Thoracolumbar Injury Classification and Severity Score in Children: A Validity Study.

BACKGROUND: The Thoracolumbar Injury Classification and Severity Score (TLICS) has been shown to be a valid tool for assessing the need for surgical intervention in adult patients. There is limited insight into its usefulness in children. OBJECTIVE: To assess the validity of the TLICS system in pediatric patients. METHODS: The medical records for pediatric patients with acute, traumatic thoracolumbar fractures at two Level 1 trauma centers were reviewed retrospectively. A TLICS score was calculated for each patient using computed tomography and magnetic resonance images, along with the neurological examination recorded in the patient's medical record. TLICS scores were compared with the type of treatment received. Receiver operating characteristic (ROC) curve analysis was employed to quantify the validity of the TLICS scoring system. RESULTS: TLICS calculations were completed for 165 patients. The mean TLICS score was 2.9 (standard deviation ± 2.7). Surgery was the treatment of choice for 23% of patients. There was statistically significant agreement between the TLICS suggested treatment and the actual treatment received (P < 0.001). The ROC curve calculated using multivariate logistic regression analysis of the TLICS system's parameters as a tool for predicting treatment demonstrated excellent discriminative ability, with an area under the ROC curve of 0.96, which was also statistically significant (P < 0.001). CONCLUSION: The TLICS system demonstrates good validity for selecting appropriate thoracolumbar fracture treatment in pediatric patients.

Thoracolumbar Injury Classification and Severity Score in children: a reliability study.

OBJECTIVE There are many classification systems for injuries of the thoracolumbar spine. The recent Thoracolumbar Injury Classification and Severity Score (TLICS) has been shown to be a reliable tool for adult patients. The aim of this study was to assess the reliability of the TLICS system in pediatric patients. The validity of the TLICS system is assessed in a companion paper. METHODS The medical records of pediatric patients with acute, traumatic thoracolumbar fractures at a single Level 1 trauma center were retrospectively reviewed. A TLICS was calculated for each patient using CT and MRI, along with the neurological examination recorded in the patient's medical record. TLICSs were compared with the type of treatment received. Five raters scored all patients separately to assess interrater reliability. RESULTS TLICS calculations were completed for 81 patients. The mean patient age was 10.9 years. Girls represented 51.8% of the study population, and 80% of the study patients were white. The most common mechanisms of injury were motor vehicle accidents (60.5%), falls (17.3%), and all-terrain vehicle accidents (8.6%). The mean TLICS was 3.7 ± 2.8. Surgery was the treatment of choice for 33.3% of patients. The agreement between the TLICS-suggested treatment and the actual treatment received was statistically significant (p < 0.0001). The interrater reliability of the TLICS system ranged from moderate to very good, with a Fleiss' generalized kappa (κ) value of 0.69 for the TLICS treatment suggestion among all patients; however, interrater reliability decreased when MRI was used to contribute to the TLICS. The κ value decreased from 0.73 to 0.57 for patients with CT only vs patients with CT/MRI or MRI only, respectively (p < 0.0001). Furthermore, the agreement between suggested treatment and actual treatment was worse when MRI was used as part of injury assessment. CONCLUSIONS The TLICS system demonstrates good interrater reliability among physicians assessing thoracolumbar fracture treatment in pediatric patients. Physicians should be cautious when using MRI to aid in the surgical decision-making process.

Seizure outcomes after stereotactic radiosurgery for the treatment of cerebral arteriovenous malformations.

OBJECTIVE Patients with cerebral arteriovenous malformations (AVMs) commonly present with seizure. Seizure outcomes in patients treated with stereotactic radiosurgery (SRS) are poorly defined. A case series of patients with cerebral AVMs treated with SRS is presented to evaluate long-term seizure outcome. METHODS A retrospective review of the medical record was performed, identifying 204 consecutive patients with AVMs treated with SRS between January 1991 and June 2012. Clinical and radiographic data were evaluated. Seizure outcome was measured using the Engel Epilepsy Surgery Outcome Scale. Mean duration of follow-up was 37.1 months (SD 38.3 months) with a minimum follow-up period of 1 month. RESULTS Of the 204 patients with cerebral AVMs treated with SRS, 78 patients (38.2%) presented with seizures and 49 of those patients were treated with antiepileptic drugs (AEDs). Following SRS, 63 (80.8%) of the 78 patients who had had seizures prior to SRS were seizure-free at a mean follow-up time of 37.2 months (SD 41.3 months). Of the 49 patients who had been treated with AEDs, 17 were still taking AEDs at last follow-up. Of the 126 patients who did not present with seizures prior to treatment with SRS, only 5 patients (4.0%) had seizures in the post-SRS period. There was no significant correlation between post-SRS seizure status and patient demographic features, comorbidities, AVM characteristics, history of operative intervention, pre- or posttreatment hemorrhage, or radiographic degree of AVM resolution. CONCLUSIONS Stereotactic radiosurgery for treatment of cerebral AVMs is effective at providing long-term control of seizures. A substantial number of patients who were treated with SRS were not only seizure free at their last follow-up, but had been successfully weaned from antiepileptic medications.

