Duodenal atresia: not always a double bubble.

A newborn infant with a prenatal diagnosis of duodenal atresia and abdominal radiographs demonstrating air in distal bowel is presented. An upper gastrointestinal series revealed complete duodenal obstruction and duodenal atresia was confirmed at surgery. The significance of distal bowel gas and the embryological development of this unusual entity is discussed.

An evidence-based algorithm for intraoperative monitoring during cochlear implantation.

OBJECTIVE: To generate an evidence-based algorithm for the use of intraoperative testing during cochlear implantation (CI). STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: A total of 277 children (aged 6 mo to 17 yr) and adults 18 years and older with normal cochlear anatomy who underwent primary and revision cochlear implantation at a single center between 2005 and 2010 were included. INTERVENTION: Intraoperative electrophysiologic monitoring and intraoperative Stenver's view plain film radiography. MAIN OUTCOME MEASURE: Intraoperative testing included the following: 1) individual electrode impedance measurements; 2) neural response telemetry (tNRT) levels for electrodes E20, E15, E10, and E5; and 3) plain film radiograph assessment of electrode position. RESULTS: No patient demonstrated abnormalities on all 3 modalities. Open or short electrodes on impedance testing were found in 6% of patients; half of these normalized when remeasured. Absent tNRT responses on 1 or more electrodes occurred in 14% of patients, although complete lack of response was rare (1.4%) and did not correlate with a dysfunctional device. Spread of excitation was performed in 1 patient and was consistent with a tip rollover. Intraoperative radiography identified tip-rollover and extracochlear electrode placement in all cases (n = 5, 1.8%) and prompted the use of the backup device. CONCLUSION: Immediate intraoperative determination of device functionality and optimal electrode placement is advantageous. Of the modalities tested, including electrode impedance, tNRT, and plain radiograph, only the radiographic results impacted intraoperative surgical decision making and led to the use of the backup device.

Sonic hedgehog agonist fails to induce neural stem cell precursors in a porcine model of experimental intracranial hemorrhage.

BACKGROUND: The role of endogenous neural stem cell progenitors in recovery from intracranial hemorrhage remains to be elucidated. Proliferation of such stem cells in the subventricular zone has been described in rodent models of experimental intracranial hemorrhage. Administration of a sonic hedgehog agonist at the time of hemorrhage was hypothesized to increase the quantity of such precursor cells. METHODS: Two groups of pigs were subjected to injection of autologous blood into the right frontal lobe. One group was also injected at the same site with a sonic hedgehog agonist at the time of the hemorrhage to stimulate cell growth, and the other was given a vehicle control. The pigs received intravenous BrdU for 5 days postoperatively to label replicating cells, and then were sacrificed at intervals up to 21 days. RESULTS: Pigs in the hemorrhage only group demonstrated increased and more persistent BrdU staining in the subventricular zone relative to pigs in the group that received sonic hedgehog agonist. The latter group demonstrated increased BrdU activity in non-neural lineage cells in the area of the hemorrhage. CONCLUSION: Sonic hedgehog agonist did not induce subventricular zone neural stem cell progenitor division after experimental intracranial hemorrhage in a pig model.

A retrospective analysis of pedicle screws in contact with the great vessels.

OBJECT: Pedicle screws placed in the thoracic, lumbar, and sacral spine occasionally come in contact with the aorta, vena cava, or iliac vessels. When such screws are seen on postoperative imaging in an asymptomatic patient, the surgeon must decide whether it is riskier to revise the screw or to observe it. The authors hypothesized that the incidence of screw placement causing perioperative vessel injury is low and, further, that screws placed in contact with major vessels do not always result in vessel injury. METHODS: A retrospective review of the operative records of 182 consecutive patients undergoing thoracic, lumbar, and lumbosacral pedicle screw fusion was performed to determine the frequency of intraoperative vessel injury. Postoperative imaging for 107 patients was available to determine the incidence of screws in contact with major vessels. Charts were examined to determine if any adverse sequelae had resulted from malpositioned screws. Patient outcomes were documented. RESULTS: There were no intraoperative vessel injuries or deaths in 182 consecutive operations. One hundred seven patients with available postoperative films had 680 pedicle screws placed between T-3 and the sacrum during 115 operations. No patient had arterial screw penetration or deformation on postoperative imaging. Thirty-three of the 680 inserted screws were in contact with a major vessel on routine postoperative imaging. The contacted vessels included the aorta (4 cases), the iliac artery (7 cases), and the iliac veins (22 cases). Patients were followed up until death or November 2009, for a mean follow-up of 44 months (median 44 months, range 5-109 months). None of the patients with vessel contact was noted to suffer symptoms or sequelae as a result of vessel contact. Radiographic follow-up as long as 50 months after surgery revealed no detectable vessel abnormality at the contacted site. CONCLUSIONS: Placing pedicle screws in contact with major vessels is a known risk of spinal surgery. The risk of repositioning a screw in contact with a major vessel but causing no symptoms must be weighed against the relative risk of leaving it in place.

Administration of human recombinant bone morphogenetic protein-2 for spine fusion may be associated with transient postoperative renal insufficiency.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: We reviewed the peri- and postoperative outcomes of our patients who had undergone lumbar and lumbosacral fusion both with and without recombinant human bone morphogenetic protein (rhBMP) over a period of 8 years to assess the frequency of complications and new diagnoses associated with the use of rhBMP2. SUMMARY OF BACKGROUND DATA: Administration of rhBMP2 for augmentation of lumbar and lumbosacral spinal fusion has not previously been associated with systemic complications. METHODS: A review of all patients undergoing lumbar and lumbosacral fusion over an 8-year period was performed to determine the frequency of postoperative complications and new diagnoses. Comparisons in complication frequency and new postoperative diagnoses between patients receiving rhBMP2 versus only allo- or autograft were made. Statistical methodology was applied to determine significance. RESULTS.: None of the 105 patients not receiving rhBMP2 and 3 of 24 patients receiving rhBMP2 had blood urea nitrogens and creatinines that more than doubled and reached values >30 and 1.5 mg/dL, respectively, after surgery (P = 0.006). Renal parameters returned to baseline within 45 days of surgery. Two of the 3 patients with postoperative renal insufficiency had been administered 16 mL (24 mg) of rhBMP2, whereas all other patients receiving rhBMP2 had received 8 mL (12 mg). Both of these patients also had supraventricular tachycardia, fever, and mental status changes after surgery. We recorded no significant increase in the incidence of new endocrinologic, autoimmune, neurologic, or neoplastic disorders associated with the use of rhBMP2 in our small patient population. CONCLUSION: A small subset of patients may develop transient renal insufficiency after rhBMP2 to augment spinal fusion. Higher doses of rhBMP2 may possibly increase the risk of developing renal insufficiency in particular patients; however, additional study is needed before all the risk factors are understood.