Splenogonadal fusion in an 18-month-old.

BACKGROUND: Splenogonadal fusion is rare abnormal congenital connection of splenic tissue and gonad. It commonly presents with either cryptorchidism or as a palpable mass. As a benign anomaly, orchiectomy is often unnecessary. Removal of the splenic component may be accomplished with preservation of the testicle. METHODS: An 18-month-old boy presented with right cryptorchidism and left retractile testicle. Laparoscopic examination found a viable right testicle, and a successful orchiopexy was performed. The left testicle demonstrated splenogonadal fusion. Discontinuous accessory splenules were noted along the path of testicular descent. After confirmation from a radionucleotide liver-spleen scan the patient was brought back to the operating room for open excision of the adherent splenic tissue and orchiopexy of the testicle via an open inguinal approach. CONCLUSION: Splenogonadal fusion is a rare condition, but may be suspected in children with cryptorchidism or palpable peri-testicular mass. As with the present patient, in most cases the splenic tissue may be successfully excised without injury to the testicle.

Segmental arterial mapping during pediatric robot-assisted laparoscopic heminephrectomy: A descriptive series.

INTRODUCTION: The incidence of innocent moiety injury during heminephrectomy is estimated to be 4-5%. This complication can have long-term consequences for the child. Selective arterial mapping (SAM) with indocyanine green (ICG)-aided near infrared fluorescence (NIRF) imaging using the Firefly™ system on the da Vinci(®) surgical robotic console has proven to be valuable in robotic partial nephrectomy for adult renal tumors. However, there is nothing in the literature for using this technique in pediatric robot-assisted laparoscopic heminephrectomy (RALHN). OBJECTIVE: To present a descriptive series of children who had SAM RALHN using ICG-aided NIRF imaging. To determine the feasibility of using ICG-aided NIRF SAM during RALHN, and to study if real-time delineation of the selective arterial anatomy of the upper and lower moieties would be helpful or change the immediate outcomes of the surgery. STUDY DESIGN: A descriptive series of six children who received RALHN at the present institution. RESULTS: Selective arterial mapping was performed safely without toxicity or vascular complications; it did not extend the operative time and did not change the complexity of the operation. As shown in the summary table below, SAM added value by increasing safety of the operation. The individual operation cost increase of using SAM was only related to the single-use vial of ICG. DISCUSSION: Inadvertent injury to the innocent moiety in pediatric heminephrectomy is seldom noted intraoperatively, and many times only becomes evident postoperatively when there is acute ischemia or a chronic reduction in renal function. Although there is no replacement for good surgical technique and judgment, SAM during RALHN is a useful real-time way of alerting the surgeon to unexpected anatomy, and possible unintended or occult injury to the innocent moiety that could have devastating short-term and long-term consequences to the child, despite immediate recovery from surgery. CONCLUSIONS: This report achieved its aim of reporting the feasibility of SAM on a small descriptive series of children who had RALHN.

Self-contained tubular drill guard for anterior cervical fusion.

A self-contained tubular drill guard was adapted for use in performing anterior cervical discectomies and interbody fusions. The use of this instrument eliminates steps, provides absolute safety against drilling too deeply, allows for adjustment in individual cases, provides for easy inspection of the trephine hole, permits electing the cephalocaudal angle of the drill, and gives a measurement of the ultimate depth of the trephine hole. In 171 consecutive operations only one neurological complication occurred, and total morbidity related to cervical surgery was 6% (7% morbidity was associated with surgery at the donor site). The data suggest that the technical modification herein advocated reduces the surgical complication rate.

Rehabilitative neurosurgery.

