✓ A series of 8814 head-injured patients admitted to 41 hospitals in three separate metropolitan areas were prospectively studied. Of these, 1906 patients (21.6%) were 14 years of age or less. This “pediatric population” was compared to the remaining “adult population” for mechanism of injury, admission Glasgow Coma Scale score, motor score, blood pressure, pupillary reactivity, the presence of associated injuries, and the presence of subdural or epidural hematoma. The relationship of each of these factors was then correlated with posttraumatic mortality. Except for patients found to have subdural hematoma and those who were profoundly hypotensive, the pediatric patients exhibited a significantly lower mortality rate compared to the adults, thus confirming this generally held view. This study indicates that age itself, even within the pediatric age range, is a major independent factor affecting the mortality rate in head-injured patients.
A longitudinal prospective study of adult and pediatric head injury
Thomas G. Luerssen, Melville R. Klauber and Lawrence F. Marshall
Leslie Acakpo-Satchivi and Thomas G. Luerssen
✓The authors report an unusual case of cortical herniation into a chronic subdural hematoma (SDH). The patient was successfully treated with good outcome. A 4-month-old boy with a history of macrocrania and very large bilateral chronic SDHs underwent subduroperitoneal shunt treatment shortly after presentation. Eight months later he developed a new-onset seizure disorder, which was localized by electroencephalography to the right frontal region. Neuroimaging demonstrated the development of a focal herniation of the brain through a subdural membrane into the subdural space. The patient underwent a craniotomy to resect the seizure focus and the herniated cortex. The subdural shunt was subsequently replaced. After 2 years of follow-up, the patient remains free of seizures, is on no medication regimen, and is neurologically and developmentally normal. To the authors' knowledge, this is only the fourth report in the medical literature of cortical herniation through a chronic subdural membrane and the first in which successful treatment with a good outcome is described.
Loyola V. Gressot, Javier A. Mata, Thomas G. Luerssen and Andrew Jea
Spondyloptosis refers to complete dislocation of a vertebral body onto another. The L5–S1 level is frequently affected. As this condition is rare, few published reports describing its clinical features and surgical outcomes exist, especially in the pediatric patient population.
The authors report the presentation, pathological findings, and radiographic studies of a 2-year-old girl who presented to Texas Children's Hospital with a history since birth of progressive spastic paraparesis. Preoperative CT and MRI showed severe spinal cord compression associated with T11–12 spondyloptosis. The patient underwent a single-stage posterior approach for complete resection of the dysplastic vertebral bodies at the apex of the spinal deformity with reconstruction and stabilization of the vertebral column using a titanium expandable cage and pedicle screws. At the 12-month follow-up, the patient remained neurologically stable without any radiographic evidence of instrumentation failure or loss of alignment.
To the best of the authors' knowledge, there have been only 2 other children with congenital thoracolumbar spondyloptosis treated with the above-described strategy. The authors describe their case and review the literature to discuss the aggregate clinical features, surgical strategies, and operative outcomes for congenital thoracolumbar spondyloptosis.
Jonathan N. Sellin, Aditya Vedantam, Thomas G. Luerssen and Andrew Jea
The complication profile of epidural triamcinolone acetonide use during lumbar decompression surgery is not known. However, isolated reports of increased risk of delayed CSF leakage with the use of triamcinolone acetonide in adult spinal surgery patients have been published. The purpose of this study was to determine the safety of epidural triamcinolone acetonide use in conjunction with lumbar decompression surgery in pediatric patients.
The medical records of all patients who underwent lumbar decompression surgery with or without discectomy between July 1, 2007, and July 31, 2015, were retrospectively reviewed.
During the study period, 58 patients underwent 59 spine procedures at Texas Children's Hospital. There were 33 female and 25 male patients. The mean age at surgery was 16.5 years (range 12–24 years). Patients were followed for an average of 38.2 months (range 4–97 months). Triamcinolone acetonide was used in 28 (of 35 total) cases of discectomy; there were no cases of delayed symptomatic CSF leaks (0%) in the minimally invasive and open discectomies. On the other hand, triamcinolone acetonide was used in 14 (of 24 total) cases of multilevel laminectomy, among which there were 10 delayed CSF leaks (71.4%) requiring treatment. The use of triamcinolone acetonide in patients who underwent multilevel laminectomy was significantly associated with an increased risk of delayed CSF leaks or pseudomeningoceles (Fisher's exact test, p < 0.001).
There was an unacceptable incidence of delayed postoperative CSF leaks when epidural triamcinolone acetonide was used in patients who underwent multilevel laminectomy.
Christopher E. Wolfla, Thomas G. Luerssen and Robin M. Bowman
✓ A porcine model of regional intracranial pressure was used to compare regional brain tissue pressure (RBTP) changes during expansion of an extradural temporal mass lesion. Measurements of RBTP were obtained by placing fiberoptic intraparenchymal pressure monitors in the right and left frontal lobes (RF and LF), right and left temporal lobes (RT and LT), midbrain (MB), and cerebellum (CB). During expansion of the right temporal mass, significant RBTP gradients developed in a reproducible pattern: RT > LF = LT > RF > MB > CB. These gradients appeared early, widened as the volume of the mass increased, and persisted for the entire duration of the experiment. The study indicates that RBTP gradients develop in the presence of an extradural temporal mass lesion. The highest RBTP was recorded in the ipsilateral temporal lobe, whereas the next highest was recorded in the contralateral frontal lobe. The RBTP that was measured in either frontal lobe underestimated the temporal RBTP. These results indicated that if a frontal intraparenchymal pressure monitor is used in a patient with temporal lobe pathology, the monitor should be placed on the contralateral side and a lower threshold for therapy of increased intracranial pressure should be adopted. Furthermore, this study provides further evidence that reliance on a single frontal intraparenchymal pressure monitor may not detect all areas of elevated RBTP.
