A Comparison of Ventriculoperitoneal and Ventriculoatrial Shunts in a Population of 544 Consecutive Pediatric Patients.

BACKGROUND: Although ventriculoperitoneal shunts (VPS) remain the first-line option in most instances of pediatric hydrocephalus, the long-term efficacy of ventriculoatrial shunts (VAS) remains unknown. OBJECTIVE: To characterize the long-term outcomes and adverse occurrences associated with both VPS and VAS at our institution. METHODS: The authors retrospectively analyzed all cerebrospinal fluid (CSF) shunting procedures performed over a 13-yr period at a single institution. A total of 544 pediatric shunt patients were followed for at least 90 d (VPS: 5.9 yr; VAS: 5.3 yr). RESULTS: A total of 54% of VPS and 60% of VAS required at least 1 revision. VPS demonstrated superior survival overall; however, if electively scheduled VAS lengthening procedures are not considered true "failures," no statistical difference is noted in overall survival (P = .08). VPS demonstrated significantly greater survival in patients less than 7 yr of age (P = .001), but showed no difference in older children (P = .4). VAS had a significantly lower rate of infection (P < .05) and proximal failure (P < .001). CONCLUSION: VAS can be a useful alternative to VPS when the abdomen is unsuitable, particularly in older children. Although VPS demonstrates superior overall survival, it should be understood that elective VAS lengthening procedures are often necessary, especially in younger patients. If elective lengthening procedures are not considered true failures, then the devices show similar survival.

A Novel Technique for Prevention of Subarachnoid-Pleural Fistula After Incidental Durotomy During Transthoracic Spinal Surgery.

BACKGROUND: Subarachnoid-pleural fistulas (SPFs) are rare but significant complications of transthoracic spinal surgery. Whether noted intraoperatively or in the postoperative period, SPF requires implementation of aggressive management, with consideration given to direct surgical repair. Additionally, the physical constraints of the thoracic cavity often hinder direct SPF repair. OBJECTIVE: To present a novel operative technique that can be used to easily and quickly address incidental durotomy incurred during transthoracic spinal surgery while working within the confines of the thorax. METHODS: Surgical hemostatic clips were used to affix a patch-graft of dural substitute to the parietal pleura surrounding the site of a transthoracic spinal decompression in which an incidental durotomy was incurred. The patch-graft was augmented with the application of biological glue and was successful in preventing symptomatic SPF. RESULTS: The use of surgical clips to affix a patch graft is a quick, easy, and effective means of addressing an incidental durotomy during thoracotomy and preventing SPF. The clip applier is significantly easier to maneuver within the narrow working channel of the thorax than are instruments used during direct repair. CONCLUSION: Preventing SPF can be challenging. The physical constraints of the thoracic cavity make water-tight repair difficult and time-consuming, particularly when the morphology of the dural tear prevents primary apposition of the defect. The authors present a novel technique of preventing development of SPF using hemostatic clips to simply and quickly affix suturable dural substitute to the parietal pleura overlying the site of an incidental durotomy.

Delayed hardware complication after lateral retroperitoneal lumbar surgery: an unusual case of painless hematuria.

Lateral approaches to the spine are becoming increasingly popular methods for decompression, restoration of alignment, and arthrodesis. Although individual cases of intraoperative injuries to the renal vasculature and the ureters have been documented as rare complications of lateral approaches to the spine, the authors report the first known case of postoperative renal injury due to the delayed extrusion of the screw of a lateral plate/screw construct directly into the renal parenchyma. The migration of the screw from the L1 vertebra into the superior pole of the left kidney occurred nearly 5 years after the index procedure, and presented as painless hematuria. A traditional left-sided retroperitoneal approach had been used at the time of the initial surgery, and the same exposure was used to remove the hardware, which was done in conjunction with general surgery and urology.

Spontaneous Fusion of S2/S3 Spondyloptosis in an Adult.

BACKGROUND: Spondyloptosis is grade V on the Meyerding classification. Traumatic spondyloptosis can occur throughout the spinal column, particularly at junctional levels, and finding an ideal surgical strategy to address it remains a challenge for spinal surgeons. The sacrum is considered a united bone in adults, and sacral intersegmental spondyloptosis is extremely rare. CASE REPORT: Herein, we present an unusual case of S2/S3 spondyloptosis in a 27-year-old female patient with spontaneous solid fusion. CONCLUSIONS: This case demonstrates that similar distal sacral pathologies may be managed conservatively when there is no associated neurologic deficit, and the osteodiskoligamentous integrity of the lumbosacropelvic unit remains intact. Our report plus the very few published papers in the literature illustrate the natural history of uncomplicated traumatic spondyloptosis and support the role of in situ fusion and instrumentation as a reliable alternative to circumferential fusion in patients who cannot tolerate staged or prolonged operations.

Controversies in Spinal Trauma and Evolution of Care.

