Pediatric spinal injury: review of 174 hospital admissions.

Injury to the spinal column and spinal cord occurs relatively infrequently in the pediatric population. A review of 174 pediatric patients is presented, representing 5.4% of all patients admitted with spinal injury. Spinal cord injury was present in 45% of patients. A distinct injury profile, explained by anatomical and biomechanical features, distinguishes the young patient with an immature spine from older adolescents with a more mature, adult-like spine. The younger patients, while less likely to have spinal injury, had a higher incidence of neurological injury, in addition to a higher frequency of both spinal cord injury without radiological abnormality and upper cervical cord injury. In addition, younger patients with spinal cord injury and no radiological abnormality were more likely to have complete or severe cord injury. Prognosis was determined by the severity of spinal cord injury. Patients with complete cord injuries showed little improvement, while patients with incomplete injuries generally fared much better, with 74% showing significant improvement and 59% experiencing a complete recovery of neurological functions. There were six deaths, but none was attributed solely to spinal injury. The authors conclude that outcome is quite good after pediatric spinal cord injury that does not produce a physiologically complete cord deficit.

Pediatric spinal injury: review of 61 deaths.

Injury to the spinal column and spinal cord occurs relatively infrequently in the pediatric population. The authors present a unique review of 61 pediatric deaths associated with spinal injury. This group represented 28% of the total pediatric spine-injured population and 45% of the total pediatric spinal cord-injured group studied. The ratio of pediatric to adult spinal injury mortality was 2.5:1. Of the 61 children, 54 (89%) died at the accident scene. Thirty patients underwent a complete autopsy, 19 of whom had an Abbreviated Injury Scale Grade 6 injury (maximum score, untreatable). Spinal cord injury was found to be the cause of death in only eight children and was associated with injury to the high cervical cord and cardiorespiratory arrest. These children typically sustained severe multiple trauma. In this population, there appears to be little room for improved outcome through changes in treatment strategy.

Management of intrauterine hydrocephalus.

The aggressive treatment of hydrocephalus has been of benefit to many children. Sophisticated two-dimensional ultrasound techniques allow the diagnosis of prenatal hydrocephalus to be made with accuracy and ease. In the past, the medical decisions governing the management of hydrocephalus in utero were made by obstetricians and were directed at reducing maternal mortality and morbidity. Now, with improved diagnosis and support facilities for the newborn, neurosurgical input is being requested as more concern is expressed for the fetus. Based on their experience with seven cases of intrauterine hydrocephalus in the past 3 years, the authors present their program for the management of this problem. If antenatal ultrasonography shows hydrocephalus without other anomalies, they recommend that the fetus be born by elective Caesarean section at the time of pulmonary maturity, and that early ventricular shunting be carried out. This plan should minimize nervous system trauma resulting from hydrocephalus and the birth process. If, however, antenatal diagnostic studies show cerebral or other major system anomalies in addition to hydrocephalus, than standard obstetrical care should be given. Antenatal ultrasonography has been found to be reliable in assessing fetal lateral ventricular size and shape, and to correlate well with the results of postnatal computerized tomography scanning.

Benign osteoblastoma of the spine in childhood.

Osteoblastoma of the spine is a rare but important cause of back pain in children. Ten children with this tumor were treated at the Alberta Children's or Foothills Hospital in Calgary, Alberta, between 1974 and 1986. There were seven boys and three girls; the age at diagnosis ranged from 2 to 16 years (average 11 years). In nine patients the tumor involved the posterior vertebral elements. One of the cervical lesions was in the vertebral body. Three patients had tumor in the extradural space. The commonest symptom was pain in the back and neck. Bone scans were positive in all patients, and computerized tomography scans were abnormal in the eight patients who had this imaging performed. Nine children were treated with laminectomy and removal of the abnormal pedicle and facet. Two patients required two operations each because of incomplete tumor excision at the first operation; in these, subsequent surgery gave complete relief of symptoms and radiographic studies showed no further tumor. In three other patients, tumor removal was incomplete, and one patient received postoperative radiation therapy. Bone grafts were placed in four patients. The diagnosis of benign osteoblastoma was confirmed histologically in nine patients. The outcome was good in all cases, with excellent pain relief. The follow-up period has varied from 8 to 153 months (average 66 months) and there have been no recurrences. Based on this experience, complete excision of spinal osteoblastomas is recommended whenever possible. However, a satisfactory outcome may be achieved following incomplete excision and bone grafting.

Symptomatic hamartoma of the spinal cord associated with neurofibromatosis type 1. Case report.