Cryptococcus gattii in an Immunocompetent Patient in the Southeastern United States.

Cryptococcal infections are seen throughout the United States in both immunocompromised and immunocompetent patients. The most common form is C. neoformans. In the Northwestern United States, C. gattii has received considerable attention secondary to increased virulence resulting in significant morbidity and mortality. There are no cases in the extant literature describing a patient with C. gattii requiring neurosurgical intervention in Alabama. A middle-aged immunocompetent male with no recent travel or identifiable exposure presented with meningitis secondary to C. gattii. The patient underwent 12 lumbar punctures and a ventriculoperitoneal shunt and required 83 days of inpatient therapy with 5-flucytosine and amphotericin B. The patient was found to have multiple intracranial lesions and a large intramedullary spinal cryptococcoma within his conus. Following an almost 3-month hospitalization the patient required treatment with oral voriconazole for one year. In the United States meningitis caused by C. gattii infection is not isolated to the Northwestern region.

Predictors of delayed recovery following pediatric sports-related concussion: a case-control study.

OBJECT Pediatric sports-related concussions are a growing public health concern. The factors that determine injury severity and time to recovery following these concussions are poorly understood. Previous studies suggest that initial symptom severity and diagnosis of attention deficit hyperactivity disorder (ADHD) are predictors of prolonged recovery (> 28 days) after pediatric sports-related concussions. Further analysis of baseline patient characteristics may allow for a more accurate prediction of which patients are at risk for delayed recovery after a sports-related concussion. METHODS The authors performed a single-center retrospective case-control study involving patients cared for at the multidisciplinary Concussion Clinic at Children's of Alabama between August 2011 and January 2013. Patient demographic data, medical history, sport concussion assessment tool 2 (SCAT2) and symptom severity scores, injury characteristics, and patient balance assessments were analyzed for each outcome group. The control group consisted of patients whose symptoms resolved within 28 days. The case group included patients whose symptoms persisted for more than 28 days. The presence or absence of the SCAT2 assessment had a modifying effect on the risk for delayed recovery; therefore, stratum-specific analyses were conducted for patients with recorded SCAT2 scores and for patients without SCAT2 scores. Unadjusted ORs and adjusted ORs (aORs) for an association of delayed recovery outcome with specific risk factors were calculated with logistic regression analysis. RESULTS A total of 294 patients met the inclusion criteria of the study. The case and control groups did not statistically significantly differ in age (p = 0.7). For the patients who had received SCAT2 assessments, a previous history of concussion (aOR 3.67, 95% CI 1.51-8.95), presenting SCAT2 score < 80 (aOR 5.58, 95% CI 2.61-11.93), and female sex (aOR 3.48, 95% CI 1.43-8.49) were all associated with a higher risk for postconcussive symptoms lasting more than 28 days. For patients without SCAT2 scores, female sex and reporting a history of ADHD significantly increased the odds of prolonged recovery (aOR 4.41, 95% CI 1.93-10.07 and aOR 3.87, 95% CI 1.13-13.24, respectively). Concussions resulting from playing a nonhelmet sport were also associated with a higher risk for prolonged symptoms in patients with and without SCAT2 scores (OR 2.59, 95% CI 1.28-5.26 and OR 2.17, 95% CI 0.99-7.73, respectively). Amnesia, balance abnormalities, and a history of migraines were not associated with symptoms lasting longer than 28 days. CONCLUSIONS This case-control study suggests candidate risk factors for predicting prolonged recovery following sports-related concussion. Large prospective cohort studies of youth athletes examined and treated with standardized protocols will be needed to definitively establish these associations and confirm which children are at highest risk for delayed recovery.

