Clinical analysis of atlanto-occipital decompression in the management of chiari malformation with multi-segmental syringomyelia.

Background: Chiari malformation type I with syringomyelia (CM-I-S) is a very common disease in neurosurgery. There are also various surgical methods. But it is controversial. There are few reports about children, especially the treatment of multi-segmental beaded syringomyelia. The purpose of this study was to explore the clinical effects of atlanto-occipital decompression (AOD) in the management of Chiari malformation type I (CM-I) with multi-segmental beaded syringomyelia (MSBS) in pediatric patients. Methods: This retrospective study were pediatric patients with CM-I combined with MSBS who were treated in our hospital from January 2015 to December 2023. The patients who received the AOD treatment were screened according to inclusion and exclusion criteria. Outcomes were assessed by comparison of pre- and postoperative clinical, Chicago Chiari Outcome Scale (CCOS), the diameter and volume of the syringomyelia, morphological parameters of posterior cranial fossa (cervical spinal cord angle of medulla oblongata, CSC-MO) and complications in the enrolled children. Results: This study ultimately included 21 eligible pediatric patients with CM-I and MSBS. All the patients successfully completed the operation, which consists of atlanto-occipital decompression, partial resection of the posterior arch of the atlas, electrocoagulation of the cerebellar tonsil, pseudomembrane resection of the central canal orifice (latch) of the spinal cord, and artificial dura mater expansion repair. No death, no relapses, no serious neurological dysfunction and other complications. At the last follow-up, the clinical symptoms of all patients basically disappeared. The results of magnetic resonance imaging (MRI) showed that the average preoperative cerebellar tonsillar hernia was 12.4 ± 4.6 mm, and the postoperative were all above the foramen magnum. The average preoperative syringomyelia volume was 11.7 ± 3.7 cm2, and the syringomyelia disappeared or significantly shrunk after operation, with the volume unable to be accurately measured. The median preoperative CSC-MO was 132.5°, and the median postoperative CSC-MO was 150°, with a significant difference. The median preoperative pain and non-pain score of CCOS was 4 and 3 respectively. The symptoms disappeared after operation, and the score was 4. Only 5 children had cerebrospinal fluid leakage. Conclusion: The AOD is safe and effective in CM-I with MSBS in pediatric patients. Pseudomembrane resection of the central canal orifice (latch) of the spinal cord is crucial for the treatment of syringomyelia.

Clinical analysis of hyperbaric oxygen combined with subdural drilling and drainage in the management of subdural effusion type IV with intracranial infection in infant patients.

Background: To explore the therapeutic effect of hyperbaric oxygen combined with subdural drilling and drainage (SDD) on subdural effusion type IV with intracranial infection in infant patients. Methods: This retrospective controlled study included 328 infant patients with subdural effusion type 4 with intracranial infection between January 2005 and January 2023. 178 patients were treated by hyperbaric oxygen combined with SDD (group A). 142 cases were treated with SDD (group B). 97 infants were only received hyperbaric oxygen (group C). Clinical outcomes, the control time of intracranial infection, complications, and the degree of brain re-expansion after 6 months of treatment were compared among the three groups. According to the comprehensive evaluation of treatment effectiveness and imaging results, it is divided into four levels: cured, significantly effective, improved, and ineffective. Results: No patient died during follow-up. The three groups were similar regarding age, sex, the general information, and clinical symptoms (p > 0.05). All intracranial infections in the children were effectively controlled. There was no difference in infection control time between group A and group B, and there was no statistical significance. However, the control time of intracranial infection between the two groups was different from that of group C, which was statistically significant. Compared with group B and group C, the degree of brain re-expansion in group A has obvious advantages and significant differences. The effective rates of the three groups were 83.7%, 58.5%, and 56.7%, respectively. There were 28 cases of subcutaneous hydrops in group A and 22 cases of subcutaneous hydrops in group B after operation, and no other serious complications. Conclusion: The SDD is safe and effective for infant patients with intracranial infections through fluid replacement and intrathecal antibacterial. Hyperbaric oxygen is effective as an adjuvant therapy to promote brain re-expansion.

Effects of modified external ventricular drainage vs. an Ommaya reservoir in the management of hydrocephalus with intracranial infection in pediatric patients.

Background: Hydrocephalus with intracranial infection (HII) may cause pathological changes in brain tissue structure and irreversible damage to the nervous system. However, intracranial infection is a contraindication to ventriculo-peritoneal (VP) shunt surgery, and the prognosis is improved by early infection control and intracranial pressure reduction. This study evaluated the safety and efficacy of the Ommaya reservoir vs. modified external ventricular drainage (M-EVD) in the management of HII in pediatric patients. Methods: This retrospective controlled study included 45 pediatric patients with HII treated with an Ommaya reservoir (n = 24) or M-EVD (n = 21) between January 2018 and December 2022. Clinical outcomes, cerebrospinal fluid (CSF) test results, complications, and outcomes were compared between the Ommaya reservoir and M-EVD groups. Results: No patient died during the follow-up period. The two groups were similar regarding age, sex, admission temperature, weight, preoperative serum protein and albumin concentrations, CSF analysis (white blood cell count, glucose concentration, and protein content), and clinical symptoms (P > 0.05). Both groups had significant changes in the CSF test results postoperatively compared with preoperatively (P < 0.05). In the M-EVD group, the median days for 13 children to remove the external drainage tube and receive VP shunt was 19 days. The longest drainage tube retention time was 61 days, and there was no intracranial infection or serious complication related to the drainage tube. After the placement of the Ommaya, the median time required for CSF to return to normal was 21 days, and a total of 15 patients underwent VP shunt surgery. Conclusion: The Ommaya reservoir and M-EVD are safe and effective for pediatric patients with HII. Both methods reduce the intracranial pressure and alleviate the symptoms of hydrocephalus, although there are differences between the two methods.

[Application of dorsal foot hexagonal flap for reconstruction of web space in fourth and fifth toe syndactyly combined with polydactyly].

OBJECTIVE: To explore the application of the dorsal foot hexagonal flap for reconstruction of the web space in the fourth and fifth toe syndactyly combined with polydactyly. METHODS: Between May 2016 and October 2019, 27 patients (34 feet) with the fourth and fifth toe syndactyly combined with polydactyly were treated, including 12 males and 15 females with an average age of 22.8 months (range, 10 months to 8 years). There were 7 bilateral feet and 20 unilateral foot. Twenty-four of which were incomplete and 10 were complete syndactyly of the fourth and fifth toes, and the fifth toes showed various degrees of fibular deflection. All the 34 feet were treated with one-stage reconstruction of the toe web with the dorsal foot hexagonal flap, and the correction of the fibular deviation of the fifth toe was made by removing the tibial polydactyly and using the articular surface dressing or wedge osteotomy. RESULTS: All wounds healed by first intention without skin-frafting. All patients were followed up 6-36 months (mean, 18 months). There was no flexion contracture and obvious scar hyperplasia in all the patients, and the width and slope of the toe webs were normal. Three of the 34 webs developed web creep, and the rest of the toe webs were normal in depth. All 34 feet were corrected with peroneal fibular deviation, and the function of toe flexion was good. All parents of the children were satisfied with the outcome. CONCLUSION: The reconstruction of toe webs with dorsal foot hexagonal flaps for the treatment of the fourth and fifth toes syndactyly combined with polydactyly requires no skin graft. The operation is simple with high survival rate of the flap, the appearance and function of the toes are good, and the effectiveness is satisfactory.