Holospinal epidural abscess in elderly patient: A case presentation and review.

BACKGROUND: Holospinal epidural abscess (HEA) is a rare pathological entity with significant morbidity and mortality rates. Here, we present a 74-year-old male with HEA treated with focal skip laminectomies and catheter irrigation. CASE DESCRIPTION: A 74-year-old male presented with fever, neck/back pain, and slight weakness in his legs bilaterally (4/5). The patient underwent a magnetic resonance imaging (MRI) of the entire spine showing an epidural collection extending from C5-C6 to the L4-L5 levels. Laboratory studies revealed a leukocytosis and an elevated C-reaction protein level. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. The patient underwent skip laminectomies at C6 and C7; T2, T3, T5, T6, T8, T9, T10, and T12; and L3, L4, and L5 with catheter irrigation between these levels; this minimized the risk of postoperative kyphosis and instability. His postoperative course was uneventful. Other surgical approaches to HEA described in literature include laminectomy, focal laminectomies, and skip laminectomies. CONCLUSION: In this case of a holospinal HEA, skip laminectomies and catheter irrigation avoided neurological deterioration and delayed spinal instability in a 74-year-old male.

Cervical sagittal balance parameters after single-level anterior cervical discectomy and fusion: Correlations with clinical and functional outcomes.

BACKGROUND: Normal sagittal cervical alignment has been associated with improved outcome after anterior cervical discectomy and fusion (ACDF). OBJECTIVE: The aim of this study is to identify alterations of cervical sagittal balance parameters after single-level ACDF and assess correlations with postoperative functionality. METHODS: A retrospective chart review was performed between January 2010 and January 2014 to identify adult patients with no previous cervical spine surgery who underwent ACDF at any one level between C2 and C7 for the single-level degenerative disease. Tumor, infection, and trauma cases were excluded from the study. For the included cases, the following data were recorded preoperatively and 6 months-1 year after surgery: sagittal balance-marker measurements of the C1-C2 angle, C2-C7 angle, C7 slope, segmental angle at the operated level, and sagittal vertical axis (SVA) distance between C2 and C7, as well as the neck disability index and visual analog scale of pain. RESULTS: The present study included 47 patients (average age: 51.2 years; range: 28-86 years). A moderate negative correlation between a smaller C2-C7 angle and the presence of right arm pain before treatment was found (P = 0.0281). Postoperatively, functionality scores significantly improved in all patients. C1-C2 angle increased with statistical significance (P = 0.0255). C2-C7 angle, segmental angle, C7 slope, and SVA C2-C7 distance did not change with statistical significance after surgery. C7 slope significantly correlated with overall cervical sagittal balance (P < 0.05). CONCLUSIONS: Single-level ACDF significantly increases upper cervical lordosis (C1-C2) without significantly changing lower cervical lordosis (C2-C7). The C7 slope is a significant marker of overall cervical sagittal alignment (P < 0.05).

Bowel injury in lumbar spine surgery: a review of the literature.

Although rarely documented in the medical literature, bowel perforation injury can be a severe complication of spine surgery. Our goal was to review current literature regarding this complication and study possible methods of avoidance. We conducted a literature search in the PubMed database between January 1960 and March 2016 using the terms abrasion, bowels, bowel, complication, injury, intestine, intra-abdominal sepsis/shock, perforation, lumbar, spine, surgery, visceral. Diagnostic criteria, outcomes, risk factors, surgical approach, and treatment strategy were the parameters extracted from the search results and used for review. Thirty-one patients with bowel injury were recognized in the literature. Bowel injury was more frequent in patients who underwent lumbar discectomy and microdiscectomy (18 of 31 patients, 58.1%). Minimally invasive surgery and lateral techniques involving fusions accounted for 10 of the reported cases (32.3%). Finally, 2 cases (6.5%) were reported in conjunction with sacrectomies and 1 case (3.2%) with posterior fusion plus anterior longitudinal ligament (ALL) release. Diagnosis was made mostly by clinical signs/symptoms of acute abdominal pain, post-surgical wound infection, and abscess or enterocutaneous fistulas. Significant risk factors for postoperative bowel injury were complex surgical anatomy, medical history of previous abdominal surgeries or infections, irradiation before surgery, errors related to surgical technique, lack of surgical experience, and instrumentation failure. The overall mortality rate from bowel injury was 12.9% (4 of 31 patients). The overall morbidity rate was 87.1% (27 of 31 patients). According to our review of the literature, bowel injury is linked to significant morbidity and mortality. It can be prevented with meticulous pre-surgical planning. When it occurs, timely treatment reduces the risks of morbidity and mortality.