Preclinical Validation of Multilevel Intraparenchymal Stem Cell Therapy in the Porcine Spinal Cord.

BACKGROUND: Although multiple clinical trials are currently testing different stem cell therapies as treatment alternatives for many neurodegenerative diseases and spinal cord injury, the optimal injection parameters have not yet been defined. OBJECTIVE: To test the spinal cord's tolerance to increasing volumes and numbers of stem cell injections in the pig. METHODS: Twenty-seven female Göttingen minipigs received human neural progenitor cell injections using a stereotactic platform device. Cell transplantation in groups 1 to 5 (5-7 pigs in each) was undertaken with the intent of assessing the safety of an injection volume escalation (10, 25, and 50 µL) and an injection number escalation (20, 30, and 40 injections). Motor function and general morbidity were assessed for 21 days. Full necropsy was performed; spinal cords were analyzed for graft survival and microscopic tissue damage. RESULTS: No mortality or permanent surgical complications were observed during the 21-day study period. All animals returned to preoperative baseline within 14 days, showing complete motor function recovery. The histological analysis showed that there was no significant decrease in neuronal density between groups, and cell engraftment ranged from 12% to 31% depending on the injection paradigm. However, tissue damage was identified when injecting large volumes into the spinal cord (50 µL). CONCLUSION: This series supports the functional safety of various injection volumes and numbers in the spinal cord and gives critical insight into important safety thresholds. These results are relevant to all translational programs delivering cell therapeutics to the spinal cord.

Bone morphogenetic protein-associated complications in pediatric spinal fusion in the early postoperative period: an analysis of 4658 patients and review of the literature.

OBJECT: Use of recombinant human bone morphogenetic protein-2 has risen steadily since its approval by the FDA for use in anterior lumbar interbody fusion in 2002. The FDA has not approved the use of bone morphogenetic protein (BMP) in children. Age less than 18 years or lack of evidence of epiphyseal closure are considered by the manufacturer to be contraindications to BMP use. In light of this, the authors performed a query of the database of one of the nation's largest health insurance companies to determine the rate of BMP use and complications in pediatric patients undergoing spinal fusion. METHODS: The authors used the PearlDiver Technologies private payer database containing all records from United Health-Care from 2005 to 2011 to query all cases of pediatric spinal fusion with or without BMP use. A review of the literature was also performed to examine the complications associated with BMP use in pediatric spinal fusion. RESULTS: A total of 4658 patients underwent spinal fusion. The majority was female (65.4%), and the vast majority was age 10-19 years (94.98%) and underwent thoracolumbar fusion (93.13%). Bone morphogenetic protein was used in 1752 spinal fusions (37.61%). There was no difference in the rate of BMP use when comparing male and female patients or age 10 years or older versus less than 10 years. Anterior cervical fusions were significantly less likely to use BMP (7.3%). Complications occurred in 9.82% of patients treated with versus 9.88% of patients treated without BMP. The complication rate was nearly identical in male versus female patients and in patients older versus younger than 10 years. Comparison of systemic, wound-related, CNS, and other complications showed no difference between groups treated with and without BMP. The reoperation rate was also nearly identical. CONCLUSIONS: Bone morphogenetic protein is used in a higher than expected percentage of pediatric spinal fusions. The rate of acute complications in these operations does not appear to be different in patients treated with versus those treated without BMP. Caution must be exercised in interpreting these data due to the many limitations of the administrative database as a data source, including the short length of follow-up.

Observer reliability of arteriovenous malformations grading scales using current imaging modalities.

