Midline anterior craniofacial approach for malignancy: results of en bloc versus piecemeal resections

Thirty consecutive cases of midline anterior craniofacial procedures for the treatment of malignant neoplasms arising from the paranasal sinuses were reviewed. Posterior and lateral base craniofacial procedures were specifically excluded. This review compares the results, in terms of survival and major complication rate, between en bloc and piecemeal resections. The average follow-up was 4 years and 3 months. Sixteen patients were treated with an en bloc resection. The major complication rate was 31%. One-year survival rate was 94% for the en bloc resection group, 67% for patients with positive margins, and 100% for patients with clear margins. Three-year survival for en bloc resection dropped to 56, 33, and 67%, respectively. Fourteen patients were treated with piecemeal resections. The major complication rate was 21%. One-year survival rate was 83% for the piecemeal resection group, 60% for patients with positive margins, and 100% for patients with clear margins. Three-year survival dropped to 70, 60, and 80%, respectively. Although it is considered desirable to obtain an en bloc resection in some craniofacial procedures, we conclude that a piecemeal resection is a viable alternative in situations where an en bloc procedure is difficult to obtain safely.

Successful use of rib grafts for cranioplasty in children

Numerous materials are available for use in cranioplasty including bone, plastics and metals. Rib grafts as a construct for cranial reconstruction offer several advantages: autologous bone source, a formable platform, low infection, regeneration at the donor site and high fusion rates. Criticism of rib graft cranioplasty includes scarring and pain at the donor site, irregular contour at the graft site and graft reabsorption. Since 1988, we have performed rib autograft cranioplasty on 13 patients. Seven females and 6 males combined for an average age of 6 years (11 months to 20 years) at the time of surgery. The mean follow-up from surgery is 27 months (2-48 months), with 11 subjects having at least 12 months. The commonest reasons for cranial reconstruction were: post-traumatic calvarial defect (n = 4), defect from previous craniotomy (n = 3), "growing" skull fracture (n = 2), and defect from previous encephalocele closure (n = 2). Mean defect size was 41 cm(2) (8-144 cm(2)) and average number of ribs harvested was 1.75 (1-3). Simple rib cranioplasty had a mean time in the operating room of 6 h and 30 min. No donor site complications were noted (pneumothorax, significant post-operative pain) and no post-operative infections were encountered. Excellent cranial contour was achieved in each of the 11 patients followed for a minimum of 12 months. One subject required staged reconstructive procedures owing to the size of the defect.

Treatment of Down syndrome-associated craniovertebral junction abnormalities

OBJECT

Operative intervention for craniovertebral junction (CVJ) instability in patients with Down syndrome has become controversial, with reports of a low incidence of associated neurological dysfunction and high surgical morbidity rates. The authors analyzed their experience in light of these poor results and attempted to evaluate differences in management.

METHODS

Medical and radiographic records of 36 consecutive patients with Down syndrome and CVJ abnormalities were reviewed. The most common clinical complaints included neck pain (15 patients) and torticollis (12 patients). Cervicomedullary compression was associated with ataxia and progressive weakness. Hyperreflexia was documented in a majority of patients (24 cases), and 13 patients suffered from varying degrees of quadriparesis. Upper respiratory tract infection precipitated the presentation in five patients. Four patients suffered acute neurological insults after a minor fall and two after receiving a general anesthetic agent. Atlantoaxial instability was the most common radiographically observed abnormality (23 patients), with a rotary component present in 14 patients. Occipitoatlantal instability was also frequently observed (16 patients) and was coexistent with atlantoaxial dislocation in 15 patients. Twenty individuals had bone anomalies, the most frequent of which was os odontoideum (12 patients) followed by atlantal arch hypoplasia and bifid anterior or posterior arches (eight patients). Twenty-seven patients underwent surgical procedures without subsequent neurological deterioration, and a 96% fusion rate was observed. In five of 11 patients basilar invagination was irreducible and required transoral decompression. Overall, 24 patients enjoyed good or excellent outcomes.

