Neurosurgery Blog

Neurosurg Focus 31 (5):E5, 2011. DOI: 10.3171/2011.8.FOCUS11177

Traumatic brain injury (TBI) is the current leading cause of death in children over 1 year of age. Adequate management and care of pediatric patients is critical to ensure the best functional outcome in this population.

In their controversial trial, Cooper et al. concluded that decompressive craniectomy following TBI did not improve clinical outcome of the analyzed adult population. While the study did not target pediatric populations, the results do raise important and timely clinical questions regarding the effectiveness of decompressive surgery in pediatric patients. There is still a paucity of evidence regarding the effectiveness of this therapy in a pediatric population, and there is an especially noticeable knowledge gap surrounding age-stratified interventions in pediatric trauma.

The purposes of this review are to first explore the anatomical variations between pediatric and adult populations in the setting of TBI. Second, the authors assess how these differences between adult and pediatric populations could translate into differences in the impact of decompressive surgery following TBI.

J Neurosurg Pediatrics 8:171-176, 2011.DOI: 10.3171/2011.5.PEDS1139

Nonaccidental head trauma (NAHT) is a major cause of death in infants. During the current economic recession, the authors noticed an anecdotal increase in infants with NAHT without an increase in the overall number of infants admitted with traumatic injuries. An analysis was performed to determine whether there was an association between economic recession and NAHT.

Methods. With Institutional Review Board approval, the trauma database was searched for NAHT in infants 0–2 years old during nonrecession (December 2001 to November 2007) and recession (December 2007 to June 2010) periods. Incidence is reported as infants with NAHT per month summarized over time periods. Continuous variables were compared using Mann-Whitney U-tests, and proportions were compared using the Fisher exact test.

Results. Six hundred thirty-nine infant traumas were observed during the study time period. From the nonrecession to the recession period, there was an 8.2% reduction in all traumas (458 in 72 months [6.4 /month] vs 181 in 31 months [5.8/month]) and a 3.5% reduction in accidental head traumas (142 in 72 months [2.0/month] vs 59 in 31 months [1.9/month]). Nonaccidental head trauma accounted for 14.6% of all traumas (93/639). The median patient age was 4.0 months and 52% were boys. There were no significant differences in the representative counties of referral or demographics between nonrecession and recession populations (all p > 0.05). The monthly incidence rates of NAHT doubled from nonrecession to recession periods (50 in 72 months [0.7/month] vs 43 in 31 months [1.4/month]; p = 0.01). During this recession, at least 1 NAHT was reported in 68% of the months compared with 44% of the months during the nonrecession period (p = 0.03). The severity of NAHTs also increased, with a greater proportion of deaths (11.6% vs 4%, respectively; p = 0.16) and severe brain injury (Glasgow Coma Scale score ≤ 8: 19.5% vs 4%, respectively; p = 0.06) during the recession.

Conclusions. In the context of an overall reduction in head trauma, the significant increase in the incidence of NAHT appears coincident with economic recession. Although the cause is likely multifactorial, a full analysis of the basis of this increase is beyond the scope of this study. This study highlights the need to protect vulnerable infants during challenging economic times.

Neurosurgery 68[ONS Suppl 2]:ons250–ons256, 2011 DOI: 10.1227/NEU.0b013e31821421b9

Balloon kyphoplasty is widely used to treat vertebral compression fractures. Procedure outcome and safety are directly linked to precise radiological imaging requiring 1 or 2 C arms to allow correct visualization throughout the procedure. This minimally invasive spinal surgery is associated with radiation exposure for both patient and surgeon. In our center, we switched from using a C-arm to an O-arm image guidance system to perform balloon kyphoplasty. Our preliminary experience is reported in Acta Neurochirurgica, and the encouraging results led us to study this subject more extensively. This article presents our complete results. To the best of our knowledge, there is no comparable clinical series describing O-arm use in kyphoplasty procedures published in the literature. OBJECTIVE: To report our complete results of using the O-arm guidance system to perform balloon kyphoplasty.

METHODS: We prospectively evaluated O-arm–guided kyphoplasty procedure in 54 consecutive patients and measured x-ray exposure and fluoroscopy time.

RESULTS: The mean surgical time for the procedure was 38 minutes with a mean fluoroscopy procedure time of 3.1 minutes. The mean fluoroscopy time by level was 2.5 minutes. Mean irradiation dose by procedure was 220 mGy and by level was 166 mGy. There was a significant reduction in fluoroscopy time and x-ray exposure from 5.1 minutes with classic C-arm use to 3.1 minutes when with O-arm use without additional time required for positioning the system.

CONCLUSION: With this new intraoperative system, the overall surgical and fluoroscopy times can be further reduced in the near future.

