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Jodi L. Smith and Laurie L. Ackerman

Previous studies have shown that the correct use of car safety seats can protect infants and children from vehicular injury. Although child passenger devices are increasingly used in the US, motor vehicle crashes continue to be the leading cause of death and acquired disability in infants and children younger than 14 years of age. These events are likely related, at least in part, to the high percentage of children who are unrestrained or improperly restrained. The authors present 2 cases of severe cervical spine trauma in young children restrained in car safety seats during a motor vehicle crash: 1) a previously healthy 14-month-old girl who was improperly restrained in a forward-facing booster seat secured to the vehicle by a lap belt, and 2) a previously healthy 30-month-old girl who was a rear seat passenger restrained in a car safety seat. This study points out the unique challenges encountered in treating cervical spine injuries in infants and young children, as well as the lessons learned, and emphasizes the significance of continuing efforts to increase family and public awareness regarding the importance of appropriate child safety seat selection and use.

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Laurie L. Ackerman, Daniel H. Fulkerson, Andrew Jea, and Jodi L. Smith

OBJECTIVE

Patients with shunts often interact with providers distant from their primary hospital, making it important that the parent(s)/guardian(s) is well versed in the type of shunt implanted and symptoms of malfunction/infection. This is particularly important with magnetic-sensitive programmable valves, as the use of MRI becomes more prevalent.

METHODS

Over a 6-month period, primary caregivers of 148 consecutive patients who received shunts were prospectively administered questionnaires at clinic visits. Caregivers were asked to do the following: 1) identify shunt valve name, type, and setting if applicable; 2) list symptoms of shunt malfunction/infection; and 3) indicate whether they had access to references regarding shunt type/setting, booklets from the Hydrocephalus Association, and quick reference cards with symptoms of shunt malfunction/infection. One cohort of caregivers (n = 75) was asked to carry informational cards with shunt valve/setting information (group I); this cohort was compared with another subgroup of caregivers (n = 73) not carrying cards (group II).

RESULTS

The mean (± SD) age of patients at implantation/revision was 3.71 ± 4.91 years, and the age at follow-up was 6.12 ± 5.4 years. The average time from surgery to administration of the questionnaire was 2.38 ± 3.22 years. There were 86 new shunt insertions and 62 revisions. One hundred twenty-eight caregivers (87%) could identify the type of valve (programmable vs nonprogrammable). On the other hand, only 72 caregivers (49%) could identify the valve name. Fifty-four of 73 (74%) caregivers of patients who had shunts with programmable valves could correctly identify the valve setting. One hundred caregivers (68%) had a copy of the Hydrocephalus Association booklet, and 103 (70%) had quick reference cards. Eighty caregivers (54%) had references on shunt type/setting. Most caregivers (127 [86%]) could name ≥ 3 signs/symptoms of shunt malfunction, with vomiting (61%), headache (49%), and sleeps more/lethargic (35%) most frequently reported. Caregivers of patients in group I were more likely to have cards with symptoms of shunt infection or malfunction (p = 0.015); have information cards regarding shunt type/setting (p < 0.001); and correctly identify valve type (p = 0.001), name (p < 0.001), and setting if programmable (p = 0.0016). There were no differences in ability to list symptoms of shunt malfunction or infection (p = 0.8812) or in access to Hydrocephalus Association booklets (p = 0.1288). There were no significant demographic differences between the groups, except that group I patients had a shorter time from surgery to last follow-up (1.66 vs 3.17 years; p = 0.0001).

CONCLUSIONS

Education regarding the care of patients with shunts by providing written cards with shunt type/setting and access to reference materials seems to be effective. Developing plans for guided instruction with assessment in the clinic setting of a caregiver’s knowledge is important for patient safety.

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Andrea G. Scherer, Ian K. White, Kashif A. Shaikh, Jodi L. Smith, Laurie L. Ackerman, and Daniel H. Fulkerson

OBJECTIVE

The risk of venous thromboembolism (VTE) from deep venous thrombosis (DVT) is significant in neurosurgical patients. VTE is considered a leading cause of preventable hospital deaths and preventing DVT is a closely monitored quality metric, often tied to accreditation, hospital ratings, and reimbursement. Adult protocols include prophylaxis with anticoagulant medications. Children’s hospitals may adopt adult protocols, although the incidence of DVT and the risk or efficacy of treatment is not well defined. The incidence of DVT in children is likely less than in adults, although there is very little prospectively collected information. Most consider the risk of DVT to be extremely low in children 12 years of age or younger. However, this consideration is based on tradition and retrospective reviews of trauma databases. In this study, the authors prospectively evaluated pediatric patients undergoing a variety of elective neurosurgical procedures and performed Doppler ultrasound studies before and after surgery.