CONCLUSIONS

The results of this series highlight the clinicopathological characteristics of CVJ instability in patients with Down syndrome and suggest that satisfactory outcomes can be achieved with low surgical morbidity rates.

Intraspinal familial clear cell meningioma in a mother and child. Case report

The authors present a case of familial clear cell meningioma in which the proband is a child with an intraspinal tumor. The clear cell meningioma variant has recently been studied. The literature regarding clear cell meningioma is reviewed.

Three choroid plexus papillomas in a patient with Aicardi syndrome. A case report

Aicardi syndrome is an X-linked dominant disorder primarily defined by the triad of corpus callosum agenesis, infantile spasms and a pathognomonic lacunar chorioretinopathy. Papillomas of the choroid plexus have been reported in affected patients. We report an Aicardi syndrome patient who had three separate choroid plexus papillomas and associated hydrocephalus. A dizygotic twin was unaffected. Staged resection of the tumors was safely accomplished, with improvement in seizure control. Imaging between procedures revealed rapid tumor growth.

Cervical vertebral anomalies in patients with anomalies of the head and neck

Congenital head and neck anomalies can occur in association with vertebral anomalies, particularly of the cervical vertebrae. While the former are easily recognized, especially when part of a syndrome, the latter are often occult, thereby delaying their diagnosis. The presence of vertebral anomalies must be considered in pediatric patients with head and neck abnormalities to expedite management of select cases and to prevent neurologic injury. We present our experience with 5 pediatric patients who were referred to the Department of Otolaryngology-Head and Neck Surgery at the University of Iowa with a variety of syndromic anomalies of the head and neck. Each patient was subsequently also found to have a vertebral anomaly. The relevant embryogenesis of the anomalous structures is discussed, with highlighting of potential causes such as teratogenic agents and events and germ-line mutations. A review of syndromes having both head and neck and vertebral anomalies is presented to heighten awareness of otolaryngologists evaluating children with syndromic disorders. Finally, the findings on radiographic imaging studies, particularly computed tomography, are discussed to facilitate the prompt diagnosis of vertebral anomalies.

Presentation, management and follow-up of Schilder's disease

Schilder's diffuse myelinoclastic sclerosis is a rare demyelinating disease which often mimics intracranial neoplasm or abscess. We have treated 3 patients with this disorder in the past 5 years and followed their postoperative course. Certain distinct features of this disease will allow neurosurgeons to preoperatively entertain this diagnosis. We discuss postoperative treatment and propose a new hypothesis regarding the variable prognoses of this disorder. Schilder's disease constitutes an important diagnosis for any neurosurgeon to be aware of (especially those treating the pediatric age group) which has not received adequate coverage in the neurosurgical literature.

A comparative analysis of fusion rates and donor-site morbidity for autogeneic rib and iliac crest bone grafts in posterior cervical fusions

OBJECT

Autogeneic bone graft is often incorporated into posterior cervical stabilization constructs as a fusion substrate. Iliac crest is used frequently, although donor-site morbidity can be substantial. Rib is used rarely, despite its accessibility, expandability, unique curvature, and high bone morphogenetic protein content. The authors present a comparative analysis of autogeneic rib and iliac crest bone grafts, with emphasis on fusion rate and donor-site morbidity.

METHODS

A review was conducted of records and radiographs from 600 patients who underwent cervical spinal fusion procedures in which autogeneic bone grafts were used. Three hundred patients underwent rib harvest and posterior cervical fusion. The remaining 300 patients underwent iliac crest harvest (248 for an anterior cervical fusion and 52 for posterior fusion). The analysis of fusion focused on the latter subgroup; donor-site morbidity was determined by evaluating the entire group. Fusion criteria included bony trabeculae traversing the donor-recipient interface and long-term stability on flexion-extension radiographs. Graft morbidity was defined as any untoward event attributable to the graft harvest. Statistical comparisons were facilitated by using Fisher's exact test.

