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Dominic A. Harris and Sandi Lam

Object

The risk of venous thromboembolism (VTE) in children with traumatic brain injury (TBI) has not been well characterized given its rarity in the pediatric population. Investigation of risk factors for VTE in this group requires the use of a large sample size. Using nationally representative hospital discharge data for 2009, the authors of this study characterize the incidence and risk factors for VTE in children hospitalized for TBI.

Methods

The authors conducted a cross-sectional study using data from the Healthcare Cost and Utilization Project Kids' Inpatient Database to examine VTE in TBI-associated hospitalizations for patients 20 years of age or younger during the year 2009.

Results

There were 58,529 children with TBI-related admissions, including 267 with VTE diagnoses. Venous thromboembolisms occurred in 4.6 per 1000 TBI-associated hospitalizations compared with 1.2 per 1000 pediatric hospitalizations overall. By adjusted logistic regression, patients significantly more likely to be diagnosed with VTE had the following: older age of 15–20 years (adjusted odds ratio [aOR] 3.7, 95% CI 1.8–8.0), venous catheterization (aOR 3.0, 95% CI 2.0–4.6), mechanical ventilation (aOR 1.9, 95% CI 1.2–2.9), tracheostomy (aOR 2.3, 95% CI 1.3–4.0), nonaccidental trauma (aOR 2.8, 95% CI 1.1–6.9), increased length of stay (aOR 1.02, 95% CI 1.01–1.03), orthopedic surgery (aOR 2.4, 95% CI 1.8–3.4), and cranial surgery (aOR 1.8, 95% CI 1.1–2.8).

Conclusions

Using the Kids' Inpatient Database, the authors found that risk factors for VTE in the setting of TBI in the pediatric population include older age, venous catheterization, nonaccidental trauma, increased length of hospital stay, orthopedic surgery, and cranial surgery.

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Sandi Lam and Larry T. Khoo

Object

Vertebroplasty and kyphoplasty are minimally invasive procedures used to treat persistently symptomatic vertebral compression fractures (VCFs). Both interventions usually involve injection of polymethyl methacrylate (PMMA). The purpose of this technical note was to review the theory and surgical technique for a novel percutaneous system for fracture reduction and stabilization of VCFs by using bone graft.

Methods

This technical note highlights the Optimesh system as an alternative method of minimally invasive VCF reduction and stabilization with the delivery of a bone graft containment device. Instead of using PMMA as in vertebroplasty or kyphoplasty, this system allows the delivery of allograft and/or autograft bone, with its osteoinductive, osteoconductive, and osteogenic properties.

Conclusions

This system allows for restoration of sagittal alignment of the spine with direct control of bone graft delivery by using a mesh graft containment device that allows for ingrowth of new bone and vascular tissue.

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Sandi Lam, Ulrich Batzdorf and Marvin Bergsneider

Object

The most commonly reported treatment of primary syringomyelia has been laminectomy with duraplasty or direct shunting from the syrinx cavity. Diversion of cerebrospinal fluid (CSF) from the spinal subarachnoid space to peritoneal, atrial, or pleural cavities has been described previously in only a few case reports. Shunting of the CSF from the subarachnoid space rostral to the level of myelographic blockage may reduce the filling force of the syrinx cavity and avoids myelotomy and manipulation of the spinal cord parenchyma. The authors report on 7 patients who underwent thecal shunt placement for primary spinal syringomyelia.

Methods

This study is a retrospective review of a consecutive series. The authors reviewed the medical records and neuroimaging studies of 7 adult patients with posttraumatic, postsurgical, or postinflammatory syringomyelia treated with thecoperitoneal, thecopleural, or thecoatrial shunt placement at the University of California Los Angeles Medical Center. Myelographic evidence of partial or complete CSF flow obstruction was confirmed in the majority of patients. The mean duration of follow-up was 33 months (range 6–104 months).