METHODS

A total of 100 patients were prospectively enrolled in this study. All of the patients were between the ages of 1 month and 12 years and were undergoing elective neurosurgical procedures. The 91 patients who completed the protocol received a bilateral lower-extremity Doppler ultrasound examination within 48 hours prior to surgery. Patients did not receive either medical or mechanical DVT prophylaxis during or after surgery. The ultrasound examination was repeated within 72 hours after surgery. An independent, board-certified radiologist evaluated all sonograms. We prospectively collected data, including potential risk factors, details of surgery, and details of the clinical course. All patients were followed clinically for at least 1 year.

RESULTS

There was no clinical or ultrasound evidence of DVT or VTE in any of the 91 patients. There was no clinical evidence of VTE in the 9 patients who did not complete the protocol.

CONCLUSIONS

In this prospective study, no DVTs were found in 91 patients evaluated by ultrasound and 9 patients followed clinically. While the study is underpowered to give a definitive incidence, the data suggest that the risk of DVT and VTE is very low in children undergoing elective neurosurgical procedures. Prophylactic protocols designed for adults may not apply to pediatric patients.

Clinical trial registration no.: NCT02037607 (clinicaltrials.gov)

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Daniel T. Cater, Colin M. Rogerson, Michael J. Hobson, Laurie L. Ackerman, and Courtney M. Rowan

OBJECTIVE

The aim of this study was to determine the association of postoperative dexmedetomidine with markers of pain in children undergoing Chiari malformation decompression. The authors hypothesized that patients receiving dexmedetomidine postoperatively would have decreased cumulative opiate use. They further hypothesized that there would be no difference in median pain scores, outcomes, or medication adverse events.

METHODS

An IRB-approved retrospective cohort study of patients undergoing Chiari malformation decompression from December 1, 2015, to December 31, 2018, was performed. Patients aged 0–21 years who underwent intradural Chiari malformation decompression at a single institution were included. Data for those who used dexmedetomidine postoperatively were compared with those who did not use dexmedetomidine. The primary outcome was cumulative opiate use throughout hospitalization. Secondary outcomes included pain scores, ancillary medication use, adverse events, hospital and ICU length of stay, readmission rates, and hospital cost.

RESULTS

The authors reviewed the records of 172 patients who underwent Chiari malformation decompression. Of those patients, 86 received dexmedetomidine postoperatively and 86 did not. Demographics were not different between the groups. Patients who received dexmedetomidine postoperatively received more doses of dexamethasone and were also more frequently exposed to dexmedetomidine intraoperatively (p = 0.028). Patients who received dexmedetomidine postoperatively used fewer morphine equivalents during their admission (1.02 mg/kg vs 1.43 mg/kg, p = 0.003). The patients who received dexmedetomidine postoperatively also had lower median pain scores on postoperative day 0 (0 vs 2, p < 0.001), lower median pain scores throughout the entire admission (1 vs 2, p < 0.001), and lower maximum pain scores recorded (6 vs 8, p = 0.005). Adjusting for steroid dose number and intraoperative dexmedetomidine exposure, postoperative dexmedetomidine remained associated with lower opiate dosing, lower pain scores on postoperative day 0, lower scores throughout hospital stay, and lower maximum pain scores. Patients who received dexmedetomidine had shorter hospital lengths of stay by 19 hours (p < 0.001). There were no statistically significant differences in medication adverse events or hospital costs between the two groups.

CONCLUSIONS

Postoperative dexmedetomidine use was associated with decreased opiate use, lower pain scores, and shorter hospital length of stay in this cohort. Dexmedetomidine may be considered as a safe adjuvant medication that may have opiate-sparing effects for this patient population.

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Neal B. Patel, Matthew A. Hazzard, Laurie L. Ackerman, and Eric M. Horn

Unstable pediatric cervical spine injuries present significant challenges in terms of fixation. Given the smaller cervical vertebral bodies in the preschool-aged population, commercially available pediatric cervical fixation instrumentation may be unsuitable because of the inappropriately large size of the screws and plates. The authors describe a 2-year-old girl who sustained an unstable C6–7 distraction injury during a motor vehicle accident. Because of the small size of her vertebral bodies, standard cervical spine instrumentation was not feasible, and posterior wiring alone was believed to be insufficient because of the complete distraction of all 3 spinal columns. The patient was taken to the operating room where craniofacial plates with an inherent locking mechanism were used to circumferentially stabilize the cervical spine. Follow-up examination 6 months postoperatively demonstrated stable cervical spine alignment and fusion with no evidence of the failure of either the anterior or posterior hardware. The use of craniofacial miniplates with an intrinsic locking mechanism represents a superior alternative for both anterior and posterior cervical fixations when spinal instrumentation is needed in the pediatric age group.