CONCLUSIONS

Demographic data obtained in both groups were comparable. Rib constructs were placed in the following regions: occipitocervical (196 patients), atlantoaxial (35 patients), and subaxial cervical spine (69 patients). Iliac crest grafts were placed in the occipitocervical (28 patients), atlantoaxial (10 patients), and subaxial cervical (14 patients) regions. Fusion occurred in 296 (98.8%) of 300 rib graft and 49 (94.2%) of 52 iliac crest graft constructs (p = 0.056). Graft morbidity was greater with iliac crest than with rib (p < 0.00001). Donor-site morbidity for the rib graft was 3.7% and included pneumonia (eight patients), persistent atelectasis (two patients), and superficial wound dehiscence (one patient). Pneumothorax, intercostal neuralgia, and chronic chest wall pain were not encountered. Iliac crest morbidity occurred in 25.3% of the patients and consisted of chronic donor-site pain (52 patients), wound dehiscence (eight patients), pneumonia (seven patients), meralgia paresthetica (four patients), hematoma requiring evacuation (three patients), and iliac spine fracture (two patients). Even when chronic pain was not considered, morbidity encountered in obtaining iliac crest still exceeded that encountered with rib harvest (p = 0.035). The fusion rate and donor-site morbidity for rib autograft compare favorably with those for iliac crest when used in posterior cervical constructs. To the authors' knowledge, this represents the largest series to date in which the safety and efficacy of using autogeneic bone graft materials in spinal surgery are critically analyzed.

Occipital calvarial bone graft in posterior occipitocervical fusion

STUDY DESIGN

Dorsal occipitocervical fusion is associated with a high rate of fusion failure and requires an additional surgical site for donor bone graft harvesting. In this series, an autologous occipital calvarial bone graft obtained from the same occipitocervical incision with contoured metal loops was used in 25 adults to achieve craniovertebral stabilization and fusion.

OBJECTIVES

To study the use of autologous occipital calvarial bone grafts in occipitocervical fusion.

SUMMARY OF BACKGROUND DATA

Cranial bone grafts have been used successfully in craniofacial reconstruction with good long-term results. In the plastic surgery literature, there are claims that membranous bone grafts are superior to endochondral bone grafts in fusions because of decreased resorption. In recent studies, results have shown successful use of calvarial bone in fusing the upper cervical spine in children. The use of autologous occipital bone in posterior occipitocervical fusions avoids many of the problems associated with traditional donor sites and provides a sufficient quantity of good quality bone for the fusion. This is especially true in the fragile rheumatoid arthritis patient with cranial cervical instability.

METHOD

Split-thickness, autologous calvarial bone grafts with contoured loop and cable instrumentation were used for posterior occipitocervical stabilization and fusion in 25 patients, most of whom had rheumatoid arthritis. The calvarial bone graft was harvested from the occipital skull, using a microair impactor, and was secured next to the loop construct. After surgery, all patients were immobilized with external orthoses.

RESULTS

None of the patients had hardware failure or complications from the occipital graft procurement. In 22 patients, good alignment, stability, and bony fusion were shown on radiographs.

CONCLUSIONS

Occipital calvarial bone graft appears to work as well as other autologous corticocancellous bone grafts routinely used in posterior occipitocervical fusions.

Craniovertebral junction anomalies: diagnosis and management

The craniovertebral junction is the most complex of the axial skeleton, residing between the skull and the upper cervical spine. Congenital, developmental, and acquired bony abnormalities result in compression and distortion of the neural structures, the vertebrobasilar vascular system, and the cerebrospinal fluid channels. The clinical significance of this has only been recently recognized, and mistaken diagnoses have led to a delayed treatment and at times adverse results. A review of the anatomy, the embryology, and the mechanics of this region is essential to the understanding of the pathophysiology encountered.

Neuromuscular scoliosis: diagnostic and therapeutic considerations

Neuromuscular scoliosis in a child presents as a diagnostic and therapeutic dilemma to the pediatric neurologist, the pediatric neurological surgeon, and the pediatric orthopaedist. Because of its progressive nature, it tends to be refractory to conservative management and requires active intervention. Neuromuscular scoliosis is a symptom, and the diseases leading to the deformity must be addressed together with the spinal abnormality. The framework of the diagnosis and management is addressed in this article.

