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Nathan R. Selden

The theme of the 65th Annual Meeting of the Congress of Neurological Surgeons and the title of this presidential address focus on mentorship as a valuable service owed to the profession of neurological surgery by its members, a crucial tool for the education of new neurosurgeons, and a fundamental contributor to the progress of the specialty. The author explores the origin of the term “mentor” in Homeric tradition and the impact of mentorship on the historical legacy of neurological surgery. He outlines the role mentorship played in his own professional development, as well as the changing face of mentorship today due to increasing numbers of women in neurosurgery.

Many surgeons perceive modern educational approaches as threats to the tradition of personal mentorship in medicine. The author argues that intentional educational methods, such as the Society of Neurological Surgeons (SNS) “matrix” curriculum, the Accreditation Council for Graduate Medical Education “milestones,” and the SNS “boot camp” courses, each focus, enhance, and empower, but do not replace, personal mentorship. The author further describes the important role of mentorship in the definition, growth, and health of the specialty of neurological surgery and in the personal well-being and fulfillment of its practitioners.

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Nathan R. Selden

Object

Controversy exists regarding proper indications for surgical lysis of the terminal filum in children with voiding dysfunction and tethered spinal cord. Recently, surgery has been offered to children who have a normally positioned conus medullaris and no terminal filum abnormality visible on 1.5-tesla magnetic resonance images (referred to as minimal or occult tethered cord syndrome [TCS]). The author evaluates existing clinical and scientific evidence relevant to this controversy.

Methods

Five retrospective, observational, noncontrolled studies of surgical terminal filum lysis for occult TCS in children were identified. Two further studies in which the authors reported surgical results in children with a normal-level conus medullaris were also identified.

Conclusions

These studies document encouraging clinical outcomes following surgery. Clinicopathological evidence suggests that occult TCS may result from radiographically occult structural abnormalities of the terminal filum. Although a preponderance of Class III clinical evidence supports the use of surgical filum lysis to treat occult TCS, no Class I or II evidence exists. Clinical practice varies; therefore, performance of a prospective randomized clinical trial of surgical terminal filum lysis for the treatment of occult TCS is advocated.

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Farhad M. Limonadi and Nathan R. Selden

Object. The choice of surgical technique for decompressive surgery in patients with Chiari I malformation is controversial. Good preliminary postoperative outcomes have been achieved in patients with Chiari I malformation (without syringomyelia) after using a dura-splitting technique. The authors evaluated safety, resource use, and early outcome after this surgery in patients without syringomyelia and compared the findings associated with duraplasty in patients with syringomyelia.

Methods. A prospective series of 24 patients with Chiari I malformation (12 with a syrinx) underwent decompression of the craniocervical junction (CCJ). An allograft-augmented duraplasty was performed in patients with syringomyelia. Intraoperative ultrasonography confirmed adequate tonsillar decompression after lysis of the periosteal bands at the foramen magnum and C-1 arch as well as partial resection of the outer leaf of the dura in patients without syringomyelia. Patients in each group were of similar mean age (syringomyelia 10.8 years and no syringomyelia 7.6 years old; p = 0.07) and functional status. The mean follow-up period was 15.3 months (range 3–30 months). Dura-splitting decompression required significantly less mean operative time (99 minutes compared with 169 minutes, respectively; p < 0.001), total operating room time (166 minutes compared with 249 minutes, respectively; p < 0.001), duration of hospitalization (3 days compared with 3.75 days, respectively; p < 0.05), perioperative charges ($3615 compared with $5538, respectively; p < 0.001), and overall hospital charges ($7705 compared with $9759, respectively; p < 0.001) than the duraplasty. Mean clinical outcome scores were similar (syringomyelia 1.53 of 2; no syringomyelia 1.67 of 2; not statistically significant).

Conclusions. Dura-splitting CCJ decompression in pediatric patients with Chiari I malformation and without syringomyelia is safe, provides good early clinical results, and significantly reduces resource use. A randomized controlled trial of dura-splitting decompression in a uniform population of patients with Chiari I malformation is indicated.

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Nathaniel L. Whitney and Nathan R. Selden

Object

The authors describe a method of securing an external ventricular drain (EVD) to prevent dislodgement and discourage CSF leakage and infection.

Methods

The EVD is secured using a single permanent suture, creating a box stitch around the exit site attached to a modified roman sandal. Multiple knots are tied after each loop to avoid “telescoping,” loosening, and pullout.

Results

In 12 years of high-volume pediatric practice by one of the authors, only one drain has broken, and none have pulled out.

Conclusions

The modified roman sandal technique tightly secures EVDs against pullout. Anecdotal evidence suggests that the strength of the suture construct securing the drain is greater than that of the drain tubing itself.

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Nathan R. Selden

✓Traditionally, surgical division of the terminal filum (filum terminale) has been reserved for patients with imaging-apparent spinal cord tethering. The occurrence of medically refractory voiding dysfunction of neurogenic origin, without magnetic resonance (MR) imaging documentation of abnormality in the spine, has been termed “minimal” tethered cord syndrome (TCS). The rationale for and utility of using surgical division of the terminal filum in the treatment of minimal TCS are unproven.

Six studies that involved surgical division of the terminal filum for minimal TCS were identified and reviewed. A seventh study conducted prior to the MR imaging era, in which authors used myelography, was also included. In addition, two investigations of the clinicopathological findings in such cases were analyzed. A tripartite criterion for justifying the introduction of a new surgical indication is proposed and analyzed in light of this evidence.

