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Randolph J. Canterbury

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Joshua J. Wind and Douglas E. Anderson

The history of psychosurgery is described and analyzed. This historical perspective largely begins with analysis of the work of Egas Moniz in the development of the leukotomy, and follows the rise and fall of its popularity in the 1900s. The reemergence of psychosurgical procedures and the development of new therapeutic technologies such as vagus nerve stimulation and deep brain stimulation are discussed. In addition, an introduction to the field of neuroethics is provided, given its importance in any discussion about surgical therapy for psychiatric patients.

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Letter to the Editor

Cervical spine clearance

Joseph H. Piatt Jr.

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Expansion of arachnoid cysts in children

Report of two cases and review of the literature

Ganesh Rao, Richard C. E. Anderson, Neil A. Feldstein, and Douglas L. Brockmeyer

✓Arachnoid cysts are intracranial, space-occupying lesions that typically remain stable in size on serial imaging. The authors describe two cases of rapidly enlarging arachnoid cysts, including one located in the anterior fossa.

In the first case a 7-month-old boy presented with increasing head circumference and a rapidly enlarging arachnoid cyst in the left middle fossa, which had been documented by serial imaging over the preceding 6 months. In the second case a 4-year-old girl presented with an arachnoid cyst compressing the right frontal lobe. The cyst had not been present on imaging studies performed during the perinatal period. In both cases, a craniotomy for open fenestration of the cyst was performed with successful resolution of the mass effect.

Rare cases of expansion of arachnoid cysts have been reported in the literature. In this article the authors report the dramatic enlargement of two arachnoid cysts, including the first description of enlargement of an arachnoid cyst located in the anterior fossa.

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Anne G. Osborn, Jonathan H. Daines, S. Douglas Wing, and Robert E. Anderson

✓ Intracranial gas may be epidural, subdural, subarachnoid, parenchymal, or intraventricular. Intracranial air can be easily diagnosed and its location correctly assessed by computerized tomography. Potentially serious complications of intracranial air, such as tension pneumocephalus, can be rapidly and accurately identified, facilitating appropriate clinical therapy.

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Richard C. E. Anderson, Peter Kan, Kris W. Hansen, and Douglas L. Brockmeyer

Object

Currently, no diagnostic or procedural standards exist for clearing the cervical spine in children after trauma. The purpose of this study was to determine if reeducation of nonneurosurgical personnel and initiation of a new protocol based on the National Emergency X-Radiography Utilization Study criteria could safely increase the number of pediatric cervical spines cleared of suspected injury without a neurosurgical consultation.

Methods

Data regarding cervical spine clearance in children (ages 0–18 years) after trauma protocol activation at Primary Children's Medical Center between 2001 and 2005 were collected and reviewed. Radiographic and clinical methods of clearing the cervical spine as well as the type and management of injuries were determined for two time frames: Period I (January 2001–December 2003) and Period II (January 2004–July 2005).

Between 2001 and 2003, 95% of 936 cervical spines were cleared of suspected injury by the neurosurgical service. Twenty-one ligamentous injuries (2.2%) and 12 fracture–dislocations (1.3%) were detected, with five patients requiring surgical stabilization (0.5%). Between January 2004 and July 2005, 507 (68%) of 746 cervical spines were cleared by nonneurosurgical personnel. Six ligamentous injuries (0.8%) and 10 fracture–dislocations (1.3%) were identified, with three patients (0.4%) requiring surgical stabilization. No late injuries were detected in either period.

Conclusions

The protocol used has been effective in enabling detection of cervical spine injuries in children after trauma, with the new protocol increasing by more than 60% the number of cervical spines cleared by nonneurosurgical personnel. Reeducation with establishment of the new protocols can safely facilitate clearance of the cervical spine by nonneurosurgical personnel after trauma.

