Overcoming the challenge of a thin skull in a 2-year-old patient undergoing laser interstitial thermal therapy using an individualized stereotactic platform: illustrative case.

BACKGROUND: Ependymoma is the third most common pediatric brain tumor that can present with headaches, cranial nerve deficits, nausea, vomiting, and ataxia. Current treatment is maximal safe resection followed by radiation therapy. More recently, laser interstitial thermal therapy (LITT) has become an alternative to traditional resection. In this report, the authors describe the utilization of a single-use, patient-specific stereotactic platform for the treatment of supratentorial ependymoma with LITT. OBSERVATIONS: A 2-year-old female had a complex history of supratentorial ependymoma after multiple craniotomies for repeated tumor progression and ventriculoperitoneal shunt placement. Imaging demonstrated an enlarging, complex, enhancing mass in the right occipital region. LITT was decided on for treatment. Given the thinness of the patient's skull, which precluded traditional means of stereotaxy, the authors elected to use a personalized stereotactic platform. Immediate postoperative imaging captured complete laser ablation of the tumor, with long-term imaging demonstrating a decreased tumor size. LESSONS: Individualized stereotactic platforms are increasingly used in adult populations, but pediatric use continues to be infrequent. In this report, the authors present the youngest reported case using a personalized stereotactic platform and show the effectiveness of this system for performing LITT in the youngest of populations with very thin skulls.

Cargo areas of pickup trucks: an avoidable mechanism for neurological injuries in children.

OBJECT: Falls from pickup truck cargo areas represent a unique mode of injury in children and adolescents. The goal of this study was to identify the neurological spectrum of injuries resulting from children riding in the back of pickup trucks. METHODS: The authors undertook a retrospective review of the University of New Mexico Hospital trauma registry of data compiled over a 7-year period. Their goal was to identify instances in which a fall or ejection from a pickup truck cargo area was the mechanism of injury. The charts of pediatric patients (< or = 16 years of age) with neurological injuries were reviewed and analyzed. Seventy-three pediatric patients with injuries related to riding in the cargo areas of trucks were identified, of which 53 children (73%) had sustained neurological injuries. Among these 53 children, 64% sustained isolated head injuries, 15% isolated spine injuries, 9.4% combined spine and head injuries, 2% combined peripheral nerve, spine, and head injuries, 4% isolated peripheral nerve injuries, and 5.6% concussive events. In 53.4% of patients with neurological injuries the results of computed tomography (CT) examination were abnormal. In 36% of patients with Glasgow Coma Scale (GCS) scores of 14 to 15 there was evidence of intracranial hemorrhage on head CT scans. Injury Severity Scores were similar in the patients who were ejected and those who fell from cargo areas, but patients who were ejected had a lower mean GCS score than those who suffered falls (GCS score 12.5 and 14.3, respectively). CONCLUSIONS: Falls or ejections from pickup truck cargo areas result in a relatively high incidence of traumatic head, spine, and peripheral nerve injury. Head CT scanning should therefore be considered in pediatric patients with this mechanism of injury. Cargo area occupancy poses an unacceptable risk of injury and should be avoided.

Spinal Stabilization Using Orthopedic Extremity Instrumentation Sets During Operation Enduring Freedom-Afghanistan.

BACKGROUND: The Role III, Multinational Medical Unit at Kandahar Air Field, Afghanistan, was established to provide combat casualty care in theater for International Security Assistance Forces, Afghanistan National Security Forces, and local nationals during Operation Enduring Freedom-Afghanistan. The authors describe their experience of treating unstable lumbar spine fractures with orthopedic extremity instrumentation sets from January 2007 to January 2008 and November 2010 to May 2011. METHODS: During the study periods, 15 patients comprising Afghanistan National Security Forces and local nationals presented to the medical facility for treatment of unstable lumbar spine fractures. The patients underwent surgery for either anterior corpectomy and instrumented fusion (n = 5) or posterior instrumented fusion (n = 10). Because of periodic scarcity of spinal instrumentation sets, orthopedic extremity instrumentation sets were used (Synthes Large Fragment LCP Instrument and Implant Set) for spinal stabilization. RESULTS: Immediate postoperative standing and sitting plain radiographs demonstrated no evidence of fracture progression or immediate hardware failure. One patient was seen in follow-up at 4 weeks and demonstrated construct stability on follow-up radiographs. CONCLUSIONS: In the combat environment with sparse resources, unstable spine fractures may potentially be treated using instrumentation not specifically designed for spinal implantation. This is an off-label use, and the authors do not recommend the use of these techniques as standard treatment in most medical environments.

