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Scott Elton and W. Jerry Oakes

Dermal sinus tracts in the spine range from asymptomatic pits to tracts with significant disease. These tracts may be associated with lesions that tether the spinal cord and can either become infected or produce neurological deficits. Over time the treatment of these lesions has varied little: complete resection and intradural exploration are the standard surgical interventions. The authors review their experience with 23 dermal sinus tracts treated in the last 19 years by the senior author. The clinical findings, radiographic appearance, treatment, and pathological findings of these lesions will be discussed. The authors will also provide a summary of the literature covering these lesions.

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Jeffrey P. Blount and Scott Elton

Lipomas of the spinal cord are among the most fascinating lesions encountered by the pediatric neurosurgeon. An understanding of spinal lipomas may, however, be difficult because the terminology used to describe the accumulations of spinal fat is confusing, inconsistently applied, and at times contradictory. An anatomical characterization of lipomas may assist in understanding these lesions. Lipomas of the spinal cord are very rare and cause symptoms related to mass effect and secondary compressive myelopathy. Lipomas of the conus medullaris (or lipomyelomeningocele) are the most common form of fatty masses in the spine and can be divided into dorsal, caudal, and transitional forms. These lesions are a manifestation of occult spinal dysraphism and a common cause of the tethered cord syndrome (TCS). The natural history of untreated lipomyelomeningocele, although incompletely understood, appears to be progressive neurological deterioration with loss of bladder control. Timely, careful surgical intervention may prevent significant neurological deterioration and progressive disability in the majority of children harboring these lesions. In surgical intervention the surgeon seeks to disrupt the connection between the fibrofatty mass and underlying cord as well as to reestablish normal anatomical planes. Several intraoperative video segments illustrating lipomyelome-ningocele resection are included in this paper. Lipomas of the terminal filum (fatty filum) are truly occult and are also associated with TCS. Surgical treatment of filum lipomas carries significantly lower risk than that for lipomas of the conus medullaris. Again, the goal of surgery is to disrupt the connection between the abnormal fibrofatty tissue and the underlying spinal cord.

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Michael J. Cools, Carolyn S. Quinsey and Scott W. Elton

OBJECTIVE

The choice of graft material for duraplasty in decompressions of Chiari malformations remains a matter of debate. The authors present a detailed technique for harvesting ligamenta nuchae, as well as the clinical and radiographic outcomes of this technique, in a case series.

METHODS

The authors conducted a retrospective study evaluating the outcomes of Chiari malformation type I decompression and duraplasty in children aged 0–18 years at a single institution from 2013 to 2016. They collected both intraoperative and postoperative variables and compared them qualitatively to published data.

RESULTS

During the study period, the authors performed 25 Chiari malformation decompressions with ligamentum nuchae graft duraplasties. Of the 25 patients, 10 were females, and the mean age at surgery was 8.6 years (range 13 months to 18 years). The median operative time was 163 minutes (IQR 152–187 minutes), with approximately 10 minutes needed by a resident surgeon to harvest the graft. The mean length of stay was 3 nights (range 2–6 nights), and the mean follow-up was 12.6 months (range 0.5–43.5 months). One patient (4%) developed a CSF leak that was repaired using an oversewing patch. There were no postoperative pseudomeningoceles or infections. Of the 19 patients presenting with a syrinx, imaging showed improvement in 10 (53%) and 8 (42%) had stable syrinx size on imaging. Of 16 patients presenting with a symptomatic Chiari malformation, 14 (87.5%) experienced resolution of symptoms and in 1 (4%) symptoms remained the same. One patient (4%) presented with worsening syrinx and symptoms 1.5 months after initial surgery and underwent repeat decompression.

CONCLUSIONS

The authors describe a series of clinical and imaging outcomes of patients who underwent Chiari malformation decompression and duraplasty with a harvested ligamentum nuchae. The rates of postoperative CSF leak are similar to established techniques of autologous and artificial grafts, with similarly successful outcomes. Further study will be needed with larger patient cohorts to more directly compare duraplasty graft outcomes.

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Brandon Miller, Mirza Baig, John Hayes and Scott Elton

Object

The authors performed an analysis of retrospectively obtained data to compare the outcomes of pediatric patients admitted to their institution for traumatic injuries resulting from car, motorcycle, and all-terrain vehicle (ATV) accidents.

Methods

The authors conducted a retrospective review of Columbus Children’s Hospital’s Trauma Registry data collected between January 1993 and December 2003. Data obtained in patients admitted with motor vehicle–related injuries were compiled for a total of 1608 patient records. Data regarding sex, age, hospital length of stay (LOS), Glasgow Coma Scale (GCS) score, revised trauma score, injury severity score (ISS), and use of a protective device were analyzed.

Conclusions

Of 1608 patients, 1257 (78%) were injured in automobile accidents, 123 (7.6%) in motorcycle accidents, and 228 (14.2%) in ATV accidents. Injuries sustained in all vehicle types peaked during the summer months. Patients involved in automobile crashes presented with significantly lower GCS scores than those injured in motorcycle and ATV accidents; however, there was no statistically significant difference in LOS among all three injury modalities. Protective devices were underutilized in all three motor vehicle categories but, when used, were associated with significantly higher GCS scores, ISSs, and shorter LOSs among patients admitted after automobile accidents. The correlation of seat belt use with better outcomes underscores the necessity to improve motor vehicle safety education for children, who are less likely to be restrained as they age.

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R. Shane Tubbs, George Salter, Scott Elton, Paul A. Grabb and W. Jerry Oakes

Object. Historically, the sagittal suture has been used as an external landmark to indicate the middle portion of the superior sagittal sinus (SSS). The goal of this study was to verify this relationship.

