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Hannah E. Goldstein, Neil A. Feldstein and Richard C. E. Anderson

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Atul Goel

Abstract (Jea et al.)

The authors describe the novel use of C-1 lateral mass screws in four children 8 years of age or younger, in whom occipitocervical or atlantoaxial fusion was performed for trauma or os odontoideum. The authors retrospectively reviewed the demographics and procedural data of four children, ranging in age from 2 to 8 years, who required and underwent surgical fixation. Although C1–2 screw/rod constructs involving individual C-1 lateral mass screws and C-2 pars interarticularis or pedicle screws have been widely applied in adults, only C1–2 transarticular screw fixation has been reported in children less than 8 years of age. This report demonstrates the successful results of rigid occipitocervical and atlantoaxial fusion in four children in whom C-1 lateral mass screws were placed as part of a screw/rod construct. There was one instance of a vertebral artery injury, and the lessons learned from this complication are discussed.

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Paul R. Gigante, Neil A. Feldstein and Richard C. E. Anderson

Os odontoideum is a common cause of atlantoaxial instability in the pediatric population. The authors present the cases of 2 patients whose initial clinical presentation and MR imaging findings were suggestive of an intramedullary neoplasm, but whose ultimate diagnosis was determined to be cervical spine instability and cord injury due to os odontoideum.

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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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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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Benjamin C. Kennedy, Michael B. Cloney, Richard C. E. Anderson and Neil A. Feldstein

OBJECT

Choroid plexus papillomas (CPPs) are rare neoplasms, often found in the atrium of the lateral ventricle of infants, and cause overproduction hydrocephalus. The extensive vascularity and medially located blood supply of these tumors, coupled with the young age of the patients, can make prevention of blood loss challenging. Preoperative embolization has been advocated to reduce blood loss and prevent the need for transfusion, but this mandates radiation exposure and the additional risks of vessel injury and stroke. For these reasons, the authors present their experience using the superior parietal lobule approach to CPPs of the atrium without adjunct therapy.

METHODS

A retrospective review was conducted of all children who presented to Columbia University/Morgan Stanley Children's Hospital of New York with a CPP in the atrium of the lateral ventricle and who underwent surgery using a superior parietal lobule approach without preoperative embolization.

RESULTS

Nine children were included, with a median age of 7 months. There were no perioperative complications or new neurological deficits. All patients had intraoperative blood loss of less than 100 ml, with a mean minimum hematocrit of 26.9% (range 19.6%–36.2%). No patients required a blood transfusion. The median follow-up was 39 months, during which time no patient demonstrated residual or recurrent tumor on MRI, nor did any have an increase in ventricular size or require CSF diversion.

CONCLUSIONS

The superior parietal lobule approach is safe and effective for very young children with CPPs in the atrium of the lateral ventricle. The results suggest that preoperative embolization is not essential to avoid transfusion or achieve overall good outcomes in these patients. This management strategy avoids radiation exposure and the additional risks associated with embolization.

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Todd C. Hankinson, Elizabeth J. Fontana, Richard C. E. Anderson and Neil A. Feldstein

The traditional reasons for surgical intervention in children with single-suture craniosynostosis (SSC) are cosmetic improvement and the avoidance/treatment of intracranial hypertension, which has been thought to contribute to neurocognitive deficits. Despite considerable work on the topic, the exact prevalence of intracranial hypertension in the population of patients with SSC is unknown, although it appears to be present in only a minority. Additionally, recent neuropsychological and anatomical literature suggests that the subtle neurocognitive deficits identified in children with a history of SSC may not result from external compression. They may instead reflect an underlying developmental condition that includes disordered primary CNS development and early suture fusion. This implies that current surgical techniques are unlikely to prevent neurocognitive deficits in patients with SSC. As such, the most common indication for surgical treatment in SSC is cosmetic, and most patients benefit from considerable subjective cosmetic normalization following surgery. Pediatric craniofacial surgeons have not, however, agreed upon objective means to assess postoperative cranial morphological improvement. We should therefore endeavor to agree upon objective craniometric tools for the assessment of operative outcomes, allowing us to accurately compare the various surgical techniques that are currently available.