Correlation of Clinical and Radiological Outcome After Anterior Cervical Discectomy and Fusion With a Polyetheretherketone Cage.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) with a polyetheretherketone (PEEK) cage is considered as the gold standard for patients with cervical disc disease. However, there are limited in vivo data on the impact of ACDF on the cervical kinematics and its association with patient-reported clinical outcomes. The purpose of this study was to investigate the impact of altered cervical sagittal alignment (cervical lordosis) and sagittal range of motion (ROM) on patients' self-reported pain and functional disability, after ACDF with a PEEK cage. METHODS: We prospectively studied 74 patients, who underwent single-, or consecutive two-level ACDF with a PEEK interbody cage. The clinical outcomes were assessed by using the pain numeric rating scale (NRS) and the neck disability index (NDI). Radiological outcomes included cervical lordosis and C2-C7 sagittal ROM. The outcome measures were collected preoperatively, at the day of patients' hospital discharge, and also at 6 and 12 months postoperatively. RESULTS: There was a statistically significant reduction of the NRS and NDI scores postoperatively at each time point (P < 0.005). Cervical lordosis and also ROM significantly reduced until the last follow-up (P < 0.005). There was significant positive correlation between NRS and NDI preoperatively, as well as at 6 and 12 months postoperatively (P < 0.005). In regard to the ROM and the NDI scores, there was no correlation preoperatively (P = 0.199) or postoperatively (6 months, P = 0.322; 12 months, P = 0.476). Additionally, there was no preoperative (P = 0.134) or postoperative (6 months, P = 0.772; 12 months, P = 0.335) correlation between the NDI scores and cervical lordosis. CONCLUSIONS: In our study, reduction of cervical lordosis and sagittal ROM did not appear to significantly influence on patients' self-reported disability. Such findings further highlight the greater role of pain level over the mechanical limitations of ACDF with a PEEK cage on patients' own perceived recovery.

The role of steroid administration in the management of dysphagia in anterior cervical procedures.

Dysphagia is a common postoperative symptom for patients undergoing anterior cervical spine procedures. The purpose of this study is to present the current literature regarding the effect of steroid administration in dysphagia after anterior cervical spine procedures. We performed a literature search in the PubMed database, using the following terms: "dysphagia," "ACDF," "cervical," "surgery," "anterior," "spine," "steroids," "treatment," and "complications." We included in our review any study correlating postoperative dysphagia and steroid administration in anterior cervical spine surgery. Studies, which did not evaluate, pre- and postoperatively, dysphagia with a specific clinical or laboratory methodology were excluded from our literature review. Five studies were included in our results. All were randomized, prospective studies, with one being double blinded. Steroid administration protocol was different in every study. In two studies, dexamethasone was used. Methylprednisolone was administrated in three studies. In four studies, steroids were applied intravenously, while in one study, locally in the retropharyngeal space. Short-term dysphagia and prevertebral soft tissue edema were diminished by steroid administration, according to the results of two studies. In one study, prevertebral soft tissue edema was not affected by the steroid usage. Furthermore, short-term osseous fusion rate was impaired by the steroid administration, according to the findings of one study. The usage of steroids in patients undergoing anterior cervical spine procedures remains controversial. Multicenter, large-scale, randomized, prospective studies applying the same protocol of steroid administration and universal outcome criteria should be performed for extracting statistically powerful and clinically meaningful results.

Steinmann Pins for C1 Lateral Mass Screw Placement During Atlantoaxial Stabilization.