Neurosurgery 68:85–88, 2011 DOI: 10.1227/NEU.0b013e3181fd85f4

Intracranial pressure is routinely monitored in patients with severe traumatic brain injury (TBI). Patients with TBI sometimes develop hydrocephalus, requiring permanent cerebrospinal fluid (CSF) diversion. OBJECTIVE: To quantify the need for permanent CSF diversion in patients with TBI. METHODS: Patients who received a ventriculostomy after TBI between June 2007 and July 2008 were identified, and their medical records were abstracted to a database. RESULTS: Sixteen of 71 patients (22.5%) receiving a ventriculostomy required a ventriculoperitoneal or ventriculoatrial shunt before discharge from the hospital. The average number of days between ventriculostomy and shunt was 18.3. Characteristics that predispose these patients to require permanent CSF diversion include the need for craniotomy within 48 hours of admission (odds ratio, 5.20; 95% confidence interval, 1.48-18.35) and history of culture-positive CSF (odds ratio, 5.52; 95% confidence interval, 1.19-25.52). Length of stay was increased in patients receiving permanent CSF diversion (average length of stay, 61 vs 31 days; P = .04). Patient discharge disposition was similar between shunted and nonshunted patients. CONCLUSION: In this retrospective study, 22% of TBI patients who required a ventriculostomy eventually needed permanent CSF diversion. Patients with TBI should be assessed for the need for permanent CSF diversion before discharge from the hospital. Care must be taken to prevent ventriculitis. Future studies are needed to evaluate more thoroughly the risk factors for the need for permanent CSF diversion in this patient population.

J Neurosurg 113:982–989, 2010. DOI: 10.3171/2009.11.JNS09674

The object of this study was to propose an alternative procedure to the classic decompressive hemicraniectomy using an “in-window” craniotomy and a “bridgelike” duraplasty.

Methods. The authors performed a large, almost rectangular craniotomy involving the frontal, temporal, and parietal bones and part of the occipital squama in 5 patients. The dura mater is opened and its area is enlarged using a rectangular dural patch of the surgeon’s choice in the form of a bridge between the anterior and posterior dural edges. With a vertical cut, the bone flap is divided into 2 similarly sized pieces that function as “window lids.” The outer frontal and occipital sides of the bone are tied to the skull border at 2 points to function as a hinge joint. The angle of the bone cut must be beveled outward (inclination ~ 45° of the bone drill or saw) to allow the bone flap to rest on the adjacent skull and prevent its slippage toward the intracranial cavity.

Results. The above procedures were performed with effective control of intracranial hypertension due to cerebral venous sinus thrombosis, brain trauma, intracerebral hematoma, or malignant cerebral ischemia.

Conclusions. Decompressive surgery, which uses an in-window craniotomy that gradually opens according to the intracranial pressure, is an alternative solution for deploying autologous material. The procedure has the advantage of obviating the need for a second surgical procedure to close the bone defect, and thus preventing the metabolic cerebral impairment associated with the absence of an overlying skull.

J Neurosurg 113:581–584, 2010. DOI: 10.3171/2009.10.JNS09930

Traumatic brain injury (TBI) is a major cause of serious morbidity and mortality. The incidence is 100–500/100,000 inhabitants/year. Chronic pituitary dysfunction is increasingly recognized after TBI. To define the incidence of endocrine dysfunction and risk factors, the authors describe a prospectively assessed group of patients in whom they documented hormonal functions, early diagnosis, and treatment of neuroendocrine dysfunction after TBI.

Methods. Patients aged 18–65 years were prospectively observed from the time of injury to 1 year postinjury; the Glasgow Coma Scale score ranged from 3 to 14. Patients underwent evaluation of hormonal function at the time of injury and at 3, 6, and 12 months postinjury. Magnetic resonance imaging was also conducted at 1 year postinjury.

Results. During the study period, 89 patients were observed. The mean age of the patients was 36 years, there were 23 women, and the median Glasgow Coma Scale score was 7. Nineteen patients (21%) had primary hormonal dysfunction. Major deficits included growth hormone dysfunction, hypogonadism, and diabetes insipidus. Patients in whom the deficiency was major had a worse Glasgow Outcome Scale score, and MR imaging demonstrated empty sella syndrome more often than in patients without a deficit.

Conclusions. To the authors’ knowledge, this is the third largest study of its kind worldwide. The incidence of chronic hypopituitarism after TBI was higher than the authors expected. After TBI, patients are usually observed on the neurological and rehabilitative wards, and endocrine dysfunction can be overlooked. This dysfunction can be life threatening and other clinical symptoms can worsen the neurological deficit, extend the duration of physiotherapy, and lead to mental illness. The authors recommend routine pituitary hormone testing after moderate or severe TBI within 6 months and 1 year of injury.