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Katarzyna Kania, Kashif Ajaz Shaikh, Ian Kainoa White, and Laurie L. Ackerman

OBJECTIVE

Concerns about mild traumatic brain injury (mTBI) have increased in recent years, and neurosurgical consultation is often requested for patients with radiographic abnormalities or clinical findings suspicious for mTBI. However, to the authors' knowledge, no study has used the Acute Concussion Evaluation (ACE) tool to systematically evaluate the evolution of symptoms in patients with mTBI during neurosurgical follow-up. The goal in this study was to evaluate symptom progression in pediatric patients referred for neurosurgical consultation by using the ACE, as endorsed by the Centers for Disease Control and Prevention.

METHODS

The authors performed a retrospective review of records of consecutive pediatric patients who had presented to the emergency department, were diagnosed with possible mTBI, and were referred for neurosurgical consultation. Outpatient follow-up for these patients included serial assessment using the ACE. Data collected included the mechanisms of the patients' injuries, symptoms, follow-up duration, and premorbid conditions that might potentially contribute to protracted recovery.

RESULTS

Of 91 patients identified with mTBI, 58 met the inclusion criteria, and 33 of these had sufficient follow-up data to be included in the study. Mechanisms of injury included sports injury (15 patients), isolated falls (10), and motor vehicle collisions (8). Ages ranged from 5 to 17 years (mean age 11.6 years), and 29 of the 33 patients were male. Six patients had preinjury developmental and/or psychiatric diagnoses such as attention deficit hyperactivity disorder. Seventeen had negative findings on head CT scans. The first follow-up evaluation occurred at a mean of 30 days after injury. The mean number of symptoms reported on the ACE inventory at first follow-up were 3.2; 12 patients were symptom free. Patients with positive head CT findings required longer follow-up: these patients needed 14.59 weeks, versus 7.87 weeks of follow-up in patients with negative findings on head CT scans (p < 0.05).

CONCLUSIONS

The data suggest that patients with mTBI, particularly those with developmental and/or psychiatric comorbidities and concurrent cerebral or extracranial injury, often report symptoms for several weeks after their initial injury. Serial ACE assessment permits systematic identification of patients who are experiencing continued symptoms, leading to appropriate patient management and referral.

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Laurie L. Ackerman, Timothy C. Ryken, G. Patrick Kealey, and Vincent C. Traynelis

High-voltage electrical injuries have been reported to cause a plethora of neurological complications including cognitive, motor, and sensory deficits in an immediate or delayed fashion. In this setting, new-onset symptomatic hydrocephalus requiring CSF shunt placement has not been described. The authors present the case of an 18-year-old man who sustained a high-voltage electrical injury with a calvarial contact point that required emergency CSF diversion within hours of injury and subsequently required placement of a lumboperitoneal shunt. Management of the open calvarial wound, which required rotational flap reconstruction, and the need for ongoing CSF diversion required care and a team approach.

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Charles G. Kulwin, Neal B. Patel, Laurie L. Ackerman, Jodi L. Smith, Joel C. Boaz, and Daniel H. Fulkerson

Object

The surgical management of patients with symptoms of tethered cord syndrome (TCS) who lack significant radiographic abnormalities is controversial. One potential MRI marker for TCS is a spinal cord syrinx or syringomyelia. Alternatively, a syrinx may be a benign and incidental finding. In this report the authors evaluated a highly selected cohort of patients with symptoms of TCS with minimal radiographic abnormalities other than syringomyelia. They analyzed clinical and radiographic outcomes after tethered cord release (TCR).

Methods

A retrospective review of data from 16 children who met the study inclusion criteria was performed. All patients had been surgically treated at Riley Hospital for Children in Indianapolis, Indiana, between 2006 and 2011. All children had clinical symptoms of TCS as well as available pre- and postoperative MRI data.

Results

The most common presentation (12 [75%] of 16 patients) was urinary dysfunction, defined as symptoms of urgency or incontinence with abnormal urodynamic studies. Clinical follow-up data were available in 11 of these 12 patients. All 11 had improvement in symptoms at an average follow-up of 17 months. Seven (87.5%) of 8 patients presenting with back or leg pain had improvement. Three patients had progressive scoliosis; 2 had stabilization of the curve or mild improvement, and 1 patient had worsening deformity.