OBJECT: The aim of this study was to examine observer reliability of frequently used arteriovenous malformation (AVM) grading scales, including the 5-tier Spetzler-Martin scale, the 3-tier Spetzler-Ponce scale, and the Pollock-Flickinger radiosurgery-based scale, using current imaging modalities in a setting closely resembling routine clinical practice. METHODS: Five experienced raters, including 1 vascular neurosurgeon, 2 neuroradiologists, and 2 senior neurosurgical residents independently reviewed 15 MRI studies, 15 CT angiograms, and 15 digital subtraction angiograms obtained at the time of initial diagnosis. Assessments of 5 scans of each imaging modality were repeated for measurement of intrarater reliability. Three months after the initial assessment, raters reassessed those scans where there was disagreement. In this second assessment, raters were asked to justify their rating with comments and illustrations. Generalized kappa (κ) analysis for multiple raters, Kendall's coefficient of concordance (W), and interclass correlation coefficient (ICC) were applied to determine interrater reliability. For intrarater reliability analysis, Cohen's kappa (κ), Kendall's correlation coefficient (tau-b), and ICC were used to assess repeat measurement agreement for each rater. RESULTS: Interrater reliability for the overall 5-tier Spetzler-Martin scale was fair to good (ICC = 0.69) to extremely strong (Kendall's W = 0.73) on initial assessment and improved on reassessment. Assessment of CT angiograms resulted in the highest agreement, followed by MRI and digital subtraction angiography. Agreement for the overall 3-tier Spetzler-Ponce grade was fair to good (ICC = 0.68) to strong (Kendall's W = 0.70) on initial assessment, improved on reassessment, and was comparable to agreement for the 5-tier Spetzler-Martin scale. Agreement for the overall Pollock-Flickinger radiosurgery-based grade was excellent (ICC = 0.89) to extremely strong (Kendall's W = 0.81). Intrarater reliability for the overall 5-tier Spetzler-Martin grade was excellent (ICC > 0.75) in 3 of the 5 raters and fair to good (ICC > 0.40) in the other 2 raters. CONCLUSION: The 5-tier Spetzler-Martin scale, the 3-tier Spetzler-Ponce scale, and the Pollock-Flickinger radiosurgery-based scale all showed a high level of agreement. The improved reliability on reassessment was explained by a training effect from the initial assessment and the requirement to defend the rating, which outlines a potential downside for grades determined as part of routine clinical practice to be used for scientific purposes.

A comprehensive review with potential significance during skull base and neck operations, Part II: glossopharyngeal, vagus, accessory, and hypoglossal nerves and cervical spinal nerves 1-4.

Knowledge of the possible neural interconnections found between the lower cranial and upper cervical nerves may prove useful to surgeons who operate on the skull base and upper neck regions in order to avoid inadvertent traction or transection. We review the literature regarding the anatomy, function, and clinical implications of the complex neural networks formed by interconnections between the lower cranial and upper cervical nerves. A review of germane anatomic and clinical literature was performed. The review is organized into two parts. Part I discusses the anastomoses between the trigeminal, facial, and vestibulocochlear nerves or their branches and other nerve trunks or branches in the vicinity. Part II deals with the anastomoses between the glossopharyngeal, vagus, accessory and hypoglossal nerves and their branches or between these nerves and the first four cervical spinal nerves; the contribution of the autonomic nervous system to these neural plexuses is also briefly reviewed. Part II is presented in this article. Extensive and variable neural anastomoses exist between the lower cranial nerves and between the upper cervical nerves in such a way that these nerves with their extra-axial communications can be collectively considered a plexus.

Pediatric tectal plate gliomas: clinical and radiological progression, MR imaging characteristics, and management of hydrocephalus.

OBJECT: Tectal plate gliomas are generally low-grade astrocytomas with favorable prognosis, and observation of the lesion and management of hydrocephalus remain the mainstay of treatment. METHODS: A cohort of patients with tectal plate gliomas at 2 academic institutions was retrospectively reviewed. RESULTS: Forty-four patients with a mean age of 10.2 years who harbored tectal plate gliomas were included in the study. The mean clinical and radiological follow-up was 7.6 ± 3.3 years (median 7.9 years, range 1.5-14.7 years) and 6.5 ± 3.1 years (median 6.5 years, range 1.1-14.7 years), respectively. The most frequent intervention was CSF diversion (81.8% of patients) followed by biopsy (11.4%), radiotherapy (4.5%), chemotherapy (4.5%), and resection (2.3%). On MR imaging tectal plate gliomas most commonly showed T1-weighted isointensity (71.4%), T2-weighted hyperintensity (88.1%), and rarely enhanced (19%). The initial mean volume was 1.6 ± 2.2 cm(3) and it increased to 2.0 ± 4.4 cm(3) (p = 0.628) at the last follow-up. Frontal and occipital horn ratio (FOHR) and third ventricular width statistically decreased over time (p < 0.001 and p < 0.05, respectively). CONCLUSIONS: The authors' results support existing evidence that tectal plate gliomas frequently follow a benign clinical and radiographic course and rarely require any intervention beyond management of associated hydrocephalus.

