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Jorge A. Lazareff, Marcelo Galarza, Tooraj Gravori and Theodore J. Spinks

Object. The authors report their experience with 15 pediatric patients who underwent resection or shrinkage of the cerebellar tonsils without craniectomy or laminectomy, for the management of Chiari I malformation.

Methods. The procedure was performed in six boys and nine girls with a mean age of 10 years. Thirteen patients presented with the congenital form of this disorder and two patients with Chiari I malformation caused by lumboperitoneal shunting. Clinical complaints included headaches (seven patients), scoliosis (four patients), numbness of the extremities (four patients), and upper-limb weakness (two patients). Two patients presented with failure to thrive and one with vocal cord palsy. Eight patients (six girls and two boys) had syringomyelia. The patients' symptoms had developed within a mean time period of 21 months (range 1–70 months). In all patients the cerebellar tonsils were exposed through a dura mater—arachnoid incision at the occipitoatlantal space. In seven patients the tonsils were resected and in the remaining eight patients the tonsils were shrunk by coagulating their surfaces.

All patients improved postoperatively. Gliosis with cortical atrophy was observed in the resected neural tissue. Syringomyelia was reduced in seven of eight patients. The mean length of the follow-up period was 7 months.

Conclusions. Removal of herniated cerebellar tonsils can be sufficient for alleviating symptoms in patients with Chiari I malformations.

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Matthew J. Tormenti, Matthew A. Adamo, Jose M. Prince, Timothy D. Kane and Theodore J. Spinks

Ventriculoperitoneal (VP) shunt placement is the most common surgical treatment for hydrocephalus. Laparoscopic techniques to aid in the placement of the peritoneal portion have been reported previously. Laparoscopic shunt placement has been associated with decreased operating time, less blood loss, and shorter hospital stays. The authors describe a single-incision laparoscopic shunt (SILS) insertion technique that facilitates directed placement of the peritoneal portion of the catheter in children. A total of 6 pediatric patients underwent the SILS procedure between December 2008 and March 2009. This cohort included 5 girls and 1 boy; the average age was 6 years (range 1 day–16 years). One patient had previously undergone a VP shunt placement, but all other patients were undergoing the initial creation of their shunt. The most common pathological condition encountered was posttraumatic hydrocephalus (2 patients). All patients underwent successful placement of the peritoneal catheters. All catheters were seen to have CSF flowing freely within the peritoneal space.

The authors' recent experience shows that SILS placement is safe and feasible in children. It allows accurate, directed placement of the VP shunt with a single, almost invisible, umbilical incision. The shunt tubing is remote from this incision.

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Edward H. Oldfield

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Shelly D. Timmons, Dana Waltzman, Ann-Christine Duhaime, Theodore J. Spinks and Kelly Sarmiento

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Todd C. Hankinson, Eli Grunstein, Paul Gardner, Theodore J. Spinks and Richard C. E. Anderson

Object

In rare cases, children with a Chiari malformation Type I (CM-I) suffer from concomitant, irreducible, ventral brainstem compression that may result in cranial neuropathies or brainstem dysfunction. In these circumstances, a 360° decompression supplemented by posterior stabilization and fusion is required. In this report, the authors present the first experience with using an endoscopic transnasal corridor to accomplish ventral decompression in children with CM-I that is complicated by ventral brainstem compression.

Methods

Two children presented with a combination of occipital headaches, swallowing dysfunction, myelopathy, and/or progressive scoliosis. Imaging studies demonstrated CM-I with severely retroflexed odontoid processes and ventral brainstem compression. Both patients underwent an endoscopic transnasal approach for ventral decompression, followed by posterior decompression, expansive duraplasty, and occipital-cervical fusion.

Results

In both patients the endoscopic transnasal approach provided excellent ventral access to decompress the brainstem. When compared with the transoral approach, endoscopic transnasal access presents 4 potential advantages: 1) excellent prevertebral exposure in patients with small oral cavities; 2) a surgical corridor located above the hard palate to decompress rostral pathological entities more easily; 3) avoidance of the oral trauma and edema that follows oral retractor placement; and 4) avoidance of splitting the soft or hard palate in patients with oral-palatal dysfunction from ventral brainstem compression.

Conclusions

The endoscopic transnasal approach is atraumatic to the oral cavity, and offers a more superior region of exposure when compared with the standard transoral approach. Depending on their comfort level with endoscopic surgical techniques, pediatric neurosurgeons should consider this approach in children with pathological entities requiring ventral brainstem decompression.