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Douglas K. Anderson, Leon D. Prockop, Eugene D. Means, and Lawrence E. Hartley

✓ Cerebrospinal fluid (CSF) lactate, sodium (Na+), potassium (K+), calcium (Ca++), magnesium (Mg++), and chloride (Cl) levels were determined for 17 to 21 days following experimental spinal cord compression in cats. Laminectomies were performed at L-2 under general anesthesia with aseptic techniques. Paraplegia was produced by applying a 170-gm weight transdurally for 5 minutes. Significant increases in CSF lactate levels were observed on the first through ninth days post injury with peak levels (50% above normal) occurring at Day 5. The only significant postinjury CSF electrolyte changes were elevation in Ca++ concentration on Days 3, 9, 11, 13, and 15, elevation in K+ concentration on Days 9 and 11 and decline in Cl levels on the first day. The CSF K+ increase probably reflected cellular loss of K+ from damaged tissue whereas the Ca++ rise may have resulted from increased CSF protein levels. The prolonged elevation of CSF lactate indicates that tissue hypoxia plays a role in spinal cord compression paralysis, and that there is a continuing hypoxia of metabolically active spinal cord tissue for several days post injury.

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Oren N. Gottfried, Ganesh Rao, Richard C. E. Anderson, Gary L. Hedlund, and Douglas L. Brockmeyer

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Paul Klimo Jr., Richard C. E. Anderson, and Douglas L. Brockmeyer

✓Two cases of a previously undescribed cervical spinal anomaly distinct from cervical spondylolysis are presented. The authors report the first detailed description of a congenital vertebral anomaly characterized by multilevel cervical spondylolysis, sagittal deformity, and spinal cord compression. The sine qua non of the condition is a lack of communication between the anterior and posterior columns of the cervical spinal canal, which may occur over several vertebral levels. A kyphotic deformity of the anterior column occurs, whereas the posterior column may have relatively normal alignment. The underlying biomechanical stresses caused by the anterior–posterior column disconnection result in spinal instability and progressive kyphotic deformity, often to a profound degree. Two children, 2 and 3 years of age, presented with congenital multilevel disconnection and myelopathy. In the first stage of treatment, each underwent an anterior decompression, reduction, and reconstruction of the involved segments. This was followed by posterior stabilization and fusion as a separate procedure. In both patients, the myelopathy improved and a solid, circumferential fusion was achieved. The authors’ success in treating these patients indicates that management of these conditions can be based on the principles of deformity correction, spinal cord decompression, and combined anterior–posterior arthrodesis.

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Richard C. E. Anderson, Peter Kan, Wayne M. Gluf, and Douglas L. Brockmeyer

Object

Despite decades of surgical experience, the long-term consequences of occipitocervical (OC) and atlantoax-ial (C1–2) fusions in children are unknown. The purpose of this study was to determine the long-term effects of these fusions on growth and alignment of the maturing cervical spine.

Methods

A retrospective chart review was conducted for patients 6 years of age or younger (mean 4.7 years, range 1.7–6.8 years) who underwent OC or C1–2 fusion at the Primary Children’s Medical Center at the University of Utah within the last 10 years. Immediate postoperative plain radiographs and computed tomography (CT) scans were compared with the most recent plain and dynamic radiographs to assess changes in spinal growth and alignment.

Seventeen children met entry criteria for the study. All patients had fusion documented on follow-up radiography or CT scans. At a mean follow up of 28 months, there were no cases of sagittal malalignment (kyphotic or swanneck deformity), subaxial instability (osteophyte formation or subluxation), or unintended fusion of adjacent levels. The lordotic curvature of the cervical spine increased from a mean of 15° postoperatively to 27° at follow up (p = 0.06). A mean of 34% of the vertical growth of the cervical spine occurred within the fusion segment. When data were analyzed pertaining to a subgroup of five patients who underwent follow-up periods for longer than 48 months (mean 50.2 months, range 48–54 months), similar results were seen.

Conclusions

Preliminary follow-up results indicate that, compared with older children, children 6 years of age or younger undergoing OC or C1–2 fusion are not at an increased risk of spinal deformity or subaxial instability. Longer follow-up periods, during which measurements of the spinal canal are taken, will be necessary to determine precisely how children’s spines grow and remodel after an upper cervical spine fusion.