OBJECTIVE: The authors describe a modified technique for placement of the C1 lateral mass screw using a Steinmann pin as a guide. This technique minimizes dissection and provides atlantoaxial stabilization during arthrodesis. METHODS: In our technique, a nonthreaded 1.6-mm spade-tip Steinmann pin is placed into the lateral mass of C1 to serve as a guide over which a powered drill is used for screw insertion. Perioperative data were collected for consecutive patients who underwent a C1-2 arthrodesis that involved the modified technique between March 2010 and July 2016. Data included blood loss, operative times, and C2 nerve root injury. RESULTS: The data for 93 patients were reviewed. Most (91.4%) patients presented with a fracture from an acute trauma. A mean of 1.97 levels was fused in these patients, with a mean blood loss of 76 mL and a mean operative time of 144 minutes. The overall morbidity and mortality rate was 10.7%. The morbidity rate of 7.5% included 30-day postoperative complications of respiratory failure and dysphasia. There were no postoperative vertebral artery injuries, hardware failures, or instances of occipital neuralgia. CONCLUSIONS: The use of Steinmann pins to guide the placement of C1 lateral mass screws is safe and effective in C1-2 arthrodesis. Limiting dissection minimizes blood loss and injury, maintains efficient operative time, and assists in accurate placement of the screws. Furthermore, with less manipulation and retraction of the C2 nerve root, postoperative occipital neuralgia and the need for C2 root transection are avoided.

The Role of Gait Analysis in the Evaluation of Patients with Cervical Myelopathy: A Literature Review Study.

BACKGROUND: Gait analysis represents one of the newest methodologies used in the clinical evaluation of patients with cervical myelopathy (CM). OBJECTIVE: To describe the role of gait analysis in the clinical evaluation of patients with CM, as well as its potential role in the evaluation of the functional outcome of any surgical intervention. METHODS: A literature review was performed in the PubMed, OVID, and Google Scholar medical databases, from January 1995 to August 2016, using the terms "analysis," "anterior," "cervical myelopathy," "gait," "posterior," and "surgery." Clinical series comparing the gait patterns of patients with CM with healthy controls, as well as series evaluating gait and walk changes before and after surgical decompression, were reviewed. Case studies were excluded. RESULTS: Nine prospective and 3 retrospective studies were found. Most of the retrieved studies showed the presence of characteristic, abnormal gait patterns among patients with CM, consisting of decreased gait speed, cadence, step length, stride length, and single-limb support time. In addition, patients with CM routinely present increased step and stride time, double-limb support time, and step width, and they have altered knee and ankle joint range of motion, compared with healthy controls. Moreover, gait and walk analysis may provide accurate functional assessment of the functional outcome of patients with CM undergoing surgical decompression. CONCLUSIONS: Gait analysis may well be a valuable and objective tool along with other parameters in the evaluation of functionality in patients with CM, as well as in the assessment of the outcome of any surgical intervention in these patients.

Percutaneous screw placement in the lumbar spine with a modified guidance technique based on 3D CT navigation system.

Several guidance techniques have been employed to increase accuracy and reduce surgical time during percutaneous placement of pedicle screws (PS). The purpose of our study was to present a modified technique for percutaneous placement of lumbar PS that reduces surgical time. We reviewed 23 cases of percutaneous PS placement using our technique for minimally invasive lumbar surgeries and 24 control cases where lumbar PS placement was done via common technique using Jamshidi needles (Becton, Dickinson and Company, Franklin Lakes, NJ, USA). An integrated computer-guided navigation system was used in all cases. In the technique modification, a handheld drill with a navigated guide was used to create the path for inserting guidewires through the pedicles and into the vertebral bodies. After drill removal, placement of the guidewires through the pedicles took place. The PS were implanted over the guidewires, through the pedicles and into the vertebral bodies. Intraoperative computed tomography was performed after screw placement to ensure optimal positioning in all cases. There were no intraoperative complications with either technique. PS placement was correct in all cases. The average time for each PS placement was 6.9 minutes for the modified technique and 9.2 minutes for the common technique. There was no significant difference in blood loss. In conclusion, this modified technique is efficient and contributes to reduced operative time.

Magnetic Resonance Spectroscopy and Single-Photon Emission Computed Tomography in the Evaluation of Cerebral Tumors: A Case Report.

In their daily clinical practice, physicians have to confront diagnostic dilemmas which cannot be resolved by the application of only one imaging technique. In this case report, we present a 66-year-old woman who was admitted to our institution for the surgical resection of a recently diagnosed brain tumor. The patient had a history of epileptic seizures and was hospitalized in the past for anti-phospholipid syndrome related to a non-Hodgkin lymphoma in remission. Magnetic resonance imaging (MRI) examination revealed an enhancing right parasagittal lesion with significant edema suggestive of a high grade glioma. Advanced MRI techniques including proton magnetic resonance spectroscopy (1H-MRS) showed findings compatible of glioma. An additional examination was performed as part of a protocol that we are routinely performing in our institution for all brain tumors including not only the gold standard advanced MRI techniques but also single-photon emission computed tomography (SPECT) with technetium-99m (Tc99m). Brain SPECT indicated the presence of a meningioma which was verified by the histopathology of the resected specimen. In conclusion, a multimodality approach for the pre-surgical assessment of brain tumors has significant advantages not only for the diagnosis but also for the evaluation of intracranial tumors histology.

