Selective dorsal rhizotomy: Analysis of two rootlet sectioning techniques.

OBJECTIVE: To analyze and compare the efficacy of two selective dorsal rhizotomy (SDR) techniques with intraoperative neurophysiological monitoring, using instrumented three-dimensional gait analysis. INTRODUCTION: SDR is a common, irreversible surgical treatment increasingly used to address gait disturbances in children with chronic non-progressive encephalopathy by reducing spasticity. Various techniques have been used, which mainly differ in the percentage of rootlets selected for sectioning. A greater proportion of rootlets sectioned leads to a more effective reduction of spasticity; however, there is a potential risk of unwanted neurological effects resulting from excessive deafferentation. While there is evidence of the short- and long-term benefits and complications of SDR, no studies have compared the effectiveness of each technique regarding gait function and preservation of the force-generating capacity of the muscles. MATERIALS AND METHODS: Instrumented three-dimensional gait analysis was used to evaluate two groups of patients with spastic cerebral palsy treated by the same neurosurgeon in different time periods, initially using a classic technique (cutting 50% of the nerve rootlets) and subsequently a conservative technique (cutting no more than 33% the nerve rootlets). RESULTS: In addition to an increase in knee joint range of motion (ROM), in children who underwent SDR with the conservative technique, a statistically significant increase (p = 0.04) in the net joint power developed by the ankle was observed. Patients who underwent SDR with the conservative technique developed a maximum net ankle joint power of 1.37 ± 0.61 (unit: W/BW), whereas those who were operated with the classic technique developed a maximum net ankle joint power of 0.98 ± 0.18 (unit: W/BW). The conservative group not only showed greater improvement in net ankle joint power but also demonstrated more significant enhancements in minimum knee flexion during the stance phase and knee extension at initial contact. CONCLUSION: Our results show that both techniques led to a reduction in spasticity with a positive impact on the gait pattern. In addition, patients treated with the conservative technique were able to develop greater net ankle joint power, leading to a better scenario for rehabilitation and subsequent gait.

Closure of a large lumbosacral myelomeningocele defect with a human pericardial graft: a case report.

INTRODUCTION: Myelomeningocele (MMC) is a complex congenital defect resulting from incomplete closure of the neural tube. The aim of this study is to present an unusual technique for the closure of a large defect. CASE REPORT: Here we report a patient that was prenatally diagnosed with MMC. At birth, a skin defect of approximately 5 x 7 cm was observed. To repair the defect, a Z-plasty was performed; however, necrosis of the flap developed 3 days after the surgery. The devitalized tissue was removed, and a human pericardial graft was used to cover the defect. DISCUSSION: Different techniques have been described for the repair of MMC with a large skin defect, such as rotation skin flaps as well as synthetic and biological grafts. In our patient, a new technique without prior experience consisting of the application of human cadaveric pericardial graft was used with good results and no complications. CONCLUSION: Closure of MMC is often a surgical challenge. Here we describe a surgical technique for the closure of large skin defects.

Choroid plexus cyst causing acute hydrocephalus and transtentorial herniation: report of a rare case and its successful neuroendoscopic treatment.

Choroid plexus cysts (CPC) are a frequent incidental neuroimaging finding and completely asymptomatic in the vast majority of cases. We hereby describe a rare case of acute hydrocephalus secondary to a CPC, atypical in size, location and presentation, which required urgent neuroendoscopic management. There are very few reported cases of CPC causing obstructive hydrocephalus. The authors present the case of a previously healthy 2-year-old boy with severe symptoms of acute intracranial hypertension, triventricular hydrocephalus, and left ventricle exclusion after placement of a right external ventricular drain. Magnetic resonance imaging (MRI) showed a very subtle gadolinium enhancement in the anterior region of the third ventricle and foramen of Monro (FM). An emergency neuroendoscopic exploration was performed, where a big cyst was found in the choroid plexus near the FM. The foramen was completely unblocked by thoroughly fenestrating and coagulating the cyst, and a preventive endoscopic septum pellucidotomy was done in the same procedure. The patient completely resolved his symptoms, without neurological morbidity or requirement of a cerebrospinal fluid shunt placement. It is important to consider this infrequent presentation in cases of acute or intermittent obstructive hydrocephalus without apparent cause, bearing in mind its difficult detection in neuroimaging studies and the possibility of effective neuroendoscopic treatment.

Abdominal complications in patients with a ventriculoperitoneal shunt: proposal for management recommendations from a single pediatric tertiary center.

PURPOSE: The aim of this study was to describe our experience in the management of patients with ventriculoperitoneal shunt-related complications (abdominal pseudocyst, bowel-related complications, and ascites) and to propose treatment recommendations. MATERIAL AND METHODS: A retrospective descriptive study was conducted in patients with ventriculoperitoneal shunt-related abdominal complications seen between 2009 and 2019 at a tertiary-care pediatric center. Patients were classified according to their diagnosis into the following: group A (abdominal pseudocyst), group B (bowel-related complications), and group C (ascites). The following variables were studied in all three groups: age, sex, etiology of hydrocephalus, history of pyogenic ventriculitis, history of abdominal surgery, clinical presentation, presence of ventricular enlargement on computed tomography scan, abdominal ultrasonography, shunt series X-ray, cerebrospinal fluid cultures, urgent as well as elective surgical interventions, antibiotic treatment, length of hospital stay, follow-up, and outcome. RESULTS: Overall, 48 patients were analyzed: group A, n=29; group B, n=15; and group C, n=4. In all cases, surgical decision-making was based on symptom severity at the time of diagnosis, presence of ventricular enlargement on computed tomography scan, and cerebrospinal fluid culture results. In patients with positive cultures, the shunt system was removed, and an external ventricular drain was placed. In oligosymptomatic patients, cerebrospinal fluid culture results were awaited to define long-term treatment and in patients with ventricular enlargement or clinically difficult-to-treat symptoms, the distal catheter was exteriorized at the thoracic level. CONCLUSION: In patients with shunt-related abdominal complications, surgical management depends on symptom severity and/or whether infection is present at the time of diagnosis.

Safe First-Time use of Stereotactic Headband Fixation in a 5-Month-Old Child: An Economical and Easily Accessible Method.

OBJECTIVE: We present a low-cost and easily accessible adaptation system to perform stereotactic procedures in infants. METHODS: We used an adaptive device consisting of a headband with a plaster bandage, cotton bandage roll, and gauze bandages. Prior to its clinical application, the device was tested in our neuroscience laboratory using a simulation model of a size similar to that of a 5-month-old infant, during which no complications arose. The headband cast technique was subsequently reproduced in a 5-month-old patient, serving as a fixation point for the placement of a Micromar frame for biopsy of a thalamic lesion. RESULTS: A stereotactic biopsy was successfully performed in a 5-month-old patient using a headband cast to secure the stereotactic frame. This method enabled precise targeting of the selected site, resulting in a histopathological diagnosis without any associated complications. CONCLUSIONS: The adaptive device is safe, easily accessible, and reproducible, facilitating the performance of stereotactic diagnostic procedures in infants, accurately reaching the planned objective without causing injuries or additional complications.