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Paul Klimo Jr. and Ann Marie Flannery

TO THE EDITOR: After publication of the Pediatric Hydrocephalus Guidelines, it came to our attention that we made an error in preparing our article, “Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 6: Preoperative antibiotics for shunt surgery in children with hydrocephalus: a systematic review and meta-analysis” (J Neurosurg Pediatr (Suppl) 14: 44–52, 2014). We are grateful to Drs. Jeff Campbell and Joseph Piatt for bringing this error to our attention. Despite multiple attempts at proofreading, we mistakenly

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Paul Klimo Jr. and Liliana C. Goumnerova

generally been treated either with steroid and analgesic agents or by the placement of a shunt. 2 Often, this surgery is performed late in the course of the illness, and the patient requires hospitalization of several days, which for some families is undesirable. We therefore elected to perform ETVCs in patients with DPGs or other lesions in the brainstem region in an attempt to provide palliation and possibly decrease the hospital stay and steroid medication requirements. F ig . 1 Sagittal (left) and axial (right) T 2 -weighted MR images showing a diffuse

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Paul Klimo Jr. and Cody L. Nesvick

TO THE EDITOR: We recently came upon the article by Lee et al. 1 (Lee CC, Chen CJ, Ball B, et al: Stereotactic radiosurgery for arteriovenous malformations after Onyx embolization: a case-control study. J Neurosurg 123:126–135, July 2015). The authors followed 25 patients with an arteriovenous malformation who had Onyx embolization prior to Gamma Knife surgery and compared them to a group of 50 propensity-matched patients without prior embolization. It is a well-written and important study on a question many of us have when treating patients with

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William C. Gump

TO THE EDITOR: I was intrigued by the counterintuitive result reported by Klimo et al. 5 (Klimo P Jr, Van Poppel M, Thompson CJ, et al: Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 6: Preoperative antibiotics for shunt surgery in children with hydrocephalus: a systematic review and meta-analysis. JNeurosurg Pediatr (Suppl) 14:44-52 , November 2014) in the Pediatric Hydrocephalus Guideline paper addressing preoperative antibiotic use and its apparent lack of effect in decreasing shunt infection rate. The authors

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Paul Klimo Jr. and John R. W. Kestle

not include a definition of shunt failure. It appeared that shunt failure and shunt revision surgery were synonymous. We therefore developed definitions by consensus among the investigators on the basis of history, physical findings, and ancillary tests. Separate definitions were developed for shunt obstruction, shunt overdrainage, loculated ventricles, and shunt infection. 17 At the time of follow up, if the patient met any of the definitions in a blinded review of a follow-up examination, he or she was said to have reached the selected primary study end point

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Paul Klimo Jr., Brian T. Ragel, Michael Rosner, Wayne Gluf and Randall McCafferty

potential surgical indications, the most controversial of which is whether decompressive laminectomy has any effect on neurological recovery. Medical civilian and military literature is replete with opinions for and against the use of surgery. Although missile characteristics such as size, composition and design are important, the major determinant of the destructive ability of a projectile is velocity at impact and thus the kinetic energy imparted to the surrounding tissue. 10 Energy is calculated based on mass and velocity as follows: energy = 1/2mv 2 . Therefore

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Garrett T. Venable, Cain S. Green, Zachary S. Smalley, E. Cydnie Bedford, Joseph S. Modica and Paul Klimo Jr.

significance of these factors varies considerably between studies. 17 , 21 , 24 , 26 , 28 , 29 The risk of shunt failure secondary to elective nonneurosurgical operations has been reported in several specialties, including obstetrics, 6 , 9 orthopedics, 1 , 13 and urology, 27 with the risk related to abdominal surgery being the most widely studied. 4 , 10 , 14 , 15 , 22 There are few reports of shunt malfunction following neurosurgical procedures or surgery. There are 2 small case series of low-pressure shunt failure after lumbar puncture. 7 , 19 Tubbs et al. were the

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Garrett T. Venable, Nicholas B. Rossi, G. Morgan Jones, Nickalus R. Khan, Zachary S. Smalley, Mallory L. Roberts and Paul Klimo Jr.

H ydrocephalus is characterized by impaired CSF flow or absorption occurring within or outside the ventricular system, which leads to an expansion of the ventricles. 38 There are many causes and predisposing risk factors, such as congenital brain malformations, cyst formation, genetic mutations, hemorrhage, infection, neoplasms, and neural tube defects. 49 Shunt surgery is currently the procedure most commonly performed by pediatric neurosurgeons, and although there is hope that the combination of endoscopic third ventriculostomy with choroid plexus

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Paul Klimo Jr., Patrick J. Codd, Holcombe Grier and Liliana C. Goumnerova

sarcomas are rare; nevertheless, the literature is replete with numerous case reports. Examples of adult patients include those with epitheliod angiosarcoma, 55 osteosarcoma, 36 , 41 chondrosarcoma, 47 , 56 , 76 and liposarcoma. 35 A recent retrospective review from a high-volume tertiary cancer center spanning a 12-year period identified 29 patients who underwent surgery for a primary spinal sarcoma (excluding Ewing sarcoma). The most common histological type was chondrosarcoma, found in 16 patients (55%). 65 There are fewer reports of such lesions in children, but

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Paul Klimo Jr., Valerie Coon and Douglas Brockmeyer

not to perform a posterior fossa decompression for her mild Chiari malformation because we believed it was asymptomatic. A CT scan obtained 4 months after surgery showed a solid fusion. Embryological Development and Pathogenesis During normal embryological development, the odontoid process is derived from somites 4 (fourth occipital sclerotome, “C0”); 5 (first cervical sclerotome, “C1”); and 6 (second cervical sclerotome, “C2”). The body of the odontoid begins as part of the centrum of the first cervical vertebra, but becomes separated from the atlas to fuse