In children with minimal TCS there are definite pathological changes in the terminal filum that are not visible on routine spinal MR imaging. These changes suggest that the pathophysiology of minimal TCS, like TCS that is demonstrated on neuroimaging, may involve abnormal traction on the distal spinal cord. Additional data are needed regarding the sensitivity and specificity of various clinical studies intended to identify children with minimal TCS. All existing data supporting the efficacy of surgery for minimal TCS have been generated by Class III studies. Clinical equipoise exists for this surgical indication, and, therefore, a prospective randomized trial should be completed.

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Susan R. Durham, Kenneth C. Liu and Nathan R. Selden

Object

The purpose of this study was to evaluate the risk of progression of traumatic intracranial lesions in children by comparing initial and subsequent computed tomography (CT) scans. Reserving repeated CT imaging for patients who harbor higher-risk lesions may reduce overall radiation exposure, the need for sedative agents, and cost.

Methods

The authors performed a retrospective cohort study in 268 patients younger than 18 years of age who underwent repeated CT scanning within 24 hours of their initial CT scanning procedure. The risk of progression between the initial and repeated CT scanning sessions and the need for delayed neurosurgical intervention were determined for each lesion type.

In 54 patients (20.1%) the normal findings on the initial CT study did not change on subsequent imaging. In 61 (28.5%) of the 214 patients in whom abnormal findings were present on the initial scan, progression was demonstrated. Patients with epidural hematoma (EDH; odds ratio [OR] 12.29), subdural hematoma (SDH; OR 3.18), cerebral edema (OR 9.34), and intraparenchymal hemorrhage (IPH; OR 18.3) were found to be at a significantly increased risk for progression and to require delayed neurosurgical intervention (OR 11.91). No significantly increased risk was found for patients with subarachnoid hemorrhage (SAH), intraventricular hemorrhage (IVH), diffuse axonal injury (DAI), or skull fracture.

Conclusions

Repeated CT imaging in children with high-risk lesions such as EDH, SDH, cerebral edema, and IPH is recommended. However, in children with low-risk lesions, such as SAH, IVH, DAI, and isolated skull fractures but no sign of clinical deterioration, repeated imaging may be less likely to alter the clinical management scheme. The limited benefits of undertaking repeated imaging in these patients should be weighed against the risks of radiation exposure, sedation, intrahospital transportation, and patient monitoring.

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Seth F. Oliveria, Eric M. Thompson and Nathan R. Selden

Sacrococcygeal teratomas may arise in association with regional developmental errors affecting the caudal embryonic segments and may originate within lumbosacral lipomas. It is therefore possible that sacrococcygeal teratomas and lumbosacral lipomas represent related disorders of embryogenesis. Accordingly, the authors report the cases of 2 siblings. The first child (female) was born with a mature Altman Type III sacrococcygeal teratoma that was resected when she was a neonate. Subsequently, a younger brother was found soon after birth to have an L-4–level lipomyelomeningocele and underwent partial resection and spinal cord untethering at 4 months of age. Although familial forms of each of these conditions have been reported, this is, to the authors' knowledge, the first reported occurrence of lipomyelomeningocele and sacrococcygeal teratoma in siblings. They propose that an inherited regional tendency to developmental error affecting the caudal embryonic segments was shared by these siblings and resulted in spinal teratoma formation in one of them.

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Susan E. Wozniak, Eric M. Thompson and Nathan R. Selden

Object

Vagal nerve stimulator (VNS) hardware infections are fraught with difficult management decisions. As with most implanted medical device–related infections, standard practice traditionally involves complete hardware removal, systemic antibiotic therapy, and subsequent reimplantation of the device. To avoid the potential morbidity of 2 repeat left carotid sheath surgical dissections, the authors have implemented a clinical protocol for managing VNS infections that involves generator removal and antibiotic therapy without lead removal.

Methods

A prospective, single-surgeon database was compared with hospital billing records to identify patients who underwent primary implantation or reimplantation of a VNS lead, generator, or both, from January 2001 to May 2010, at Oregon Health & Science University. From these records, the authors identified patients with VNS hardware infections and characterized their management, using a lead salvage protocol.

Results

In their review, the authors found a matching cohort of 206 children (age 3 months–17 years) who met the inclusion criteria. These children underwent 258 operations (including, in some children, multiple operations for generator end of life and/or lead malfunction). Six children experienced a single postimplantation infection (2.3% of the 258 operative cases), and no child experienced repeated infection. A lead-salvage protocol was used in 4 of 6 infected patients and was successful in 3 (75%), with clinical follow-up ranging from 10 months to 7.5 years. The fourth patient subsequently underwent lead removal and later reimplantation in standard fashion, with no adverse sequelae.

Conclusions

Vagal nerve stimulator lead salvage is a safe and potentially advantageous strategy in the management of VNS-related infection. Further study is necessary to validate appropriate patient selection, success rates, and risks of this approach.

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Brian D. Duty, Susan E. Wozniak and Nathan R. Selden

Congenital central hypoventilation syndrome (CCHS) is a rare, idiopathic disorder characterized by a failure of automatic respiration. Abnormalities such as seizure disorder, failure to thrive, and Hirschsprung disease have been associated with CCHS. In this report, the authors discuss the use of vagal nerve stimulation (VNS) to treat a medically refractory seizure disorder in a child who had previously undergone placement of bilateral phrenic nerve stimulators for treatment of CCHS. Concomitant use of phrenic and vagal nerve stimulators has not previously been reported in the literature. No adverse reactions were noted with both devices working. Diaphragmatic pacing (DP) was clinically unaffected by VNS. The patient experienced a marked reduction in seizure frequency and severity following vagal nerve stimulator placement. Based on this case, the authors conclude that VNS is a potentially safe and efficacious treatment option for seizure disorder associated with CCHS in patients undergoing DP.