Results

Six (86%) of 7 patients showed signs of clinical improvement, whereas 1 remained with stable clinical symptoms. Of the 6 patients with available postoperative imaging, each demonstrated a reduction in syrinx size. Three patients (43%) had ≥ 1 complication, including shunt-induced cerebellar tonsillar descent in 1 patient and infections in 2.

Conclusions

If laminectomy with duraplasty is not possible for the treatment of primary syringomyelia, placement of a thecoperitoneal shunt (or thecal shunt to another extrathecal cavity) should be considered. Although complications occurred in 3 of 7 patients, the complication rate was outweighed by a relatively high symptomatic and imaging improvement rate.

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Sandi Lam, Ramesh Grandhi and Stephanie Greene

Meconium staining of open myelomeningoceles has been reported to occur both prenatally and postnatally, but meconium staining of the brainstem has not been previously documented. The authors present a case of meconium staining of the brainstem in an infant with a meconium-stained myelomeningocele, Chiari malformation Type II, and hydrocephalus and discuss possible implications for prenatal and perinatal care.

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Aditya Vedantam, Daniel Hansen, Bradley Daniels and Sandi Lam

The authors report an unusual case of acute, rapidly progressive, unilateral neck swelling following extubation after elective left anterior temporal lobectomy with amygdalohippocampectomy. Due to severe neck swelling, the patient developed critical airway compromise, brachial plexopathy, and Horner's syndrome. After critical airway management and appropriate rehabilitation, the patient recovered completely and remains seizure free at 1.5 years of follow-up.

This case highlights the importance of early recognition of acute postoperative sialadenitis and the steps needed to prevent serious morbidity and possible mortality from this rare complication.

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Caroline Hadley, Carrie A. Mohila, Thomas G. Luerssen and Sandi Lam

In infants, the presence of a cranial defect may be due to a variety of traumatic, inflammatory, neoplastic, and congenital abnormalities. Differentiation between these possible etiologies is facilitated by clinical presentation, patient history, and physical examination. Congenital cutaneous neural crest–derived lesions are unlikely to be considered in a patient presenting with an asymptomatic cranial defect without overlying mass or skin pigmentation. The authors present an unusual case of a 2-month-old infant with an asymptomatic calvarial defect with normal overlying skin. Pathology of the excised tissue showed features consistent with a congenital neurocristic tumor: a pigmented, neural crest–derived hamartomatous tumor that typically presents as a melanotic skin lesion.

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Yimo Lin, I-Wen Pan, Rory R. Mayer and Sandi Lam

OBJECT

Research conducted using large administrative data sets has increased in recent decades, but reports on the fidelity and reliability of such data have been mixed. The goal of this project was to compare data from a large, administrative claims data set with a quality improvement registry in order to ascertain similarities and differences in content.

METHODS

Data on children younger than 12 months with nonsyndromic craniosynostosis who underwent surgery in 2012 were queried in both the Kids’ Inpatient Database (KID) and the American College of Surgeons Pediatric National Surgical Quality Improvement Program (Peds NSQIP). Data from published clinical craniosynostosis surgery series are reported for comparison.

RESULTS

Among patients younger than 12 months of age, a total of 1765 admissions were identified in KID and 391 in Peds NSQIP in 2012. Only nonsyndromic patients were included. The mean length of stay was 3.2 days in KID and 4 days in Peds NSQIP. The rates of cardiac events (0.5% in KID, 0.3% in Peds NSQIP, and 0.4%-2.2% in the literature), stroke/intracranial bleeds (0.4% in KID, 0.5% in Peds NSQIP, and 0.3%-1.2% in the literature), infection (0.2% in KID, 0.8% in Peds NSQIP, and 0%-8% in the literature), wound disruption (0.2% in KID, 0.5% in Peds NSQIP, 0%-4% in the literature), and seizures (0.7% in KID, 0.8% in Peds NSQIP, 0%-0.8% in the literature) were low and similar between the 2 data sets. The reported rates of blood transfusion (36% in KID, 64% in Peds NSQIP, and 1.7%-100% in the literature) varied between the 2 data sets.

