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Elsa V. Arocho-Quinones, Sean M. Lew, and Andrew B. Foy

OBJECTIVE

The management of children with ping-pong skull fractures may include observation, nonsurgical treatments, or surgical intervention depending on the age, clinical presentation, imaging findings, and cosmetic appearance of the patient. There have been 16 publications on nonsurgical treatment using negative pressure with various devices. Herein, the authors report their experience with vacuum-assisted elevation of ping-pong skull fractures and evaluate the variables affecting procedural outcomes.

METHODS

The authors performed a retrospective chart review of all ping-pong skull fractures treated via vacuum-assisted elevation at the Children’s Hospital of Wisconsin between 2013 and 2017. Data collected included patient age, head circumference, mode of injury, time to presentation, imaging findings, procedural details, treatment outcomes, and complications.

RESULTS

Four neonates and 5 infants underwent vacuum-assisted elevation of moderate to severe ping-pong skull fractures during the study period. Modes of injury included birth-related trauma, falls, and blunt trauma. All patients had normal neurological examination findings and no evidence of intracranial hemorrhage. All fractures were deemed severe enough to require elevation by the treating neurosurgeon. All fractures involved the parietal bone. Skull depressions ranged from 23 to 62 mm in diameter and from 4 to 14 mm in depth. Bone thickness ranged from 0.6 to 1.8 mm. The time from fracture to intervention ranged from 7 hours to 8 days. The Kiwi OmniCup vacuum delivery system was used in all cases. Negative pressures were increased sequentially to a maximum of 500 mm Hg. A greater number of sequential vacuum applications was required for patients with a skull thickness greater than 1 mm at the site of depression and for those undergoing treatment more than 72 hours from fracture onset. Successful fracture elevation was attained in 7 of 9 patients. Two patients required subsequent surgical elevation of their fractures. Postprocedure imaging studies revealed no evidence of complications.

CONCLUSIONS

Increasing bone thickness and time from fracture onset to intervention appeared to be the greatest limiting factors to the successful elevation of moderate to severe ping-pong fractures via this vacuum-assisted approach. This procedure is a well-tolerated option that should be considered prior to performing an open repair in cases deemed to require fracture elevation. Future efforts will focus on larger-volume studies to better delineate inclusion and exclusion criteria, and volumetric analysis for better fracture-to-suction device customization.

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Andrew B. Foy, Caterina Giannini, and Corey Raffel

✓Bovine tissues are now routinely used for dural closure in cranial and spinal surgery. The authors report the case of an 18-year-old woman with a history of myelomeningocele who had symptoms of tethered cord syndrome and presented to a regional hospital. At that hospital she underwent a cord untethering procedure. The spinal dura was closed with Durepair, a dural substitute derived from fetal bovine skin. Her postoperative course was complicated by a cerebrospinal fluid leak that was surgically repaired. Following this, she developed erythroderma, intermittent fevers, eosinophilia, and marked elevation in serum immunoglobulin E. She was then transferred to the authors' institution. A skin antigen test to beef was administered, which revealed a positive reaction. A radioallergosorbent test to beef also yielded positive results. She was taken to the operating room for removal of the bovine graft due to concern for an allergic reaction to the graft. The graft material showed evidence of eosinophilic infiltration. Her clinical symptoms and laboratory values all improved after surgery. To the authors' knowledge this is the first reported case of an allergic reaction to bovine-based dural substitutes.

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Michelle J. Clarke, Andrew B. Foy, Nicholas Wetjen, and Corey Raffel

Object

Subependymal giant cell astrocytomas (SEGAs) are a common manifestation of tuberous sclerosis (TS). These evolving tumors have a propensity to cause obstructive hydrocephalus, usually due to obstruction at the level of the foramen of Monro. Differentiating SEGAs from subependymal nodules (SENs) before obstruction occurs may improve the morbidity associated with these tumors. In this study the authors' aim was to determine imaging characteristics of proven tumors in a single-center pediatric population.