Cellular therapeutics delivery to the spinal cord: technical considerations for clinical application.

Current literature demonstrates the efficacy of cell-based therapeutics in small animal models of varied spinal cord diseases. However, logistic challenges remain towards development of an optimized delivery approach to the human spinal cord. Clinical trials utilize a variety of methods to achieve this aim. In this article, the authors review currently employed delivery methods, compare the merits of alternate delivery paradigms, introduce their implementation in completed and ongoing clinical trials, and discuss promising near-term advances in image-guided delivery and in vivo graft tracking.

Oberlin transfer and partial radial to axillary nerve neurotization to repair an explosive traumatic injury to the brachial plexus in a child: case report.

PURPOSE: Explosive injuries to the pediatric brachial plexus are exceedingly rare and as such are poorly characterized in the medical literature. METHODS: Herein, we describe an 8-year-old who was struck in the neck by a piece of shrapnel and suffered multiple vascular injuries in addition to a suspected avulsion of the cervical 5 and 6 ventral rami. The patient had a complete upper brachial plexus palsy and failed to demonstrate any clinical improvement at 6-months follow-up. He was taken to the operating from for a partial ulnar to musculocutaneous nerve neurotization as well as a partial radial to axillary nerve neurotization. RESULTS: The patient's motor exam improved from a Medical Research Council scale 1 to 4+ for biceps brachii and 0 to 4 deltoid function with greater than 90° of shoulder abduction. CONCLUSIONS: This outcome supports complex neurotization techniques as viable treatment options for persistent motor deficits following an upper brachial plexus injury in older, non-infant age, children.

Neurosurgical injuries resulting from the 2011 tornados in Alabama: the experience at the University of Alabama at Birmingham Medical Center.

OBJECT: The April 27, 2011, tornados that affected the southeastern US resulted in 248 deaths in the state of Alabama. The University of Alabama at Birmingham (UAB) Medical Center, the largest Level I trauma center in the state, triaged and treated a large number of individuals who suffered traumatic injuries during these events, including those requiring neurosurgical assessment and treatment. METHODS: A retrospective review of all adult patients triaged at UAB Medical Center during the April 27, 2011, tornados was conducted. Those patients who were diagnosed with and treated for neurosurgical injuries were included in this cohort. RESULTS: The Division of Neurosurgery at UAB Medical Center received 37 consultations in the 36 hours following the tornado disaster. An additional patient presented 6 days later, having suffered a lumbar spine fracture that ultimately required operative intervention. Twenty-seven patients (73%) suffered injuries as a direct result of the tornados. Twenty-three (85%) of these 27 patients experienced spine and spinal cord injuries. Four patients (15%) suffered intracranial injuries and 2 patients (7%) suffered combined intracranial and spinal injuries. The spinal fractures that were evaluated and treated were predominantly thoracic (43.5%) and lumbar (43.5%). The neurosurgery service performed 14 spinal fusions, 1 ventriculostomy, 2 halo placements, 1 diagnostic angiogram, 1 endovascular embolectomy, and 1 wound debridement and lavage. Twenty-two patients (81.5%) were neurologically intact at discharge and all but 4 had 1 year of follow-up. Three patients had persistent deficits from spinal cord injuries and there was 1 death in a patient with multisystem injuries in whom no procedures were performed. Two patients experienced postoperative complications in the form of 1 wound infection and 1 stroke. CONCLUSIONS: The April 27, 2011, tornados in Alabama produced significant neurosurgical injuries that primarily involved the spine. There were a disproportionate number of patients with thoracolumbar fractures, a finding possibly due to the county medical examiner's postmortem findings that demonstrated a high prevalence of fatal cervical spine and traumatic brain injuries. The UAB experience can be used to aid other institutions in preparing for the appropriate allotment of resources in the event of a similar natural disaster.

Surgical technique for spinal cord delivery of therapies: demonstration of procedure in gottingen minipigs.