Caroline Hadley, Sandi K. Lam, Valentina Briceño, Thomas G. Luerssen and Andrew Jea
Currently there is no standardized tool for assessment of neurosurgical resident performance in the operating room. In light of enhanced requirements issued by the Accreditation Council for Graduate Medical Education’s Milestone Project and the Matrix Curriculum Project from the Society of Neurological Surgeons, the implementation of such a tool seems essential for objective evaluation of resident competence. Beyond compliance with governing body guidelines, objective assessment tools may be useful to direct early intervention for trainees performing below the level of their peers so that they may be given more hands-on teaching, while strong residents can be encouraged by faculty members to progress to conducting operations more independently with passive supervision. The aims of this study were to implement a validated assessment tool for evaluation of operative skills in pediatric neurosurgery and determine its feasibility and reliability.
All neurosurgery residents completing their pediatric rotation over a 6-month period from January 1, 2014, to June 30, 2014, at the authors’ institution were enrolled in this study. For each procedure, residents were evaluated by means of a form, with one copy being completed by the resident and a separate copy being completed by the attending surgeon. The evaluation form was based on the validated Objective Structured Assessment of Technical Skills for Surgery (OSATS) and used a 5-point Likert-type scale with 7 categories: respect for tissue; time and motion; instrument handling; knowledge of instruments; flow of operation; use of assistants; and knowledge of specific procedure. Data were then stratified by faculty versus resident (self-) assessment; postgraduate year level; and difficulty of procedure. Descriptive statistics (means and SDs) were calculated, and the results were compared using the Wilcoxon signed-rank test and Student t-test. A p value < 0.05 was considered statistically significant.
Six faculty members, 1 fellow, and 8 residents completed evaluations for 299 procedures, including 32 ventriculoperitoneal (VP) shunt revisions, 23 VP shunt placements, 19 endoscopic third ventriculostomies, and 18 craniotomies for tumor resection. There was no significant difference between faculty and resident self-assessment scores overall or in any of the 7 domains scores for each of the involved residents. On self-assessment, senior residents scored themselves significantly higher (p < 0.02) than junior residents overall and in all domains except for “time and motion.” Faculty members scored senior residents significantly higher than junior residents only for the “knowledge of instruments” domain (p = 0.05). When procedure difficulty was considered, senior residents’ scores from faculty members were significantly higher (p = 0.04) than the scores given to junior residents for expert procedures only. Senior residents’ self-evaluation scores were significantly higher than those of junior residents for both expert (p = 0.03) and novice (p = 0.006) procedures.
OSATS is a feasible and reliable assessment tool for the comprehensive evaluation of neurosurgery resident performance in the operating room. The authors plan to use this tool to assess resident operative skill development and to improve direct resident feedback.
Andrew Jea, Keyne K. Johnson, William E. Whitehead and Thomas G. Luerssen
The use of spinal instrumentation to stabilize the occipitocervical junction in pediatric patients has increased and evolved in recent years. Wiring techniques have now given way to screw-rod or screw-plate techniques with or without postoperative external immobilization. Although C-2 translaminar screws have been used in these constructs, subaxial translaminar screws have not, to date, been described in either the pediatric or adult patient populations.
The authors describe the feasibility of translaminar screw placement in the C-3 lamina. Rigid fixation with translaminar screws offers an alternative to subaxial fixation with lateral mass screws, allowing for formation of biomechanically sound spinal constructs and minimizing potential neurovascular morbidity. Their use requires careful analysis of preoperative imaging studies, intact posterior elements, and avoidance of violation of the inner laminar wall.
Richard C. Ostrup, Thomas G. Luerssen, Lawrence F. Marshall and Mark H. Zornow
✓ A No. 4 French fiberoptic catheter initially developed as an intravascular pressure sensor was incorporated into a system to be used as an intracranial pressure (ICP) monitor. Initially, a series of acute and chronic animal experiments carried out in the rabbit and pig, respectively, demonstrated the reliability and safety of the device. Subsequently, this new monitor was compared to a concurrently functioning ICP monitor in 15 adult and five pediatric patients. This clinical experience also confirmed the safety, accuracy, and reliability of the device. Since these initial studies, this monitor has been used to routinely measure ICP in a large number of adult and pediatric patients. The monitor has functioned well, and there have been no complications related to its use except for an occasional problem with breakage of the optic fiber as a result of patient movement or nursing maneuvers, which has been easily corrected by replacement of the probe. As nursing personnel and ancillary services have become familiar with this new monitor, breakage has not been a problem. This new device can be placed into the ventricular system, the brain parenchyma, or the subdural space, and appears to offer substantial advantages over other monitors presently in use.