Methods

The authors retrospectively reviewed all records and images obtained in patients with TS in whom results of biopsy sampling had proven that their tumors were SEGAs. Time to presentation, signs and symptoms at presentation, and imaging characteristics of the evolving tumors were noted. Twelve patients with 14 SEGAs proven by the results of biopsy sampling were reviewed. Resection was recommended for symptomatic and neuroimaging evidence of hydrocephalus (41%), tumor growth without evidence of hydrocephalus (33%), and for poorly controlled seizures (25%). The mean diameter of the tumors at the time of resection was 1.9 cm (range 0.3–4 cm), and no tumor recurred. Because of the pathological and radiographic continuum of SENs and SEGAs, it remains difficult to predict whether and when a given lesion will progress. Tumor growth and contrast enhancement are the most common signs of progression on neuroimages, and may be seen prior to the development of obstructive hydrocephalus.

Conclusions

Patients with SENs and SEGAs should undergo follow-up neuroimaging at yearly intervals, and if lesions show signs of progression (contrast enhancement or growth), these intervals should be shortened and consideration given to early resection.

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Elsa V. Arocho-Quinones, Amie Kolimas, Peter S. LaViolette, Bruce A. Kaufman, Andrew B. Foy, Marike Zwienenberg, and Sean M. Lew

OBJECTIVE

Split laminotomy is a technique for accessing the spinal canal from the posterior midline that minimizes muscle dissection and bone removal. Benefits of this approach in minimizing postoperative pain and muscle atrophy in the adult population have been reported, but pediatric data are limited. Herein, the authors evaluate the benefits of the split laminotomy technique in pediatric patients.

METHODS

Data obtained in patients who underwent posterior spine surgery at Children’s Hospital of Wisconsin for an intradural midline pathology between April 2008 and June 2015 were reviewed retrospectively. Each patient was assigned to one of two groups, the split-laminotomy or conventional-laminotomy group. The primary outcomes assessed were mean daily pain score, total opioid use over a period of 72 hours after surgery, and the degree of paraspinal muscle atrophy and fat infiltration found on short-term (1–4 months) and long-term (1–4 years) follow-up spine MRI studies.

RESULTS

A total of 117 patients underwent lumbar-level surgery (83 conventional laminotomy, 34 split laminotomy), and 8 patients underwent thoracic-level surgery (4 in each group). No significant difference in the mean daily pain scores between groups was found. The daily opioid use was significantly lower in the split-laminotomy group on postoperative day 0 (POD0) and POD1 but not on POD2 (p = 0.01, 0.01, and 0.10, respectively). The total opioid use over the 72-hour postoperative period was significantly lower in the split-laminotomy group (p = 0.0008). The fat/muscle ratio was significantly higher in both the short-term and long-term follow-up periods in the conventional-laminotomy group (p = 0.01 and 0.0002, respectively). The rate of change of paraspinal muscle fat infiltration was significantly lower in the split-laminotomy group than in the conventional-laminotomy group (p = 0.007). The incidence of complications was not significantly different between groups (p = 0.08).

CONCLUSIONS

This study was of the largest series reported thus far of pediatric patients who underwent split laminotomy and the only controlled study that has involved children. The authors’ results reinforce the short-term benefit of split laminotomy in minimizing acute postoperative pain and long-term benefits of decreasing muscle atrophy and fatty degeneration, which are known to be associated with the development of chronic pain and spinal instability. Additional efforts for assessing long-term effects in the development of chronic pain, spinal instability, and spinal deformity are still necessary.

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Jeffrey P. Blount, Brandon G. Rocque, and Betsy D. Hopson

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Michelle J. Clarke, Daniel L. Price, Harry J. Cloft, Leal G. Segura, Cindy A. Hill, Meghen B. Browning, Jon M. Brandt, Sean M. Lew, and Andrew B. Foy

Osteosarcoma is an aggressive primary bone tumor. It is currently treated with multimodality therapy including en bloc resection, which has been demonstrated to confer a survival benefit over intralesional resection. The authors present the case of an 8-year-old girl with a C-1 lateral mass osteosarcoma, which was treated with a 4-stage en bloc resection and spinal reconstruction. While technically complex, the feasibility of en bloc resection for spinal osteosarcoma should be explored in the pediatric population.