This is a compact visual description of a combination of surgical technique and device for the delivery of (gene and cell) therapies into the spinal cord. While the technique is demonstrated in the animal, the procedure is FDA-approved and currently being used for stem cell transplantation into the spinal cords of patients with ALS. While the FDA has recognized proof-of-principle data on therapeutic efficacy in highly characterized rodent models, the use of large animals is considered critical for validating the combination of a surgical procedure, a device, and the safety of a final therapy for human use. The size, anatomy, and general vulnerability of the spine and spinal cord of the swine are recognized to better model the human. Moreover, the surgical process of exposing and manipulating the spinal cord as well as closing the wound in the pig is virtually indistinguishable from the human. We believe that the healthy pig model represents a critical first step in the study of procedural safety.

Progressive symptomatic increase in the size of choroidal fissure cysts.

Cysts of the choroidal fissure are often incidentally identified. Symptoms from such cysts appear to be exceedingly rare. Herein, the authors report a case series of symptomatic enlargement of choroidal fissure cysts that were surgically treated. Although cysts of the choroidal fissure do not normally become symptomatic, the neurosurgeon should be aware of such a complication. Based on the authors' experience, surgical fenestration of such cysts has good long-term results.

Clinical evaluation and surveillance imaging in children with spina bifida aperta and shunt-treated hydrocephalus.

OBJECT: Most children with spina bifida aperta have implanted CSF shunts. However, the efficacy of adding surveillance imaging to clinical evaluation during routine follow-up as a means to minimize the hazard of shunt failure has not been thoroughly studied. METHODS: A total of 396 clinic visits were made by patients with spina bifida aperta and shunt-treated hydrocephalus in a spina bifida specialty clinic during the calendar years 2008 and 2009 (initial clinic visit). All visits were preceded by a 6-month period during which no shunt evaluation of any kind was performed and were followed by a subsequent visit in the same clinic. At the initial clinic visit, 230 patients were evaluated by a neurosurgeon (clinical evaluation group), and 166 patients underwent previously scheduled surveillance CT scans in addition to clinical evaluation (surveillance imaging group). Subsequent unexpected events, defined as emergency department (ED) visits and caregiver-requested clinic visits, were reviewed. The time to an unexpected event and the likelihood of event occurrence in each of the 2 groups were compared using Cox proportional hazards survival analysis. The outcome and complications of shunt surgeries were also reviewed. RESULTS: The clinical characteristics of the 2 groups were similar. In the clinical evaluation group, 2 patients underwent shunt revision based on clinical findings in the initial visit. In the subsequent follow-up period, there were 27 visits to the ED and 25 requested clinic visits that resulted in 12 shunt revisions. In the surveillance imaging group, 11 patients underwent shunt revision based on clinical and imaging findings in the initial visit. In the subsequent follow-up period, there were 15 visits to the ED and 9 requested clinic visits that resulted in 8 shunt revisions. Patients who underwent surveillance imaging on the day of initial clinic visit were less likely to have an unexpected event in the subsequent follow-up period (relative risk 0.579, p = 0.026). The likelihood of needing shunt revision and the morbidity of shunt malfunction was not significantly different between the 2 groups. CONCLUSIONS: Surveillance imaging in children with spina bifida aperta and shunted hydrocephalus decreases the likelihood of ED visits and caregiver-requested clinic visits in the follow-up period, but based on this study, its effect on mortality and morbidity related to shunt malfunction was less clear.

Massive pediatric neurosurgical injuries and lessons learned following a tornado disaster in Alabama.

OBJECT: A large volume of patients presented to a Level I pediatric trauma center during and after a recent tornado disaster. Injuries of the central and peripheral nervous systems and the medical responses of a pediatric neurosurgical team are reviewed. METHODS: The clinical courses of patients who suffered cranial, spinal, and peripheral nerve injuries due to the tornado storm are reported. The clinical actions taken by the neurosurgical team during and after the event are reviewed and the lessons learned are discussed. RESULTS: The tornado storm system moved through the Tuscaloosa and Birmingham metropolitan areas on the early evening hours of April 27, 2011. Twenty-four patients received care from the neurosurgical team. A total of 11 cranial (including placement of an external ventricular drain), 2 spine, and 2 peripheral procedures were performed for the victims. Nine procedures were performed within the first 12 hours of the event, and an additional 6 surgeries were performed in the following 24 hours. Injuries of the peripheral nervous system often presented in a delayed fashion. Several key components were identified that enabled adequate neurosurgical care for a large influx of acute patients. CONCLUSIONS: Massive casualties due to tornados are rare. A well-organized physician team working with the hospital administration may decrease the mortality and morbidity of such events.

