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Ashley Brones, Sarah Mengshol, and C. Corbett Wilkinson

The authors present the case of a 21-month-old girl with a posterior cervical subcutaneous/spinal lipoma that contained heterotopic bone. The patient demonstrated no neurological deficits and the lesion was resected without complication. The lesion was determined to be an ossifying lipoma. The literature on ossifying lipomas and osteolipomas is reviewed and the differences between the two are enumerated.

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Ken R. Winston, Elizabeth Trinidad, C. Corbett Wilkinson, and Lori A. McBride

Object

Cranial bandages are commonly applied over scalp incisions immediately after cerebrospinal fluid (CSF) shunt surgery, putatively to prevent complications, particularly infection. These bandages require resources, consume the time of healthcare workers, and incur non-negligible expenses. It is therefore both reasonable and important to examine the efficacy of cranial bandaging.

Methods

The combined experience of 3 neurosurgeons over 6.75 years with using no cranial bandaging after operations for implantation or revision of CSF shunts is the basis of this report. These data were prospectively accrued and retrospectively analyzed.

Results

The infection rate was 4.2% (95% CI 3.1–5.6%) for 1064 operations performed without postoperative cranial bandaging after either shunt insertion or revision surgery through clean or clean-contaminated wounds. The age distribution extended from premature infants through adults 77 years of age.

Conclusions

The results of this investigation support the position that bandaging scalp wounds after CSF shunt implantation or revision surgery adds no benefit beyond the easier, simpler, faster, and cheaper practice of using antibiotic ointment as a dressing without bandaging.

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Steven B. Carr, Greg Imbarrato, Robert E. Breeze, and C. Corbett Wilkinson

The authors present the case of a pediatric patient with Loeys-Dietz syndrome (LDS) who underwent craniotomy for clip ligation of a ruptured intracranial aneurysm. To the authors’ knowledge, this is the youngest reported patient with LDS who has been treated for a ruptured intracranial aneurysm. The patient presented with aneurysmal subarachnoid hemorrhage even though the results of surveillance screening were negative, and the aneurysm arose from the wall of the parent artery away from an arterial branch point. She was treated with open clip ligation and recovered well. The authors review the other reported cases of treated intracranial aneurysms in patients with LDS.

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Chima O. Oluigbo, C. Corbett Wilkinson, Nicholas V. Stence, Laura Z. Fenton, Sean A. McNatt, and Michael H. Handler

Object

The goal of this study was to compare clinical outcomes following decompressive craniectomy performed for intracranial hypertension in children with nonaccidental, blunt cranial trauma with outcomes of decompressive craniectomy in children injured by other mechanisms.

Methods

All children in a prospectively acquired database of trauma admissions who underwent decompressive craniectomy over a 9-year span, beginning January 1, 2000, are the basis for this study. Clinical records and neuroimaging studies were systematically reviewed.

Results

Thirty-seven children met the inclusion criteria. Nonaccidental head trauma was the most common mechanism of injury (38%). The mortality rate in patients with abusive brain injury (35.7%) was significantly higher (p < 0.05) than in patients with other causes of traumatic brain injury (4.3%). Children with inflicted head injuries had a 12-fold increase in the odds of death and 3-fold increase in the odds of a poor outcome (King's Outcome Scale for Closed Head Injury score of 1, 2, or 3).

Conclusions

Children with nonaccidental blunt cranial trauma have significantly higher mortality following decompressive craniectomy than do children with other mechanisms of injury. This understanding can be interpreted to mean either that the threshold for decompression should be lower in children with nonaccidental closed head injury or that decompression is unlikely to alter the path to a fatal outcome. If decompressive craniectomy is to be effective in reducing mortality in the setting of nonaccidental blunt cranial trauma, it should be done quite early.

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Seerat Poonia, Sarah Graber, C. Corbett Wilkinson, Brent R. O'neill, Michael H. Handler, and Todd C. Hankinson

OBJECTIVE

Postoperative management following the release of simple spinal cord–tethering lesions is highly variable. As a quality improvement initiative, the authors aimed to determine whether an institutional protocol of discharging patients on postoperative day (POD) 1 was associated with a higher rate of postoperative CSF leaks than the prior protocol of discharge on POD 2.