Posterior instrumentation surgery for craniocervical junction instabilities: an update.

The surgical treatment of craniocervical junction (CCJ) instability has recently undergone significant development and change. Posterior instrumentation surgery has been the mainstay of treatment of CCJ instability, and is the focus of this review. For the treatment of atlantoaxial instability, C1-2 transarticular screw fixation has shown good stability, and has been regarded as the "gold standard" procedure. Because of potentially hazardous complications including vertebral artery injury, however, C-1 lateral mass-C-2 pedicle screw fixation is gaining popularity. For treatment of atlantooccipital instability, occipitocervical fixation using screw constructs (combined with either rods or plates) has shown more stability than sublaminar wiring techniques, and has been utilized more frequently. Both innovation in material engineering and in vitro biomechanical studies have contributed significantly to the development of more rigid internal fixation devices, and as a result, many patients who would have been treated conservatively with external orthosis are treated nowadays with instrumentation surgery, resulting in earlier ambulation, shortened hospital stay, and earlier recovery into social activities. New surgical techniques and instruments, however, need to stand the test of time to see whether they are free from long-term adverse events. The rapid turnover of new surgical techniques and hardware has made it difficult for less experienced surgeons to keep up with the latest developments. Conventional techniques can be safer and less technically demanding than newer techniques for those who are not familiar with them.

An unusual presentation of pediatric osteoblastoma in a patient with Klippel-Trenaunay-Weber syndrome: case report.

Osteoblastoma is an uncommon primary bone tumor that usually presents as a painful lesion in a long bone or in the spine. Osteoblastoma has been reported only twice in the literature in conjunction with systemic fibromatosis. The authors report the case of an 8-year-old girl with suspected Klippel-Trenaunay-Weber syndrome, a rare syndrome of systemic fibromatosis, who presented with a painless thoracic rib lesion that was found to be an osteoblastoma.

Contemporary imaging of mild TBI: the journey toward diffusion tensor imaging to assess neuronal damage.

OBJECTIVES: To follow the progression of neuroimaging as a means of non-invasive evaluation of mild traumatic brain injury (mTBI) in order to provide recommendations based on reproducible, defined imaging findings. METHODS: A comprehensive literature review and analysis of contemporary published articles was performed to study the progression of neuroimaging findings as a non-invasive 'biomarker' for mTBI. RESULTS: Multiple imaging modalities exist to support the evaluation of patients with mTBI, including ultrasound (US), computed tomography (CT), single photon emission computed tomography (SPECT), positron emission tomography (PET), and magnetic resonance imaging (MRI). These techniques continue to evolve with the development of fractional anisotropy (FA), fiber tractography (FT), and diffusion tensor imaging (DTI). DISCUSSION: Modern imaging techniques, when applied in the appropriate clinical setting, may serve as a valuable tool for diagnosis and management of patients with mTBI. An understanding of modern neuroanatomical imaging will enhance our ability to analyse injury and recognize the manifestations of mTBI.

Incidence and characteristics of spinal decompression surgery after the onset of symptoms of amyotrophic lateral sclerosis.

OBJECTIVE: The high incidence of spondylosis in patients at the mean age of onset (55.7 yr) of amyotrophic lateral sclerosis (ALS) can make recognition of ALS as a cause of weakness difficult. METHODS: To assess the impact of this diagnostic dilemma on neurosurgical practice, we performed a retrospective analysis of a database of more than 1500 patients with motor neuron disease. RESULTS: Of 1131 patients with typical, sporadic ALS, 47 (4.2%) underwent decompressive spinal surgery after the onset of retrospectively recognized symptoms of ALS. Among 55 operations in 47 ALS patients, 86% yielded no improvement, 9% produced minor improvement, and only 5% provided significant benefit. Cervical decompression was performed in 56%, lumbar in 42%, and thoracic in 2%. Foot drop was a symptom prompting surgery in 11 patients, and in 10, this finding was subsequently attributed solely to ALS. No differences between ALS patients who underwent spinal decompression and other ALS patients were noted regarding age at symptom onset, severity of impairment at time of diagnosis, or rate of disease progression. Not surprisingly, patients who had spinal surgery tended to have a longer interval between retrospectively recognized symptom onset and diagnosis of ALS. CONCLUSION: A small but significant number of patients with unrecognized ALS undergo spinal surgery that in retrospect may be inappropriate. The possibility of ALS must be considered in the evaluation of patients with weakness even in the presence of radiographic evidence of spondylosis and nerve root or spinal cord impingement.