Management of spinal trauma is a complex and rapidly evolving field. To optimize patient treatment algorithms, an understanding of and appreciation for current controversies and advancing technologies in the field of spinal trauma is necessary. Therefore, members of the AOSpine Knowledge Forum Trauma initiative used a modified Delphi method to compile a list of controversial issues and emerging technologies in the field of spinal trauma, and a list of the 14 most relevant topics was generated. A total of 45 440 manuscripts covering the breadth of spine and spinal trauma were initially identified. This broad search was then refined using the 14 categories felt to be most relevant to the current field of spinal trauma. The results were further pared down using inclusion criteria to select for the most relevant topics. The 8 remaining topics were classification schemes, treatment of vertebral compression fractures, treatment of burst fractures, timing of surgery in spinal trauma, hypothermia, the importance of global sagittal balance, lumbar subarachnoid drainage, and diffusion magnetic resonance imaging. These 8 topics were felt to be the most relevant, controversial, rapidly evolving, and most deserving of inclusion in this summary. In summary, despite recent advances, the field of spinal trauma has many ongoing points of controversy. We must continue to refine our ability to care for this patient population through education, research, and development. It is anticipated that the new AOSpine fracture classification system will assist with prospective research efforts.

Noncalcified Hypertrophic Ligamentum Flavum Causing Severe Cervical Stenosis and Myelopathy: Case Report and Review of the Literature.

BACKGROUND: Calcified hypertrophic ligamentum flavum is a known entity that causes myeloradiculopathy of the cervical, thoracic, and lumbar spine and is seen more commonly in Asian populations. Noncalcified hypertrophic changes are less common and may mimic other epidural space-occupying lesions. CASE DESCRIPTION: A 59-year-old woman presented with progressive myelopathy, and imaging studies were consistent with an epidural space-occupying lesion from C4-T3. The patient underwent posterior cervical decompression and fusion with instrumentation. Pathology specimens revealed noncalcified hypertrophic ligamentum flavum. CONCLUSIONS: To our knowledge, noncalcified hypertrophic ligamentum flavum causing progressive cervical myelopathy has never been reported in the English literature. This entity should be considered in cases with epidural masses causing progressive myelopathy.

Use of a Minimally Invasive Retractor System for Retrieval of Intracranial Fragments in Wartime Trauma.

OBJECTIVE: Wartime penetrating brain injury can result in deep-seated parenchymal and intraventicular shrapnel, bullets, and bone. Large fragments pose a risk of secondary injury from migration, infection, and metal toxicity. It has been recommended that aggressive removal of fragments be avoided. The goal of this study is to report our technique of minimally invasive removal of select deep-seated fragments using a tubular retractor system. METHODS: A retrospective review of our database of service members presenting with penetrating traumatic brain injuries incurred during Operations Iraqi Freedom and Enduring Freedom and treated at the Walter Reed Army Medical Center and the National Naval Medical Center was performed. Six individuals were identified in which the Vycor ViewSite retractor system (Vycor Medical, Boca Raton, Florida, USA) was used to remove a ventricular or deep intraparenchymal fragment. All patients were male and ranged in age from 21 to 29 years. Fragment location included the foramen of Monro; the atrium of the right lateral ventricle; parasagittally within the right occipital lobe; the occipital horn of the right lateral ventricle; the deep white matter of the dominant temporal lobe; and within the posterior right temporal lobe deep to the junction of the transverse and sigmoid dural venous sinuses. Fragments included in-driven bone, shrapnel from improvised explosive devices, and bullets. RESULTS: In all cases the fragment was successfully removed. No patient had worsening of their neurologic condition following surgery. CONCLUSION: Deep parenchymal and intraventricular fragments can be safely removed using a tubular retractor system.

Symptomatic lumbar osteochondroma treated via a multidisciplinary military surgical team: case report and review of the literature.

The authors describe the case of a giant osteochondroma emanating from the L5 vertebral body and extending into the retroperitoneum of a 40-year-old man, causing low back pain. Osteochondromas are benign bony tumors that typically occur within the appendicular skeleton, although in the sporadic form, up to 4% occur in the spine. A review of the English language literature has returned 44 cases of lumbar osteochondroma, including the present example. The lesions were sporadic in 81% of cases. Mean age of presentation overall is 39.5 years, with a mean age of 18.4 years (range 8-34 years) for hereditary cases and 45.7 years (range 11-81 years) for solitary lesions. Of the instances where gender was reported, 64% were male. The most common level of origin was L4 (38%). The most common anatomic site of origin was the inferior articular process (one-third). Of those lesions treated operatively, 46% underwent simple decompression, with 22% requiring decompression and fusion. This particular lesion was resected via a transperitoneal approach performed by a multidisciplinary team of neurosurgeons, vascular surgeons, and urologists. The bony tumor measured 6.1 × 7.8 × 7.7 cm. Removal of the lesion resulted in a significant improvement of the patient's symptoms.