J Spinal Disord Tech 2010;23:317–320

Objective: To analyze geriatric patients with Type II odontoid fractures treated either with rigid cervical orthosis (CO) or surgery (Odontoid Screw or Transarticular screw).

Summary of Background Data: Our literature search did not yield any studies on the outcome of Type II odontoid fractures in geriatric population treated with the rigid CO. We therefore designed a study to analyze geriatric patients with Type II odontoid fractures treated with either rigid cervical collar or surgery.

Materials and Methods: This is a retrospective chart review of patients with Type II odontoid fractures between July 1998 and June 2006. Inclusion criteria consists of males and females of 70 years of age or older with Type II odontoid fractures who were treated with rigid cervical collar or surgery. Exclusion criteria were displacement >4mm, posteriorly displaced fracture, neurologic compromise, multilevel cervical spine injury, and treatment in a halo vest. Medical comorbidities were assessed using the Modified Cumulative Illness Rating Scale for Geriatrics. Primary outcomes were mortality and fusion (union, stable nonunion, nonunion). Minimum of 3 months follow-up was acceptable.

Results: One hundred eighty four odontoid fractures were identified in 8 years. Twenty patients met our inclusion criteria (9 treated in rigid collar and 11 treated surgically). Median follow-up was 5.5 months. Out of 20 patients, 4 patients died (1 treated in CO, 3 treated surgically). Cumulative Illness Rating Scale for Geriatrics index was highest in patient treated in CO. In the rigid collar group, 6 patients had union (66.6%), and 2 developed stable nonunion (22.2%); whereas in the surgically treated group, 7 patients had union (87.5%), and 1 patient developed nonunion (12.5%).

Conclusions: Patients treated nonoperatively in rigid collar seem to have an overall favorable outcome. A well-designed prospective study, to compare the outcomes of surgical intervention with nonsurgical management of Type II odontoid in elderly is recommended

Journal of Neurosurgery, June 2010. DOI: 10.3171/2010.4.JNS10132

J Neurosurg Anesthesiol 2009;21:339–345

Objective: To assess the intracranial hemodynamic modifica- tions induced by a decompressive craniectomy (DC) after severe traumatic brain injury (TBI), using transcranial Doppler (TCD) ultrasonography and intracranial pressure (ICP) sensor. Mor- tality rate and neurological outcomes were also evaluated after this procedure.

Design: A prospective study was carried out on 26 TBI patients, measuring transcranial Doppler and ICP before, immediately after, and 48 hours after the DC, allowing for statistical analysis of hemodynamic changes. The mortality rate and the neuro- logical outcomes were assessed.

Measurements and Results: After DC, ICP decreased from 37±17 to 20±13mm Hg (P=0.0003). The global cerebral blood flow was modified with diastolic velocities rising from 23±15 to 31±13cm/s (P=0.0038) and a pulsatility index decreasing from 1.70±0.66 to 1.18±0.37 (P=0.0012). This normalization of the global cerebral hemodynamics after the DC was immediate, symmetric, and constant during the first 48 hours. Outcome was evaluated at 6 months: good recovery or moderate disability was observed in 11 patients (42%), persistent vegetative state in 7 patients (27%), and 8 patients died (31%).

Conclusions: The DC results in a significant, immediate, and durable improvement of ICP associated with a normalization of cerebral blood flow velocities in most TBI patients with refractory intracranial hypertension.

J Neurosurg Anesthesiol 2009;21:339–345

A prospective study was carried out on 26 TBI patients, measuring transcranial Doppler and ICP before, immediately after, and 48 hours after the DC, allowing for statistical analysis of hemodynamic changes. The mortality rate and the neuro- logical outcomes were assessed.

Measurements and Results: After DC, ICP decreased from 37±17 to 20±13mm Hg (P=0.0003). The global cerebral blood flow was modified with diastolic velocities rising from 23±15 to 31±13cm/s (P=0.0038) and a pulsatility index decreasing from 1.70±0.66 to 1.18±0.37 (P=0.0012). This normalization of the global cerebral hemodynamics after the DC was immediate, symmetric, and constant during the first 48 hours. Outcome was evaluated at 6 months: good recovery or moderate disability was observed in 11 patients (42%), persistent vegetative state in 7 patients (27%), and 8 patients died (31%).

Conclusions: The DC results in a significant, immediate, and durable improvement of ICP associated with a normalization of cerebral blood flow velocities in most TBI patients with refractory intracranial hypertension.

Pediatr Neurosurg 2009;45:262–270. DOI: 10.1159/000228984

Objectives: The aim of this study was to describe the characteristics of patients with a minor head injury (MHI) who were admitted to a pediatric emergency unit and to identify the clinical signs and symptoms that most reliably predict the need for cranial computed tomography (CCT) and hospital admission following MHI.