Associated disorders of Chiari Type I malformations: a review.

A single pathophysiological mechanism of Chiari Type I malformations (CM-I) has been a topic of debate. To help better understand CM-I, the authors review disorders known to be associated with CM-I. The primary methodology found among most of them is deformation of the posterior cranial fossa, usually with subsequent decrease in volume. Other mechanisms exist as well, which can be categorized as either congenital or acquired. In understanding the relationship of such disorders with CM-I, we may gain further insight into the process by which cerebellar tonsillar herniation occurs. Some of these pathologies appear to be true associations, but many appear to be spurious.

Intraoperative anatomic landmarks for resection of the amygdala during medial temporal lobe surgery.

OBJECTIVE: To establish reliable gross landmarks for resecting the amygdala intraoperatively, especially during anteromedial temporal lobectomy and amygdalohippocampectomy for epilepsy surgery. Reliable landmarks would allow its safe and complete resection as well as its potential en bloc removal for detailed electrophysiological and histopathological analyses. METHODS: Ten adult cadavers (20 sides) were used. Two adjacent anatomic structures were identified: the bifurcation of the middle cerebral artery (MCA point) and the entry point of the anterior choroidal artery (AChoA) at the anterior origin of the choroid plexus into the temporal horn (inferior choroidal point referred to as the AChoA point). Following removal of the brain tissue inferior and anterior to the imaginary line connecting these 2 anatomic landmarks, cross sectional histopathological analysis of the remaining temporal and frontal lobes was performed to verify the presence or absence of any nervous tissue belonging to the amygdala complex. RESULTS: In all 20 sides, the entire amygdala complex was found anterior and inferior to the transection made along the MCA-AChoA line. No apparent injury to the adjacent striatum was discovered. CONCLUSION: Two easily identifiable points, including the middle cerebral artery bifurcation and the inferior choroidal point, may define a line that reliably disconnects the amygdala complex from the remaining temporal and frontal lobes. These landmarks may assist in resection of the amygdale while preserving important adjacent structures, including the striatum.

Enhanced case management to prevent fetal alcohol spectrum disorders in Northern Plains communities.

Women proven to be extremely high risk for drinking during pregnancy were provided case management (CM) enhanced with strategies derived from motivational interviewing (MI) as a part of a comprehensive Fetal Alcohol Syndrome (FAS) epidemiology and prevention program in four American Indian communities in Northern Plains states. Data on the first women enrolled (n=131) revealed that they have extreme issues with alcohol abuse to overcome. Sixty-five percent of these women have experienced extensive alcohol use within their immediate family. At intake, 24% of CM clients reported binge drinking one or more days in the preceding week. Heavy drinking resulted in estimated blood alcohol concentrations (BAC) as high as .576 using the BACCUS methodology. Project staff has attempted to actively engage each of these women in CM. Clients have been in CM an average of 17.2 months (SD=16.6). The mean number of significant contacts (face-to-face or telephone MI sessions) was 19. Thirty-one percent of the women entered some type of formal alcohol or drug treatment while in CM. Data were collected at 6 month intervals from 6 to 72 months after enrollment. Consumption of alcohol, as measured by both quantity and frequency measures, was reduced at 6 months. Thirty-eight percent of enrolled women reported complete abstinence from alcohol use at 6 months, and the number of binges while drinking in CM declined significantly from 15 at baseline to 4.3 at 6 months. However, mean peak BACs for the heavy drinking sessions were still problematic for those who continued to drink. They ranged from .234 to .275 from baseline to 12 month follow-up, but the total number of binges was reduced substantially at 12 months as well. Furthermore, the most important outcomes are the status of the children born while in CM. One hundred and forty nine pregnancies have occurred among these women, and 76% of those pregnancies have resulted in normal deliveries, and only two children born in CM are suspected of having some form of severe FASD. At 6, 12, 18, and 24 month follow-up milestones, 70% of the women who were not currently pregnant were protected from having a child with FAS by not drinking, using birth control, or both. Other measures of CM success include enrolling in school, regaining custody of children, completing substance abuse treatment, probation from the criminal justice system, substantial periods of abstinence, enrolling in programs to improve life skills, and employment.