George I. Jallo and Edward S. Ahn

suture, was the primary site of abnormality, with suture fusion being a secondary consequence. 12 , 40 , 41 He based this theory on 4 observations: 1) sutures were often patent at surgery, even when there was a high degree of preoperative suspicion of suture fusion; 2) there were characteristic abnormalities at the cranial base that occurred with certain suture fusion patterns; 3) excision of the fused suture did not always improve the cranial shape; and 4) embryologically, skull development occurred after cranial base development. Moss' theory fell out of favor as

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Pablo F. Recinos, Shaan M. Raza, George I. Jallo and Violette Renard Recinos

T he use of tubular retractors in cranial surgery has been one technique used to gain access to deepseated lesions while minimizing the effects seen with excessive retraction. The first reported use of tubular retractors for brain tumors was documented by Kelly et al. in 1987. 11 Prior to the widespread use of MR imaging, Kelly 9 and colleagues 10 , 11 , 13 used frame-based stereotactic CT to create a volumetric plan of deep lesions to surgically access them. In their setup, a metal tubular retractor was placed on the Leksell frame to provide retraction

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Vivek A. Mehta, Chetan Bettegowda and George I. Jallo

few seconds without support, which was a great improvement compared with the preoperative period. On examination, he moved both upper extremities equally, with good strength and tone, bearing weight on both legs well. The left leg demonstrated slightly increased tone compared with the right, but overall was significantly improved from before surgery. He required assistance to walk and still raised his toes after a few steps, but again to a lesser degree than preoperatively. At his 6-month follow-up, he was able to ambulate without any difficulty, but did have some

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Courtney Pendleton, Edward S. Ahn, George I. Jallo and Alfredo Quiñones-Hinojosa

surgery began developing into a surgical subspecialty in the US at the turn of the 20th century, with Harvey Cushing at the forefront, the operative treatment of spinal dysraphism was refined with attempts to minimize complications. In this paper we review a series of 10 patients with spinal dysraphism who underwent surgical intervention by Cushing during his time at the Johns Hopkins Hospital from 1896 to 1912. Study Overview Following Institutional Review Board approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the Johns Hopkins

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Korgun Koral

T o T he E ditor : I read with interest the article by Shakur et al. 3 (Shakur SF, McGirt MJ, Johnson MW, et al: Angiocentric glioma: a case series. Clinical article. J Neurosurg Pediatr 3: 197–202, March 2009). The authors reviewed the literature on angiocentric glioma in children and reported 3 of their cases. They stated “The median age at surgery for patients among the 25 cases was 6.5 years, compared with 9.9 years for children in the Göteborg epilepsy surgery series.” 1 This statement erroneously indicates that patients with angiocentric glioma

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Kuniaki Nakahara and Satoru Shimizu


The majority of shunt infections occur within 6 months of shunt placement and chiefly result from perioperative colonization of shunt components by skin flora. Antibiotic-impregnated shunt (AIS) systems have been designed to prevent such colonization. In this study, the authors evaluate the incidence of shunt infection after introduction of an AIS system in a population of children with hydrocephalus.


The authors retrospectively reviewed all pediatric patients who had undergone cerebrospinal fluid (CSF) shunt insertion at their institution over a 3-year period between April 2001 and March 2004. During the 18 months prior to October 2002, all CSF shunts included standard, nonimpregnated catheters. During the 18 months after October 2002, all CSF shunts included antibiotic-impregnated catheters. All patients were followed up for 6 months after shunt surgery, and all shunt-related complications, including shunt infection, were evaluated. The independent association of AIS catheter use with subsequent shunt infection was assessed via multivariate proportional hazards regression analysis.

A total of 211 pediatric patients underwent 353 shunt placement procedures. In the 18 months prior to October 2002, 208 (59%) shunts were placed with nonimpregnated catheters; 145 (41%) shunts were placed with AIS catheters in the 18 months after October 2002. Of patients with nonimpregnated catheters, 25 (12%) experienced shunt infection, whereas only two patients (1.4%) with antibiotic-impregnated catheters experienced shunt infection within the 6-month follow-up period (p < 0.01). Adjusting for intercohort differences via multivariate analysis, AIS catheters were independently associated with a 2.4-fold decreased likelihood of shunt infection.


The AIS catheter significantly reduced incidence of CSF shunt infection in children with hydrocephalus during the early postoperative period (< 6 months). The AIS system used is an effective instrument to prevent perioperative colonization of CSF shunt components.

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W. Peter Vandertop

T o T he E ditor : I read with interest the article by Garcés-Ambrossi et al. (Garcés-Ambrossi GL, McGirt MJ, Samuels R, et al: Neurological outcome after surgical management of adult tethered cord syndrome. J Neurosurg Spine 11: 304–309, September, 2009) regarding the results of improvement in pain and motor and urinary dysfunction after surgery for tethered cord syndrome (TCS) in 29 adults. They repeatedly emphasize that only cases involving adults undergoing first-time tethered cord release were reviewed, but from the figures presented I draw the