Methods: All patients were retrospectively evaluated according to age, gender, details of injury, presenting symptoms, physical examination findings, radiological investigations ordered and results, length of stay, outcome of the injury and hospitalization rates.

Results:The factors affecting indications for computed tomography and hospitalization were retrospectively analyzed in 916 patients – 585 males and 331 females, aged between 1month and 15 years (mean: 5.01 8 3.58 years), with MHI. A multivariate analysis revealed significant correlations between CCT abnormalities and Glasgow Coma Scale scores of 13 or 14, headache, posttraumatic amnesia, blurred vision, cephalohematomas, periorbital ecchymoses, otorrhea and abnormal neurological findings. CCT abnormalities were identified in 67 (19.8%) of the 338 CCT scans. Twenty of the 67 patients (29.9%) with CCT scan abnormality had no clinical signs. Of all cases, 125 (13.6%) were hospitalized, 617 (67.4%) were treated as outpatients, and 174 (19.0%) left the emergency department based on a personal decision.

Conclusion: Some clinical risk factors can be used as predictors of abnormalities in CCT scans following MHI, but the absence of such clinical findings does not exclude the possibility of intracranial injuries.

JNS Spine DOI: 10.3171/2009.5.SPINE08866

Object. Occipital condyle fractures (OCFs) are rare injuries and their treatment remains controversial. Several classification systems have been proposed, first by Anderson and Montesano and more recently by Tuli and colleagues and Hanson and associates, who sought to stratify these fractures in a manner that would guide treatment that has typically ranged from semirigid collar immobilization to halo fixation or occipitocervical fusion. It has been the authors’ impression, based on experience with OCFs at their institution, that classification is cumbersome and contributes little to the clinical decision-making process, while the identification of craniocervical misalignment and neural element compromise is paramount, and sufficient, for the planning of treatment.

Methods. The authors performed a retrospective review of 24,745 consecutive trauma presentations to a single Level I trauma center (UPMC Presbyterian Hospital) over a 6-year period, identifying 100 patients with 106 OCFs. All patients were evaluated by the spine trauma service and underwent imaging of the craniocervical junction using reconstructed CT scans. Patient characteristics, fracture characteristics (including fracture classification according to the 2 major classification systems), initial management, and status at follow-up were recorded.

Results. The incidence of OCF in this trauma population was 0.4%. Two patients had evidence of craniocervical misalignment on reconstructed CT imaging at the time of admission; both patients underwent occipitocervical fusion. One patient underwent occipitocervical fusion for unrelated C1–2 fractures. The remainder of those surviving to discharge, whose fractures represented all fracture subtypes, received treatment with a rigid cervical collar or counseling alone. No patients, including 4 patients with bilateral OCFs, were found to have developed delayed craniocervical instability or misalignment on follow-up, or to require further neurosurgical intervention for an OCF. Neural element compression was not identified in any of the patients, and there were no cases of delayed cranial neuropathy.

Conclusions. Beyond the identification of craniocervical misalignment on reconstructed CT scans at admission, further classification of OCFs is unnecessary. Management should consist of up-front occipitocervical fusion or halo fixation in cases demonstrating occipitocervical misalignment, or of immobilization in a rigid cervical collar followed by delayed clinical and radiographic evaluation in a spine trauma clinic if misalignment is not present.

The Spine Journal 9, Issue 9, September 2009, Pages 780-788doi:10.1016/j.spinee.2009.04.003

An ideal classification system for thoracolumbar (TL) spine fractures should facilitate communication between treating physicians and guide treatment by means of outlining the natural history of injuries. The classification scheme should also be comprehensive, intuitive, and simple to implement. At the present time, no classification system fully meets these criteria. In this review, the authors attempt to describe the evolution of TL fracture classification systems from their inception to the present day.

The article reviews the salient classification systems that have addressed TL injuries since Boehler’s first attempt in 1929. This progression culminates in the Thoracolumbar Injury Severity Score/Thoracolumbar Injury Classification and Severity Score (TLISS/TLICS), a system which incorporates features from earlier scales and represents the most comprehensive grading scale to date.

Each successive system played an important role in advancing contemporary understanding of TL injuries. Most classifications were, however, based on a single individual’s, or a comparatively small group’s, retrospective review of a case series. In most instances, these grading systems were never validated or modified by their original developers, a shortcoming that prevented their continued evolution. Despite the many advantages of the TLISS/TLICS system, more work in terms of refining the classification and defining its validity remains to be performed.

The classification of TL injuries has evolved significantly over the course of the last 75 years. Most of these schemes were limited by their complexity, relevance, and/or poor reliability. The TLISS classification system represents the most recent evolution as it combines several important factors capable of guiding the management of TL injuries. Nonetheless, more research regarding this rating scale remains to be performed.