Large, spontaneous spinal subdural-epidural hematoma after epidural anesthesia for caesarean section: Conservative management with excellent outcome.

BACKGROUND: Iatrogenic or spontaneous spinal hematomas are rarely seen and present with multiple symptoms that can be difficult to localize. Most spontaneous spinal hematomas are multifactorial, and the pathophysiology is varied. Here, we present a case of a scattered, multicomponent, combined subdural and epidural spinal hematoma that was managed conservatively. CASE DESCRIPTION: A 38-year-old woman came to the emergency department (ED) complaining of severe neck and back pain. She had undergone a caesarean section under epidural anesthesia 4 days prior to her arrival in the ED. She was placed on heparin and then warfarin to treat a pulmonary embolism that was diagnosed immediately postpartum. Her neurological examination at presentation demonstrated solely the existence of clonus in the lower extremities and localized cervical and low thoracic pain. In the ED, the patient's international normalized ratio was only mildly elevated. Spinal magnetic resonance imaging revealed a large thoracolumbar subdural hematoma with some epidural components in the upper thoracic spine levels. Spinal cord edema was also noted at the T6-T7 vertebral level. The patient was admitted to the neurosurgical intensive care unit for close surveillance and reversal of her coagulopathy. She was treated conservatively with pain medication, fresh frozen plasma, and vitamin K. She was discharged off of warfarin without any neurological deficit. CONCLUSIONS: Conservative management of spinal hematomas secondary to induced coagulopathies can be effective. This case suggests that, in the face of neuroimaging findings of significant edema and epidural blood, the clinical examination should dictate the management, especially in such complicated patients.

The role of diffusion tensor imaging and fractional anisotropy in the evaluation of patients with idiopathic normal pressure hydrocephalus: a literature review.

OBJECTIVE Diffusion tensor imaging (DTI) for the assessment of fractional anisotropy (FA) and involving measurements of mean diffusivity (MD) and apparent diffusion coefficient (ADC) represents a novel, MRI-based, noninvasive technique that may delineate microstructural changes in cerebral white matter (WM). For example, DTI may be used for the diagnosis and differentiation of idiopathic normal pressure hydrocephalus (iNPH) from other neurodegenerative diseases with similar imaging findings and clinical symptoms and signs. The goal of the current study was to identify and analyze recently published series on the use of DTI as a diagnostic tool. Moreover, the authors also explored the utility of DTI in identifying patients with iNPH who could be managed by surgical intervention. METHODS The authors performed a literature search of the PubMed database by using any possible combinations of the following terms: "Alzheimer's disease," "brain," "cerebrospinal fluid," "CSF," "diffusion tensor imaging," "DTI," "hydrocephalus," "idiopathic," "magnetic resonance imaging," "normal pressure," "Parkinson's disease," and "shunting." Moreover, all reference lists from the retrieved articles were reviewed to identify any additional pertinent articles. RESULTS The literature search retrieved 19 studies in which DTI was used for the identification and differentiation of iNPH from other neurodegenerative diseases. The DTI protocols involved different approaches, such as region of interest (ROI) methods, tract-based spatial statistics, voxel-based analysis, and delta-ADC analysis. The most studied anatomical regions were the periventricular WM areas, such as the internal capsule (IC), the corticospinal tract (CST), and the corpus callosum (CC). Patients with iNPH had significantly higher MD in the periventricular WM areas of the CST and the CC than had healthy controls. In addition, FA and ADCs were significantly higher in the CST of iNPH patients than in any other patients with other neurodegenerative diseases. Gait abnormalities of iNPH patients were statistically significantly and negatively correlated with FA in the CST and the minor forceps. Fractional anisotropy had a sensitivity of 94% and a specificity of 80% for diagnosing iNPH. Furthermore, FA and MD values in the CST, the IC, the anterior thalamic region, the fornix, and the hippocampus regions could help differentiate iNPH from Alzheimer or Parkinson disease. Interestingly, CSF drainage or ventriculoperitoneal shunting significantly modified FA and ADCs in iNPH patients whose condition clinically responded to these maneuvers. CONCLUSIONS Measurements of FA and MD significantly contribute to the detection of axonal loss and gliosis in the periventricular WM areas in patients with iNPH. Diffusion tensor imaging may also represent a valuable noninvasive method for differentiating iNPH from other neurodegenerative diseases. Moreover, DTI can detect dynamic changes in the WM tracts after lumbar drainage or shunting procedures and could help identify iNPH patients who may benefit from surgical intervention.