The authors present a case in which a symptomatic hamartoma was found in the spinal cord of a patient with neurofibromatosis type 1 (NF-1). This 52-year-old woman presented with painful urinary incontinence. Magnetic resonance (MR) imaging revealed an intramedullary lesion within the lower thoracic spinal cord and conus medullaris, which was surgically removed. Pathological investigation showed a hamartomatous lesion consisting of glial cells, ganglion cells, abundant disoriented axons, and thin-walled vessels. This case provides a pathological correlate to the hamartomatous lesions demonstrated on MR imaging in patients with NF-1 and illustrates that these benign lesions may become symptomatic and require neurosurgical intervention.

Selection of neurosurgical trainees.

BACKGROUND: Medical students in Canada must make career choices by their final year of medical school. Selection of students for a career in neurosurgery has traditionally been based on marks, reference letters and personal interviews. Studies have shown that marks alone are not accurate predictors of success in medical practice; personal skills and attributes which can best be assessed by letters of reference and interviews may be more important. This study was an attempt to assess the importance of, and ability to teach, personal skills and attitudes necessary for successful completion of a neurosurgical training program. METHODS: A questionnaire was sent to 185 active members of the Canadian Neurosurgical Society, asking them to give a numerical rating of the importance of 22 personal skills and attributes, and their ability to teach those skills and attributes. They were asked to list any additional skills or attributes considered important, and rate their ability to teach them. RESULTS: Sixty-six (36%) questionnaires were returned. Honesty, motivation, willingness to learn, ability to problem solve, and ability to handle stress were the five most important characteristics identified. Neurosurgeons thought they could teach problem solving, willingness to consult informed sources, critical thinking, manual dexterity, and communication skills, but honesty, motivation, willingness to learn and ability to handle stress were difficult or impossible to teach. CONCLUSIONS: Honesty, motivation, willingness to learn, ability to problem solve and handle stress are important for success in a neurosurgical career. This information should be transmitted to medical students at "Career Day" venues. Structuring letters of reference and interviews to assess personal skills and attributes will be important, as those that can't be taught should be present before the start of training.

Clinicopathological conference. Carcinoma of the pituitary gland with metastases to bone.

The diagnosis of extracranial metastases from a pituitary tumor was confirmed by the use of the immunoperoxidase technique. This is believed to be the first case of carcinoma of the pituitary gland with bony metastases where the diagnosis has been confirmed in that manner.

Idiopathic hypertrophic pachymeningitis: a report of two patients and review of the literature.

PURPOSE: We report the treatment and follow-up, including MRI, of two patients with idiopathic hypertrophic pachymeningitis and review the English language literature, with emphasis on management and outcome in this rare disorder. METHODS AND MATERIALS: The files of two patients were reviewed, with relevant histopathology and imaging (MRI). The first patient has been followed for sixteen years (the longest MRI-documented postoperative course reported for this condition) and the second for two years. The English language literature was reviewed, including a summary of all reported patients that have been followed with MRI or CT imaging. RESULTS: Despite extensive investigation, no underlying etiology was determined in either patient. Histopathological studies revealed a chronic inflammatory dural infiltrate in both patients, with granulomas in the first but not the second patient. The first patient underwent surgery twice and has remained stable for sixteen years, despite persistent neurologic deficits. The second patient was managed with dexamethasone after a surgical biopsy, and experienced complete resolution of all neurological deficits and abnormalities seen with MRI. CONCLUSIONS: Although prompt and extensive surgery has been recommended for this condition, the results from our second patient indicate that complete remission can be achieved in some patients with biopsy and steroid therapy. This also supports the view that autoimmune mechanisms underlie idiopathic hypertrophic pachymeningitis. The first patient illustrates that extensive laminectomies may be an effective therapeutic option but chronic discomfort may result. If extensive surgery must be performed, laminoplasty should be done because of the potential for reduced pain and improved long-term spinal stability.

Intrauterine hydrocephalus and ventriculomegaly: associated anomalies and fetal outcome.