METHODS

This was a single-center retrospective review of all children who underwent release of a spinal cord–tethering lesion that was not associated with a substantial fascial or dural defect (i.e., simple spinal cord detethering) during 2 epochs: prior to and following the institution of a protocol for discharge on POD 1. Outcomes included the need for and timing of nonroutine care of the surgical site, including return to the operating room, wound suturing, and nonsurgical evaluation and management.

RESULTS

Of 169 patients identified, none presented with CSF-related complications prior to discharge. In the preintervention group (n = 113), the postoperative CSF leak rate was 4.4% (5/113). The mean length of stay was 2.3 days. In the postintervention group, the postoperative CSF leak rate was 1.9% (1/53) in the patients with postdischarge follow-up. The mean length of stay in that group was 1.3 days.

CONCLUSIONS

At a single academic children's hospital, a protocol of discharging patients on POD 1 following uncomplicated release of a simple spinal cord–tethering lesion was not associated with an increased rate of postoperative CSF leaks, relative to the previous protocol. The rates identified are consistent with the existing literature. The authors' practice has changed to discharge on POD 1 in most cases.

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Brent R. O'Neill, Danielle Gallegos, Alex Herron, Claire Palmer, Nicholas V. Stence, Todd C. Hankinson, C. Corbett Wilkinson, and Michael H. Handler

OBJECTIVE

Cutaneous stigmata or congenital anomalies often prompt screening for occult spinal dysraphism (OSD) in asymptomatic infants. While a number of studies have examined the results of ultrasonography (US) screening, less is known about the findings when MRI is used as the primary imaging modality. The object of this study was to assess the results of MRI screening for OSD in infants.

METHODS

The authors undertook a retrospective review of all infants who had undergone MRI of the lumbar spine to screen for OSD over a 6-year period (September 2006–September 2012). All images had been obtained on modern MRI scanners using sequences optimized to detect OSD, which was defined as any fibrolipoma of the filum terminale (FFT), a conus medullaris ending at or below the L2–3 disc space, as well as more complex lesions such as lipomyelomeningocele (LMM).

RESULTS

Five hundred twenty-two patients with a mean age of 6.2 months at imaging were included in the study. Indications for imaging included isolated dimple in 235 patients (45%), asymmetrically deviated gluteal cleft in 43 (8%), symmetrically deviated (Y-shaped) gluteal cleft in 38 (7%), hemangioma in 28 (5%), other isolated cutaneous stigmata (subcutaneous lipoma, vestigial tail, hairy patch, and dysplastic skin) in 31 (6%), several of the above stigmata in 97 (18%), and congenital anomalies in 50 (10%).

Twenty-three percent (122 patients) of the study population had OSD. Lesions in 19% of these 122 patients were complex OSD consisting of LMM, dermal sinus tract extending to the thecal sac, and lipomeningocele. The majority of OSD lesions (99 patients [81%]) were filar abnormalities, a group including FFT and low-lying conus.

The rate of OSD ranged from 12% for patients with asymmetrically deviated gluteal crease to 55% for those with other isolated cutaneous stigmata.

Isolated midline dimple was the most common indication for imaging. Among this group, 20% (46 of 235) had OSD. There was no difference in the rate of OSD based on dimple location. Those with OSD had a mean dimple position of 15 mm (SD 11.8) above the coccyx. Those without OSD had a mean dimple position of 12.2 mm (SD 19) above the coccyx (p = 0.25).

CONCLUSIONS

The prevalence of OSD identified with modern high-resolution MRI screening is significantly higher than that reported with US screening, particularly in patients with dimples. The majority of OSD lesions identified are FFT and low conus. The clinical significance of such lesions remains unclear.

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Joel S. Katz, Chima O. Oluigbo, C. Corbett Wilkinson, Sean McNatt, and Michael H. Handler

Object

The incidence, type, and severity of pediatric cervical spine injuries (CSIs) are related to age and mechanism of injury. In this study, the authors assessed the prevalence of CSIs in infants with head trauma treated in their institution.