Methods. The authors examined 30 adult cadavers to reveal the location of the SSS with respect to the sagittal suture. Their findings demonstrated that the SSS is deviated to the right of the sagittal suture in the majority of observed specimens, although the maximum displacement to the right side was never more than 11 mm.

Conclusions. This information should be useful to the neurosurgeon who must be aware of the SSS and its relationship with superficial skull landmarks.

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Mirza N. Baig, Ali Raza, Moumen Asbahi and Scott Elton

Object

In this study, retrospective data analysis was performed to analyze the utility of head computed tomography (CT) scanning in the diagnosis of Chiari malformation Type I (CM-I) in the pediatric population.

Methods

The authors conducted a retrospective review of radiology charts describing head CT results obtained at Columbus Children's Hospital between January 2004 and January 2005. The records were searched for the key words “Chiari,” “cerebellar ectopy,” or “tonsillar ectopy.” The exclusion criteria included patients with previously known Chiari malformation Type I or Type II or those who had undergone follow-up magnetic resonance (MR) imaging at other institutions. Head CT and MR images for the remaining patients were reviewed to verify accuracy.

Results

Of the 72 patients with suspicious findings of tonsillar ectopy on CT, only 37 (51.4%) had MR imaging findings consistent with CM-I. The tonsillar ectopy in these patients ranged from 3 mm to 17 mm below the foramen magnum.

Conclusions

The authors' findings indicate that incidental standard CT scans of the head have limited value in identifying CM-I.

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Chris S. Karas, Mirza N. Baig and Scott W. Elton

Object

The authors review all cases in which ventriculosubgaleal (VSG) shunts were placed at Columbus Children's Hospital for the treatment of posthemorrhagic hydrocephalus in order to assess the surgical procedure, effectiveness of surgery, and complications of cerebrospinal fluid diversion to the subgaleal space. The purpose of the review is to make a comparison between cases in which shunts were placed in the operating room (OR) and those in which they were placed in the neonatal intensive care unit (NICU). Considerations and complications specific to patient transport to the OR or surgical implantation in the NICU are discussed.

Methods

Seventeen infants with posthemorrhagic hydrocephalus were treated with VSG shunt placement over a period of 4 years. A retrospective analysis of these cases was performed to evaluate multiple aspects of the procedure. Specifically, the surgical procedure, duration of shunt function prior to shunt conversion, neuroimaging changes, operative complications, and risk of infection are discussed. The authors also performed a comparative analysis of shunt placement in the NICU and the OR.

Results

The length of the procedure was similar in the two locations. No differences in perioperative or intraoperative risks and no increased risk of infection were seen in either location in this pilot study. Interestingly, the mean lifespan of primary implants placed in the NICU (73 days) was longer than that of those placed in the OR (43 days).

Conclusions

Ventriculosubgaleal shunt placement offers a safe and effective temporary means of treating post-hemorrhagic hydrocephalus and can be reliably and safely performed at the bedside.

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Weston Northam, Avinash Chandran, Carolyn Quinsey, Andrew Abumoussa, Alex Flores and Scott Elton

OBJECTIVE

Skull fractures represent a common source of morbidity in the pediatric trauma population. This study characterizes the type of follow-up that these patients receive and discusses predictive factors for follow-up.

METHODS

The authors reviewed cases of nonoperative pediatric skull fractures at a single academic hospital between 2007 and 2017. Clinical patient and radiological fractures were recorded. Recommended neurosurgical follow-up, follow-up appointments, imaging studies, and fracture-related complications were recorded. Statistical analyses were performed to identify predictors for outpatient follow-up and imaging.

RESULTS

The study included 414 patients, whose mean age was 5.2 years; 37.2% were female, and the median length of stay was 1 day (IQR 0.9–4 days). During 438 clinic visits and a median follow-up period of 8 weeks (IQR 4–12, range 1–144 weeks), 231 imaging studies were obtained, mostly head CT scans (55%). A total of 283 patients were given recommendations to attend follow-up in the clinic, and 86% were seen. Only 12 complications were detected, including 7 growing skull fractures, 2 traumatic encephaloceles, and 3 cases of hearing loss. Primary care physician (PCP) status and insurance status were associated with a recommendation of follow-up, actual follow-up compliance, and the decision to order outpatient imaging in patients both with and without intracranial hemorrhage. PCP status remained an independent predictor in each of these analyses. Follow-up compliance was not associated with a patient’s distance from home. Among patients without intracranial hemorrhage, a follow-up recommendation and actual follow-up compliance were associated with pneumocephalus and other polytraumatic injuries, and outpatient imaging was associated with a bilateral fracture. No complications were found in patients with linear fractures above the skull base in those without an intracranial hemorrhage.

CONCLUSIONS

Pediatric nonoperative skull fractures drive a large expenditure of clinic and imaging resources to detect a relatively small profile of complications. Understanding the factors underlying the decision for clinic follow-up and additional imaging can decrease future costs, resource utilization, and radiation exposure. Factors related to injury severity and socioeconomic indicators were associated with outpatient imaging, the decision to follow up patients in the clinic, and patients’ subsequent attendance. Socioeconomic status (PCP and insurance) may affect access to appropriate neurosurgical follow-up and deserves future research attention. Patients with no intracranial hemorrhage and with a linear fracture above the skull base do not appear to be at risk for delayed complications and could be candidates for reduced follow-up and imaging.

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Weston Northam, Kristi Hildebrand, Scott Elton and Carolyn Quinsey