The neurosurgical role in rehabilitation rehabilitation was studied. Over a 5-year period, 850 individuals were referred to a rehabilitation center after initial acute care. Surgery was indicated for 66 patients. There were 28 quadriplegic or paraplegic individuals with intractable spasticity. Percutaneous radiofrequency foramenal rhizotomies were found to be 98% effective in relieving posttraumatic spasticity. In 14 patients with cognitive impairment, intellectual improvement had reached a plateau level. These persons underwent computed tomography scanning and cisternography, revealing significant communicating hydrocephalus. After surgical shunt therapy, cognitive improvement was noted in 86%. Nineteen individuals were sent for rehabilitation following spine fracture or progressive quadriplegia; 17 were found to have persistent spinal instability requiring surgical stabilization by fusion. This was successful in all cases without complications. Two persons required decompressive spinal operations, resulting in neurological stabilization or improvement. Five patients developed pain, spasticity, ascending neurological deficit, or autonomic dysreflexia due to posttraumatic syrinx. These symptoms were stabilized or improved following syringosubarachnoid shunting. The authors submit that comprehensive neurosurgical reevaluation is desirable in patients received for rehabilitation. Periodic neurosurgical follow-up is recommended. The neurosurgeon's role is not limited to the acute process.

Spinal hemangiomas.

Three new cases of spinal cord compression due to vertebral hemangioma are reported. The clinical presentation, with spinal pain, radicular radiation, and paraparesis, is similar to that of primary lymphoma, metastatic tumor, and disc disease. If the characteristic plain film changes of vertical trabeculations and striations are present, the preoperative diagnosis is facilitated, but in the majority of cases these are not seen. In some instances, vertebral body or pedicle erosion is present. A myelographic epidural block will be seen on further study. Spinal arteriography can prove helpful. Surgical decompression results in marked neurological improvement if intervention takes place before the onset of complete paralysis. The authors recommend that the diagnosis of vertebral hemangioma be considered in the differential diagnosis of epidural spinal cord compression whenever considered in the differential diagnosis of epidural spinal cord compression whenever a primary malignant neoplasm cannot be identified.

Informed consent: is it a myth?

The issue of informed consent at it relates to neurosurgical professional malpractice liability and litigation has been of concern for 20 years or more. The problem persists, and the subject has been addressed by providing patient education with full disclosure regarding neurosurgical procedures. In the process of imparting informed consent, the authors studied the effectiveness of specific neurosurgical health care teaching. One hundred six persons undergoing anterior cervical fusion or lumbar laminectomy were instructed by a neurosurgeon and clinical nurse specialist with a master's degree in neurosurgery. Written testing was performed in each case immediately after a formal teaching session before surgery. Questions were simple and covered only four general topics: 1) diagnosis and surgical techniques; 2) operative risks; 3) postoperative care; and 4) goals and benefits relating to surgery. The mean score on testing immediate retention of information revealed a 43.5% overall performance rate. When patients were tested approximately 6 weeks later, the score dropped to 38.4%. This was statistically significant (chi 2, P less than 0.05). The authors encourage the concept of patient education. The data in the current study, however, suggest that the reasonable and prudent neurosurgeon making a concerted effort at patient education, with the assistance of a professional educator, cannot necessarily expect accurate patient or family recall or comprehension. Fulfillment of the doctrine of informed consent by neurosurgeons may very well be mythical.

The management of paralytic spasticity.

The treatment of spasticity in severely paralyzed patients undergoing rehabilitation constitutes a significant neurosurgical challenge that requires comprehensive management. In this study, 118 patients were treated with invasive modalities when medical therapy failed. The results of percutaneous radiofrequency foraminal rhizotomy were initially successful in 95% of the 77 patients who underwent this procedure; the rate of minor complications was 5%. This procedure was satisfactorily supplemented with percutaneous radiofrequency sciatic neurectomy in 32 of these 77 patients. Four myelotomies were performed with complete success and no major complications in patients in whom percutaneous techniques had proven inadequate. In 35 instances of focal spasticity and incomplete paralysis, intramuscular neurolysis by phenol injection was used. The success rate was 89%. In 9 patients with persistent recurrent spasticity of the lower limb, open tenotomies and peripheral neurectomies were done. Success was complete and without complications. Multiple modalities must be available for the comprehensive management of patients with paralytic spasticity.