Increased height in patients with medulloblastomas

OBJECTIVE

Medulloblastomas demonstrate histological features similar to neuroendocrine tumors. Expression of various receptors for growth factors and production of growth hormones have been identified to occur with medulloblastomas. We studied the preoperative height of patients with medulloblastomas.

METHODS

We studied 85 patients (64 children and 21 adults) with medulloblastomas and 42 patients (27 children and 15 adults) with cerebellar astrocytomas who served as a control group. All of the patients had their height and weight documented on standardized growth charts. In addition, age, sex, symptoms, radiographic findings, treatment, and survival were examined.

RESULTS

Preoperatively, 22.4% of the patients with medulloblastomas were above the 95% curve in height and 80.0% were above the 50% curve for height. Compared with patients with cerebellar astrocytomas, 7.1% were above the 95% curve for height and 54.8% were above the 50% curve for height. The distribution of patients along the weight curves for both tumor types demonstrated a slight prevalence for lower weights but was not significantly different from the national average. A significant number of patients presenting with medulloblastomas attained increased height, which was disproportionate to the weight loss generally observed with neoplasms. To our knowledge, the disproportionate number of patients with medulloblastomas and increased height has not been reported before. A similar deviation in height distribution from the normal population could not be identified in patients with cerebellar astrocytomas.

CONCLUSION

This study suggests that medulloblastomas may be influenced by growth hormone production or may produce growth factors in vivo.

Idiopathic spinal epidural lipomatosis

OBJECTIVE

Spinal epidural lipomatosis (SEDL) is a rare disorder often associated with the administration of exogenous steroids or the elevation of endogenous steroids. Spinal epidural lipomatosis develops in some patients in the absence of elevated steroid levels. The limited information known about idiopathic SEDL comes predominantly from isolated case reports. We proposed to study our experience with idiopathic SEDL and to review the literature.

METHODS

We identified eight symptomatic patients with idiopathic SEDL treated at our institution, which is the largest series reported. All patients were male and obese by body mass index (> 27.5 kg/m2). The mean age of the patients was 35.4 years. Idiopathic SEDL was equally distributed between the thoracic and lumbar spine. Six patients underwent laminectomy and fat debulking with good postoperative results; two patients were treated with a weight loss diet, which resulted in the relief of symptoms after losing > 15 kg each.

RESULTS AND CONCLUSION

A review of our patients in conjunction with other reported cases reveals the following: 1) idiopathic SEDL occurs almost exclusively in the obese population; 2) idiopathic SEDL seems to occur with equal frequency between the thoracic and lumber spine; 3) a strong male predominance exists; 4) thoracic SEDL presents at an earlier age compared with lumbar SEDL; 5) surgical decompression remains the treatment of choice for the immediate relief of symptoms. Our experience suggests that idiopathic epidural lipomatosis may be a pathological entity that has been underdiagnosed.

Basilar invagination in osteogenesis imperfecta and related osteochondrodysplasias: medical and surgical management