Methods

The authors reviewed the medical records of children younger than 1 year of age who presented to The Children's Hospital with head injuries between January 1993 and December 2007. They excluded infants with head injuries resulting from motor vehicle accidents and known falls from heights greater than 10 ft. For each patient, collected data included age, cause of injury, diagnosis, discharge disposition, and outcome. Relevant imaging data were reviewed, and when appropriate, autopsy reports were also reviewed.

Results

Nine hundred five infants with head trauma and without a major mechanism/cause were identified. Their mean age was 4.3 months. Of the 905 patients, only 2 cases of CSI were detected, giving a prevalence of 0.2%. The mechanism of injury in these 2 patients was nonaccidental trauma (NAT).

Conclusions

The study revealed a very low prevalence of CSIs in infants with head trauma (0.2%). Routine cervical spine imaging in these infants, therefore, appears to have low diagnostic yield. The mechanism of head injury was NAT in the 2 patients who sustained an associated CSI. This supports the need for more stringent cervical spine imaging criteria for the infant with suspected NAT.

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C. Corbett Wilkinson, Cesar A. Serrano, Brooke M. French, Sarah J. Graber, Emily Schmidt-Beuchat, Lígia Batista-Silverman, Noah P. Hubbell, and Nicholas V. Stence

OBJECTIVE

Several years ago, the authors treated an infant with sagittal and bilateral parietomastoid suture fusion. This made them curious about the normal course of fusion of “minor” lateral sutures (sphenoparietal, squamosal, parietomastoid). Accordingly, they investigated fusion of these sutures on 3D volume-rendered head CT reconstructions in a series of pediatric trauma patients.

METHODS

The authors reviewed all volume-rendered head CT reconstructions obtained from 2010 through mid-2012 at Children’s Hospital Colorado in trauma patients aged 0–21 years. Each sphenoparietal, squamosal, and parietomastoid suture was graded as open, partially fused, or fused. In several individuals, one or more lateral sutures were fused atypically. In these patients, the cephalic index (CI) and cranial vault asymmetry index (CVAI) were calculated. In a separately reported study utilizing the same reconstructions, 21 subjects had fusion of the sagittal suture. Minor lateral sutures were assessed, including these 21 individuals, excluding them, and considering them as a separate subgroup.

RESULTS

After exclusions, 331 scans were reviewed. Typically, the earliest length of the minor lateral sutures to begin fusion was the anterior squamosal suture, often by 2 years of age. The next suture to begin fusion—and first to complete it—was the sphenoparietal. The last suture to begin and complete fusion was the parietomastoid. Six subjects (1.8%) had posterior (without anterior) fusion of one or more squamosal sutures. Six subjects (1.8%) had fusion or near-complete fusion of one squamosal and/or parietomastoid suture when the corresponding opposite suture was open or nearly open. The mean CI and CVAI values in these subjects and in age- and sex-matched controls were normal and not significantly different. No individuals had a fused parietomastoid suture with open squamosal and/or sphenoparietal sutures.

CONCLUSIONS

Fusion and partial fusion of the sphenoparietal, squamosal, and parietomastoid sutures is common in children and adolescents. It usually does not represent craniosynostosis and does not require cranial surgery. The anterior squamosal suture is often the earliest length of these sutures to fuse. Fusion then spreads anteriorly to the sphenoparietal suture and posteriorly to the parietomastoid. The sphenoparietal suture is generally the earliest minor lateral suture to complete fusion, and the parietomastoid is the last. Atypical patterns of fusion include posterior (without anterior) squamosal suture fusion and asymmetrical squamosal and/or parietomastoid suture fusion. However, these atypical fusion patterns may not lead to atypical head shapes or a need for surgery.