Second thoracic sympathetic ganglionectomy in sympathetically maintained pain.

Twenty-four individuals with sympathetically maintained pain were treated by posterior paravertebral T2 sympathectomy following transient response to sympathetic nerve blockade. Eight surgical patients (33.4%) had causalgia, and 16 patients (66.4%) suffered with reflex sympathetic dystrophy. Overall, physical evidence of improvement was noted in 87% of surgical patients, with subjective improvement in 71%. Reflex sympathetic dystrophy patients fared better than those with causalgia. Complications were minor. The techniques employed appear safe and effective; a multidisciplinary approach with neurosurgery, physiatry, anesthesiology, psychology, and allied health services is recommended.

Percutaneous radiofrequency foramenal rhizotomies.

Thirty quadriplegic and paraplegic patients with intractable spasticity underwent percutaneous radiofrequency foramenal rhizotomies. This produced improvement in 94% of the patients, with excellent results in 73%. The complication rate was 3%. The major disadvantage of the procedure was recurrent spasticity, which was dealt with by simple repetition of the procedure. Rehabilitative goals were facilitated; needless painful disability was avoided; a need for intense nursing was reduced; the prevention and treatment of decubitus ulcer formation was enhanced. The study suggests that this procedure is effective, inexpensive, and at low risk to the patient.

Meckel's cave meningiomas with subarachnoid hemorrhage.

Two patients with Meckel's Cave meningiomas were initially hospitalized as a result of subarachnoid hemorrhage. Four-vessel angiography was necessary to exclude other causes of bleeding while demonstrating these lesions. Apoplectic presentation in both cases led to early diagnosis and successful surgical therapy. A review of the literature reveals subarachnoid hemorrhage to be a rarity in association with meningiomas. The two patients currently reported are believed to be the only examples on record of hemorrhagic meningiomas arising from the region of Meckel's Cave.

1992: job market in the doldrums.

Manufacturing continued to lose large numbers of jobs, and other industries had small employment declines; only services and government added substantially to their employment, but with weaker gains than in the 1980's.

Connectivity between right inferior frontal gyrus and supplementary motor area predicts after-effects of right frontal cathodal tDCS on picture naming speed.

BACKGROUND: Cathodal transcranial direct current stimulation (tDCS) of the right frontal cortex improves language abilities in post-stroke aphasic patients. Yet little is known about the effects of right frontal cathodal tDCS on normal language function. OBJECTIVE/HYPOTHESIS: To explore the cathodal tDCS effects of the right-hemispheric homologue of Broca's area on picture naming in healthy individuals. We hypothesized that cathodal tDCS improves picture naming and that this effect is determined by the anatomical and functional connectivity of the targeted region. METHODS: Cathodal and sham tDCS were applied to the right inferior frontal gyrus in 24 healthy subjects before a picture-naming task. All participants were studied with magnetic resonance imaging at pre-interventional baseline. Probabilistic tractography and dynamic causal modeling of functional brain activity during a word repetition task were applied to characterize anatomical and functional connectivity. RESULTS: Subjects named pictures faster after cathodal relative to sham tDCS. The accelerating effect of tDCS was explained by a reduced frequency of very slow responses. tDCS-induced acceleration of picture naming correlated with larger volumes of the tract connecting the right Broca's area and the supplementary motor area (SMA) and greater functional coupling from the right SMA to the right Broca's area. CONCLUSIONS: The results support the notion that the after-effects of tDCS on brain function are at least in part determined by the anatomical and functional connectivity of the targeted region.

Pediatric genitourinary tumors.

Advances in our knowledge of pediatric genitourinary tumors are being made at both the basic science and clinical levels. The molecular mechanisms underlying these pediatric malignancies are being uncovered and will aid in uncovering novel treatments. Because of the high success rate in treating these tumors, treatment options are being modified to decrease both short- and long-term morbidity, while maintaining the improved survival.