Hemoptysis as the Presenting Clinical Sign of a T8-T9 Spine Fracture with Diffuse Idiopathic Skeletal Hyperostosis Changes.

Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory degenerative disease that affects multiple spine levels and, in combination with osteoporosis, makes vertebrae more prone to fractures, especially in elderly people. We describe a rare case of thoracic fracture in an ankylosed spine in which hemoptysis was the only clinical sign. The patient (age in the early 80s) presented with chest pain and a cough associated with hemoptysis. The patient had no complaints of back pain and no neurological symptoms. Computed tomography (CT) angiography of the chest revealed changes consistent with DISH, with fractures at the T8 and T9 vertebra as well as lung hemorrhage or contusion in the right lung base. CT and magnetic resonance imaging of the thoracic spine showed similar findings, with a recent T8-T9 fracture and DISH changes. The patient underwent percutaneous pedicle screw fixation from T7 to T11 and remained neurologically intact with an uneventful postoperative course.

Anterior Cervical Discectomy and Fusion: Practice Patterns Among Greek Spinal Surgeons.

BACKGROUND: A web-based survey was conducted among Greek spinal surgeons to outline the current practice trends in regard to the surgical management of patients undergoing anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine pathology. Various practice patterns exist in the surgical management of patients undergoing anterior cervical discectomy for degenerative pathology. No consensus exists regarding the type of the employed graft, the necessity of implanting a plate, the prescription of an external orthotic device, and the length of the leave of absence in these patients. METHODS: A specially designed questionnaire was used for evaluating the criteria for surgical intervention, the frequency of fusion employment, the type of the graft, the frequency of plate implantation, the employment of an external spinal orthosis (ESO), the length of the leave of absence, and the prescription of postoperative physical therapy. Physicians' demographic factors were assessed including residency and spinal fellowship training, as well as type and length in practice. RESULTS: Eighty responses were received. Neurosurgeons represented 70%, and orthopedic surgeons represented 30%. The majority of the participants (91.3%) considered fusion necessary. Allograft was the preferred type of graft. Neurosurgeons used a plate in 42.9% of cases, whereas orthopedic surgeons in 100%. An ESO was recommended for 87.5% of patients without plates, and in 83.3% of patients with plates. The average duration of ESO usage was 4 weeks. Physical therapy was routinely prescribed postoperatively by 75% of the neurosurgeons, and by 83.3% of the orthopedic surgeons. The majority of the participants recommended 4 weeks leave of absence. CONCLUSIONS: The vast majority of participants considered ACDF a better treatment option than an ACD, and preferred an allograft. The majority of them employed a plate, prescribed an ESO postoperatively, and recommended physical therapy to their patients.

Posterior Reversible Encephalopathy Syndrome Resolving Within 48 Hours in a Normotensive Patient Who Underwent Thoracic Spine Surgery.

Posterior reversible encephalopathy syndrome (PRES) usually manifests with severe headaches, seizures, and visual disturbances due to uncontrollable hypertension. A patient (age in the early 60s) with a history of renal cell cancer presented with lower-extremity weakness and paresthesias. Magnetic resonance imaging (MRI) of the thoracic spine revealed a T8 vertebral body metastatic lesion with cord compression at that level. The patient underwent preoperative embolization of the tumor followed by posterior resection and placement of percutaneous pedicle screws and rods. Postoperatively, the patient experienced decreased visual acuity bilaterally. Abnormal MRI findings consisted of T2 hyperintense lesions and fluid-attenuated inversion recovery changes in both occipital lobes, consistent with the unique brain imaging pattern associated with PRES. The patient's blood pressure was normal and stable from the first day of hospitalization. The patient was kept on high-dose steroid therapy, which was started intraoperatively, and improved within 48 hours after symptom onset.

Patient variables and referral paradigms associated with osteoporosis screening and treatment in neurosurgical patients undergoing kyphoplasty.