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C. Corbett Wilkinson, Nicholas V. Stence, Cesar A. Serrano, Sarah J. Graber, Lígia Batista-Silverman, Emily Schmidt-Beuchat, and Brooke M. French

OBJECTIVE

Recently, the authors investigated the normal course of fusion of minor lateral calvarial sutures on “3D” volume-rendered head CT reconstructions in pediatric trauma patients. While evaluating these reconstructions, they found many more fused sagittal sutures than expected given the currently accepted prevalence of sagittal craniosynostosis. In the present study, using the same set of head CT reconstructions, they investigated the course of fusion of the sagittal as well as the lambdoid, coronal, and metopic sutures.

METHODS

They reviewed all volume-rendered head CT reconstructions performed in the period from 2010 through mid-2012 at Children’s Hospital Colorado for trauma patients aged 0–21 years. Each sagittal, lambdoid, coronal, or metopic suture was graded as open, partially fused, or fused. The cephalic index (CI) was calculated for subjects with fused and partially fused sagittal sutures.

RESULTS

After exclusions, 331 scans were reviewed. Twenty-one subjects (6%) had fusion or partial fusion of the sagittal suture. Four of the 21 also had fusion of the medial lambdoid and/or coronal sutures. In the 17 subjects (5%) with sagittal suture fusion and no medial fusion of adjacent sutures, the mean CI was 77.6. None of the 21 subjects had been previously diagnosed with craniosynostosis. Other than in the 21 subjects already mentioned, no other sagittal or lambdoid sutures were fused at all. Nor were other coronal sutures fused medially. Coronal sutures were commonly fused inferiorly early during the 2nd decade of life, and fusion progressed superiorly and medially as subjects became older; none were completely fused by 18 years of age. Fusion of the metopic suture was first seen at 3 months of life; fusion was often not complete until after 2 years.

CONCLUSIONS

The sagittal and lambdoid sutures do not usually begin to fuse before 18 years of age. However, more sagittal sutures are fused before age 18 than expected given the currently accepted prevalence of craniosynostosis. This finding is of unknown significance, but likely many of them do not need surgery. The coronal suture often begins to fuse inferiorly early in the 2nd decade of life but does not usually complete fusion before 18 years of age. The metopic suture often starts to fuse by 3 months of age, but it may not completely fuse until after 2 years of age.

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Todd C. Hankinson, Roy W. R. Dudley, Michelle R. Torok, Mohana Rao Patibandla, Kathleen Dorris, Seerat Poonia, C. Corbett Wilkinson, Jennifer L. Bruny, Michael H. Handler, and Arthur K. Liu

OBJECT

Thirty-day mortality is increasingly a reference metric regarding surgical outcomes. Recent data estimate a 30-day mortality rate of 1.4−2.7% after craniotomy for tumors in children. No detailed analysis of short-term mortality following a diagnostic neurosurgical procedure (e.g., resection or tissue biopsy) for tumor in the US pediatric population has been conducted.

METHODS

The Surveillance, Epidemiology and End Results (SEER) data sets identified patients ≤ 21 years who underwent a diagnostic neurosurgical procedure for primary intracranial tumor from 2004 to 2011. One- and two-month mortality was estimated. Standard statistical methods estimated associations between independent variables and mortality.

RESULTS

A total of 5533 patients met criteria for inclusion. Death occurred within the calendar month of surgery in 64 patients (1.16%) and by the conclusion of the calendar month following surgery in 95 patients (1.72%). Within the first calendar month, patients < 1 year of age (n = 318) had a risk of death of 5.66%, while those from 1 to 21 years (n = 5215) had a risk of 0.88% (p < 0.0001). By the end of the calendar month following surgery, patients < 1 year (n = 318) had a risk of death of 7.23%, while those from 1 to 21 years (n = 5215) had a risk of 1.38% (p < 0.0001). Children < 1 year at diagnosis were more likely to harbor a high-grade lesion than older children (OR 1.9, 95% CI 1.5–2.4).

CONCLUSIONS

In the SEER data sets, the risk of death within 30 days of a diagnostic neurosurgical procedure for a primary pediatric brain tumor is between 1.16% and 1.72%, consistent with contemporary data from European populations. The risk of mortality in infants is considerably higher, between 5.66% and 7.23%, and they harbor more aggressive lesions.