Radiographic follow-up data were obtained an average of 14.5 months after surgery. Twelve patients (75%) had stable syringomyelia after TCR. Four patients showed improvement, with 2 having complete radiographic resolution.

Conclusions

Highly selected patients with symptoms of TCS did very well clinically. Patients with abnormal urodynamic studies, pain, and gait disturbances showed a high rate of symptomatic improvement. However, a smaller percentage of patients had radiographic improvement of the syrinx. Therefore, the authors suggest that the decision to perform TCR should be based on clinical symptoms in this population. Symptomatic improvement was not necessarily related to radiographic resolution of the syrinx.

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Daniel H. Fulkerson, Todd D. Vogel, Abdul A. Baker, Neal B. Patel, Laurie L. Ackerman, Jodi L. Smith, and Joel C. Boaz

Object

The optimal treatment of symptomatic posterior fossa arachnoid cysts is controversial. Current options include open or endoscopic resection, fenestration, or cyst-peritoneal shunt placement. There are potential drawbacks with all options. Previous authors have described stenting a cyst into the ventricular system for supratentorial lesions. The current authors have used a similar strategy for posterior fossa cysts.

Methods

The authors performed a retrospective review of 79 consecutive patients (1993–2010) with surgically treated intracranial arachnoid cysts.

Results

The authors identified 3 patients who underwent placement of a stent from a posterior fossa arachnoid cyst to a supratentorial ventricle. In 2 patients the stent construct consisted of a catheter placed into a posterior fossa arachnoid cyst and connecting to a lateral ventricle catheter. Both patients underwent stent placement as a salvage procedure after failure of open surgical fenestration. In the third patient a single-catheter cyst-ventricle stent was stereotactically placed. All 3 patients improved clinically. Two patients remained asymptomatic, with radiographic stability in a follow-up period of 1 and 5 years, respectively. The third patient experienced initial symptom resolution with a demonstrable reduction of intracystic pressure. However, he developed recurrent headaches after 2 years.

Conclusions

Posterior fossa cyst–ventricle stenting offers the benefits of ease of surgical technique and a low morbidity rate. It may also potentially reduce the incidence of shunt-related headaches by equalizing the pressure between the posterior fossa and the supratentorial compartments. While fenestration is considered the first-line therapy for most symptomatic arachnoid cysts, the authors consider cyst-ventricle stenting to be a valuable additional strategy in treating these rare and often difficult lesions.

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Melinda A. Costa, Laurie L. Ackerman, Sunil S. Tholpady, S. Travis Greathouse, Youssef Tahiri, and Roberto L. Flores

Patients with multisutural craniosynostosis can develop anomalous venous connections between the intracranial sinuses and cutaneous venous system through enlarged emissary veins. Cranial vault remodeling in this subset of patients carries the risk of massive intraoperative blood loss and/or occlusion of collateral draining veins leading to intracranial venous hypertension and raised intracranial pressure, increasing the morbidity of cranial expansion. The authors report the use of spring-mediated expansion as a technique for cranial reconstruction in which the collateral intracranial venous drainage system can be preserved.

A patient with bilateral lambdoid, sagittal, and unicoronal synostosis presented for cranial reconstruction. A tracheostomy and ventriculoperitoneal shunt were placed prior to intervention. At the time of reconstruction, a Luckenschadel skull abnormality and Chiari malformation Type I were present. A preoperative CT venogram demonstrated large collateral superficial occipital veins, small bilateral internal jugular veins, and hypoplastic jugular foramina. Collateral flow from the transverse and sigmoid sinuses through large occipital emissary veins was seen. Spring-mediated cranial vault expansion was performed with care to preserve the large collateral veins at the occipital midline. Four springs were placed at each lambdoid and the posterior and anterior sagittal sutures following 1-cm strip suturectomies. Removal of the springs was performed 2 months postoperatively.

Cranial vault expansion was performed without disturbing the aberrant intracranial/extracranial venous collateral system. Estimated blood loss was 150 ml. A CT scan obtained 3 months postoperatively showed resolution of the Luckenschadel deformity and a 40% volumetric increase in the skull compared with the preoperative CT.

Patients with anomalous venous drainage patterns and multisutural synostosis can undergo spring-mediated cranial vault expansion while preserving the major emissary veins draining the intracranial sinuses. Risks of blood loss, intracranial venous hypertension, and increased intracranial pressure may be decreased compared with traditional techniques of repair.