OBJECT Vertebral fractures are the most common osteoporotic fracture. Bone density testing and medical treatment with bisphosphonates or parathormone are recommended for all patients with an osteoporotic fracture diagnosis. Inadequate testing and treatment of patients presenting with low-impact fractures have been reported in various specialties. Similar data are not available from academic neurosurgery groups. The authors assessed compliance with treatment and testing of osteoporosis in patients with vertebral compression fractures evaluated by the authors' academic neurosurgery service, and patient variable and health-systems factors associated with improved compliance. METHODS Data for patients who underwent percutaneous kyphoplasty for compression fractures was retrospectively collected. Diagnostic and medical interventions were tabulated. Pre-, intra-, and posthospital factors that had been theorized to affect the compliance of patients with osteoporosis-related therapies were tabulated and statistically analyzed. RESULTS Less than 50% of patients with kyphoplasty received such therapies. Age was not found to correlate with other variables. Referral from a specialist rather than a primary care physician was associated with a higher rate of bone density screening, as well as vitamin D and calcium therapy, but not bisphosphonate/parathormone therapy. Patients who underwent preoperative evaluation by their primary care physician were significantly more likely to receive bisphosphonates compared with those only evaluated by a hospitalist. Patients with unprovoked fractures were more likely to undergo multiple surgeries compared with those with minor trauma. CONCLUSIONS These results suggest poor compliance with current standard of care for medical therapies in patients with osteoporotic compression fractures undergoing kyphoplasty under the care of an academic neurosurgery service.

Assessment of Nogo-66 receptor 1 function in vivo after spinal cord injury.

BACKGROUND: Neuronal Nogo-66 receptor 1 (NgR1) has attracted attention as a converging point for mediating the effects of myelin-associate inhibitory ligands in the central nervous system, establishing the growth-restrictive environment, and limiting axon regeneration after traumatic injury. OBJECTIVE: To investigate the factors that may be contributing to the discrepancy in the importance of NgR1, which has been undermined by several studies that have shown the lack of substantial axon regeneration after spinal cord injury (SCI) in NgR1-knockout or -knockdown animal models. METHODS: We used mice carrying either a homozygous or heterozygous null mutation in the NgR1 gene and subjected them to either a moderate or severe SCI. RESULTS: Locomotor function assessments revealed that the level of functional recovery is affected by the degree of injury suffered. NgR1 ablation enhanced local collateral sprouting in the mutant mice. Reactive astrocytes and chondroitin sulfate proteoglycans (CSPGs) are upregulated surrounding the injury site. Matrix metalloproteinase-9, which has been shown to degrade CSPGs, was significantly upregulated in the homozygous mutant mice compared with the heterozygous or wild-type mice. However, CSPG levels remained higher in the homozygous compared with the heterozygous mice, suggesting that CSPG-degrading activity of matrix metalloproteinase-9 may require the presence of NgR1. CONCLUSION: Genetic ablation of NgR1 may lead to significant recovery in locomotor function after SCI. The difference in locomotor recovery we observed between the groups that suffered various degrees of injury suggests that injury severity may be a confounding factor in functional recovery after SCI.

Ventriculosubgaleal shunting--a strategy to reduce the incidence of shunt revisions and slit ventricles: an institutional experience and review of the literature.

BACKGROUND/AIMS: Slit ventricles and multiple episodes of shunt failure are problematic in many infants and preterm neonates shunted for hydrocephalus. We utilized ventriculosubgaleal (VSG) shunting as the initial neurosurgical intervention in neonates with hydrocephalus associated with intraventricular hemorrhage and infants with myelomeningocele. METHODS: We conducted a chart review of 21 children initially treated with a VSG shunt between November 2002 and July 2009. Patient records and imaging studies were reviewed. Demographics, case data and clinical outcome were collected. RESULTS: Five patients (27.8%) required a revision after conversion to a ventriculoperitoneal (VP) shunt. There were 9 cases of radiographic slit ventricles (45%). Average follow-up was 59.5 months (range 12-97 months). Average time interval to shunt conversion was 81.5 days. Two patients have not required conversion to a VP shunt (one with an 8-year follow-up). To date, none of these patients has required a subtemporal window or cranial vault expansion. CONCLUSION: Based on our results, initial management of selected hydrocephalic infants with a VSG shunt may prove to be advantageous in the long run for these children as the number of shunt revisions and the incidence of slit ventricles are significantly less than those reported in the literature.