CONCLUSIONS

Both the KID and Peds NSQIP databases provide large samples of surgical patients, with more cases reported in KID. The rates of complications studied were similar between the 2 data sets, with the exception of blood transfusion events where the retrospective chart review process of Peds NSQIP captured almost double the rate reported in KID.

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Kathryn Wagner, Francisco Vaz-Guimaraes, Kevin Camstra and Sandi Lam

OBJECTIVE

Appropriately chosen candidates with medically refractory epilepsy may benefit from hemispheric disconnection. Traditionally, this involves a large surgical exposure with significant associated morbidity. Minimally invasive approaches using endoscopic assistance have been described by only a few centers. Here, the authors report on the feasibility of endoscope-assisted functional hemispherotomy in a cadaver model and its first translation into clinical practice in appropriately selected patients.

METHODS

Three silicone-injected, formalin-fixed cadaver heads were used to establish the steps of the procedure in the laboratory. The steps of disconnection were performed using standard surgical instruments and a straight endoscope. The technique was then applied in two patients who had been referred for hemispherectomy and had favorable anatomy for an endoscope-assisted approach.

RESULTS

All disconnections were performed in the cadaver model via a 4 × 2–cm paramedian keyhole craniotomy using endoscopic assistance. An additional temporal burr hole approach was marked in case the authors were unable to completely visualize the frontobasal and insular cuts from the paramedian vertical view. Their protocol was subsequently used successfully in two pediatric patients. Full disconnection was verified with postoperative tractography.

CONCLUSIONS

Full hemispheric disconnection can be accomplished with minimally invasive endoscope-assisted functional hemispherotomy. The procedure is technically feasible and can be safely applied in patients with favorable anatomy and pathology; it may lead to less surgical morbidity and faster recovery.

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Kimberly A. Foster, Sandi Lam, Yimo Lin and Stephanie Greene

Object

Tethered cord (TC) is a neurological disorder caused by tissue attachments that limit the normal movement of the spinal cord. A TC can be unmasked by a cutaneous abnormality or manifest clinically in myriad neurological, urological, and orthopedic symptoms. The relationship between TC and height is previously unknown. This study investigates the association between TC release and changes in height profiles in the pediatric population.

Methods

Fifty-two children undergoing first-time TC release at a single institution were examined retrospectively. Clinical symptoms, radiographic findings, pre- and postoperative height, and height-for-age percentiles were recorded and analyzed.

Results

Children with TC experienced a statistically significant increase in age-adjusted height percentiles after TC release (p = 0.0028), with a mean increase of 7 percentile points (from 48.1st to 54.9th percentile). When stratified by age, children 5 years or older (5–18 years) demonstrated a mean percentile increase of 10 percentile points (from 46.7th to 56.4th percentile) (p = 0.0001). Among the same age group, this effect scaled significantly with age (p = 0.02, beta coefficient −1.3). There was no significant difference in height-for-age after detethering surgery in children younger than 5 years. There was no significant association between the presence of clinical symptoms or specific radiographic findings and height outcomes after surgery. Overall, 56% of TC-related clinical symptoms improved after detethering (mean follow-up 4.6 months). Among children younger than 5 years, 82% of TC-related clinical symptoms improved after detethering (average follow-up 4.5 months); in children 5–18 years, 47% of symptoms improved after detethering (average follow-up 4.8 months).

Conclusions

The authors observed a statistically significant gain in height-for-age percentiles in children undergoing surgical release of TC. The authors' data suggest that such gains may be more significant in older children (≥ 5 years) and the increase appears to scale positively with youth in the older cohort. In this study, postoperative height gains did not appear to correlate with the presence of TC-related clinical symptoms or radiographic findings. Further investigation is necessary to elucidate any potential correlation between release of TC and height changes in children postoperatively.