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Ravi Kumar, Ramesh Kumar, Grant W. Mallory, Jeffrey T. Jacob, David J. Daniels, Nicholas M. Wetjen, Andrew B. Foy, Brent R. O’Neill, and Michelle J. Clarke

OBJECT

Nonpowder guns, defined as spring- or gas-powered BB or pellet guns, can be dangerous weapons that are often marketed to children. In recent decades, advances in compressed-gas technology have led to a significant increase in the power and muzzle velocity of these weapons. The risk of intracranial injury in children due to nonpowder weapons is poorly documented.

METHODS

A retrospective review was conducted at 3 institutions studying children 16 years or younger who had intracranial injuries secondary to nonpowder guns.

RESULTS

The authors reviewed 14 cases of intracranial injury in children from 3 institutions. Eleven (79%) of the 14 children were injured by BB guns, while 3 (21%) were injured by pellet guns. In 10 (71%) children, the injury was accidental. There was 1 recognized assault, but there were no suicide attempts; in the remaining 3 patients, the intention was indeterminate. There were no mortalities among the patients in this series. Ten (71%) of the children required operative intervention, and 6 (43%) were left with permanent neurological injuries, including epilepsy, cognitive deficits, hydrocephalus, diplopia, visual field cut, and blindness.

CONCLUSIONS

Nonpowder guns are weapons with the ability to penetrate a child’s skull and brain. Awareness should be raised among parents, children, and policy makers as to the risk posed by these weapons.

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Andrew B. Foy, Kathleen J. Sawin, Tia Derflinger, Amy K. Heffelfinger, Jennifer I. Koop, Susan S. Cohen, and Eileen C. Sherburne

OBJECTIVE

Fetal surgery for myelomeningocele has become an established treatment that offers less risk of requiring a ventricular shunt and improved functional outcomes for patients. An increasing body of literature has suggested that social determinants of health have a profound influence on health outcomes. The authors sought to determine the socioeconomic and racial and ethnic backgrounds of patients who were treated with fetal surgery versus those who underwent postnatal repair.

METHODS

Demographic data, the method of myelomeningocele repair, insurance status, and zip code data for patients entered into the National Spina Bifida Patient Registry (NSBPR) from Children’s Wisconsin were collected. The zip code was used to determine the Distressed Communities Index (DCI) score, a composite socioeconomic ranking with scores ranging from 0 (no distress) to 100 (severe distress). The zip code was also used to determine the median household income for each patient based on the US Census Bureau 2013–2017 American Community Survey 5-year estimates.

RESULTS

A total of 205 patients were identified with zip code and insurance data. There were 23 patients in the fetal surgery group and 182 patients in the postnatal surgery group. All patients were born between 2000 and 2019. Patients in the fetal surgery group were more likely to have commercial insurance (100% vs 52.2%, p < 0.001). Fetal surgery patients were also more likely to be non-Hispanic White (95.7% vs 68.7%, p = 0.058), just missing the level of statistical significance. Patients who underwent fetal surgery tended to reside in zip codes with a higher median household income (mean $66,507 vs $59,133, p = 0.122) and less-distressed communities (mean DCI score 31.3 vs 38.5, p = 0.289); however, these differences did not reach statistical significance.

CONCLUSIONS

Patients treated with fetal surgery were more likely to have commercial insurance and have a non-Hispanic White racial and ethnic background. The preliminary data suggest that socioeconomic and racial and ethnic disparities may exist regarding access to fetal surgery, and investigation of a larger population of spina bifida patients is warranted.

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Surya Sri Krishna Gour, Mohit Agrawal, and Sachin A. Borkar