Advances in fetal diagnostic techniques have opened many areas to prenatal anatomical scrutiny. Intrauterine hydrocephalus and ventriculomegaly are conditions which are readily diagnosed. Fetal intervention has been undertaken in humans in order to minimize the craniofacial disfigurement and to maximize the growth potential of the brain. To justify such an approach, the significance of all anomalies should be recognized prior to treatment. The authors have reviewed 41 cases of hydrocephalus diagnosed in utero in order to define associated anomalies and patient outcome. 75% of our personal series and 72% of the reviewed literature cases had other anomalies of the central nervous system. Other system malformations, some of which proved fatal, were seen commonly. Prenatal diagnostic techniques did not always reveal these additional problems. The outcome of these pregnancies is not good. Approximately one third of these fetuses have survived to be treated postnatally and to be followed up clinically. Only 7.5% of this series were felt to have attained normal developmental milestones. The remainder of the survivors have various focal and/or global cerebral deficits.

Chiasmal glioma in neurofibromatosis type 1 with severe visual loss regained with radiation.

Children with neurofibromatosis type 1 (NFI) and chiasmal gliomas are often considered unlikely to experience progressive visual loss. However, this may not be true. We report a 5-year, 6-month-old boy, with recently diagnosed NF1, who had a chiasmal glioma diagnosed after neuroimaging. He subsequently experienced rapid visual acuity loss. His vision improved significantly after irradiation. The controversy surrounding radiotherapy for chiasmal glioma is discussed.

The human tail and spinal dysraphism.

Recent publications have endeavoured to differentiate between the true, or vestigial tail, and the pseudotail by clinical and pathological examination, and have indicated the benign nature of the true tail. The true tail arises from the most distal remnant of the embryonic tail, contains adipose, connective, muscle, and nerve tissue, and is covered by skin. Pseudotails represent a variety of lesions having in common a lumbosacral protrusion and a superficial resemblance to vestigial tails. A review of the case reports indicates spina bifida to be the most frequent coexisting anomaly with both. A review of occult spinal dysraphism shows it to be associated with cutaneous signs in more than 50% of instances. Three cases of spinal dysraphism with tail-like cutaneous structures are described and their radiological, operative, and pathological findings presented. The classification of each of the appendages into true tail or pseudotail remains obscure. Although the finding of these three tails was the subject of much curiosity, surgical treatment was clearly designed to adequately deal with the associated dysraphic state. The presence of a tail-like appendage in the lumbosacral region should alert the clinician to the possibility of underlying spinal dysraphism. Preoperative assessment must include a complete neurological history and examination as well as computed tomographic or magnetic resonance imaging.

Intraventricular hemorrhage complicating ventricular catheter revision: incidence and effect on shunt survival.

A retrospective study was conducted on 105 pediatric patients who underwent shunt revision between 1986 and 1993 at the Alberta Childrens Hospital (Calgary) to determine the frequency of intraventricular hemorrhage (IVH) with ventricular catheter revision. Ventricular catheter revision was performed 143 times in 74 patients. Intraventricular hemorrhage was noted intra-operatively or on post-operative computed tomographic (CT) scans on 45 occasions for an overall incidence of 31%. IVH was associated with a significantly shorter time (p < 0.0002) to subsequent shunt revision (227.33 +/- 392.24 days) compared to catheter survival when no hemorrhage was noted (735.02 +/- 1,001.11 days). This study raises several important questions about the prevention and management of IVH during shunt revision. It also provides the first published report on the incidence of IVH during shunt revision, thereby setting a standard to which future studies can be compared.

Injuries to the nervous system and spine in downhill skiing.

The authors describe injuries to the nervous system and spine from downhill skiing accidents through a review of the charts of downhill skiers admitted over 5 years to the three teaching hospitals of the University of Calgary. The office of the chief medical examiner provided details about accidental deaths from downhill skiing in which nervous system trauma occurred. During the study period, 145 downhill skiers suffered injury to the nervous system or spine. There were five deaths from nervous system trauma. The mean age of the injured skiers was 23.8 years, and these injuries were three times more common in men than in women. Eighty-eight skiers sustained a head injury, 25 had spinal fractures alone, 20 had spinal cord or nerve root injury and 12 had peripheral nerve injury. A simple fall on the hill was the commonest method of injury, followed in frequency by collision with a tree, which caused the most severe injuries. Reckless skiing, design of ski runs and man-made snow were contributing factors. The serious nature and number of these injuries must be recognized, and further study is needed on causal factors and preventive measures.

Cervical neuroschisis and meningocoele manque in type I (no neck) Klippel-Feil syndrome.

A male child with type I (no neck) Klippel-Feil syndrome presented at birth with a transient and partial cord injury. Investigations failed to reveal spinal instability or foramen magnum compression. Subsequent deterioration led to investigations that demonstrated neuroschisis. A cervical meningocoele manque with cord tethering was found at exploration and untethering reversed the deficit. The surgical pathology of the cervical cord is described.