Osteogenesis imperfecta (OI) is a heritable disorder of bone development caused by defective collagen synthesis. Basilar invagination is an uncommon but devastating complication of this disease. The authors present a comprehensive strategy for management of craniovertebral anomalies associated with OI and related osteochondrodysplasias. Twenty-five patients with congenital osteochondrodysplasias (18 OI, four Hajdu-Cheney syndrome, and three spondyloepiphyseal dysplasia) and basilar invagination were evaluated between 1985 and 1995. The male/female ratio in this cohort was 1:1. The mean age at presentation was 11.9 years (range 13 months-20 years). Fourteen patients (56%) presented during adolescence (11-15 years of age). Symptoms and signs included headache (76%), lower cranial nerve dysfunction (68%), hyperreflexia (56%), quadriparesis (48%), ataxia (32%), nystagmus (28%), and scoliosis (20%). Four patients (16%) were asymptomatic. Seven (28%) had undergone previous posterior fossa decompression; one had also undergone ventral decompression. Imaging findings included basilar invagination (100%), ventral brainstem compression (84%), hydrocephalus (32%), hindbrain herniation (28%), and syringomyelia/syringobulbia (16%). Patients with hydrocephalus underwent ventricular shunt placement. Reducible basilar invagination (40%) was treated with posterior fossa decompression and occipitocervical fusion. Those with irreducible ventral compression (60%) underwent transoral-transpalatopharyngeal decompression followed by occipitocervical fusion. All patients improved initially. However, basilar invagination progressed radiographically in 80% (symptomatic in 24%) despite successful fusion. Prolonged external orthotic immobilization with the modified Minerva brace afforded symptomatic improvement and arrested progression of the deformity. The mean follow-up period was 5.9 years (range 1.1-10.5 years). Ventral brainstem compression in OI should be treated with ventral decompression, followed by occipitocervical fusion with contoured loop instrumentation to prevent further squamooccipital infolding. Despite fusion, however, basilar invagination tends to progress. Prolonged immobilization (particularly during adolescence) may stabilize symptoms and halt further invagination. This study represents the largest series to date addressing craniovertebral anomalies in OI and related congenital bone softening disorders.

Primary tumors of the spine in children. Natural history, management, and long-term follow-up

STUDY DESIGN

Patients 16 years of age and younger with primary vertebral neoplasms diagnosed between 1951 and 1996 at The University of Iowa were reviewed retrospectively with specific consideration given to follow-up.

OBJECTIVE

Follow-up extending beyond the growth of the axial skeleton was used to establish the natural history, management outcome, and current approach to treatment.

SUMMARY OF BACKGROUND DATA

Primary tumors of the spine are uncommon. The treatment of such lesions generally has been based on small series of tumors, or extrapolated from the treatment of tumors in other regions and tumors in adults. Given the unique developing anatomy and dynamic nature of the growing spine in children, delineating appropriate modalities of treatment for these tumors beyond the growth of the axial skeleton is essential.

METHODS

Clinical history, radiographs, radiographic reports, and interviews were used to establish this database. Outcome with respect to the various approaches to treatment was then compared in detail.

RESULTS

Forty-five patients were identified in which follow-up greater than 10 years was available for 58% of patients. There were 29 histologically benign and 16 malignant tumors. Patients presented most frequently with pain (79%) and neurologic deficits (74%). The duration of symptoms was significantly shorter with malignant tumors (11 weeks) compared with benign tumors (26 weeks). Radiographic abnormalities were demonstrated on plain radiographs in 98% of cases. Tumor excision was achieved in 80%. Follow-up studies were available beyond the growth of the axial skeleton in these patients, with an average follow-up of 14 years. Recurrence was seen in 6 of 45 children, and the overall mortality rate was 6.7%, occurring only with malignant tumors.

CONCLUSION

Our current approach to treatment of spinal neoplasms varies from that used in the earlier part of the series and reflects the need for single stage complete resection and stabilization.

Hemorrhagic complications in association with silastic dural substitute: pediatric and adult case reports with a review of the literature

OBJECTIVE AND IMPORTANCE

Delayed intracranial hemorrhage is an unusual complication associated with the use of silastic dural substitute.

CLINICAL PRESENTATION

We present three patients with this complication. Two adult patients developed subdural and epidural hemorrhages 9 months and 10 years after posterior fossa surgery for Chiari malformations. The remaining patient, a 13-month-old child, is the youngest reported patient to develop an epidural hematoma 8 months after a craniosynostosis repair.

INTERVENTION

The hematomas were removed with the silastic dural substitute from all three patients, and the dural defect was repaired with autologous paracervical fascia.

CONCLUSION

Silastic dural grafts have an increased incidence of hemorrhage associated with their use. A slight increase in the prevalence of hemorrhagic complications with silastic dural substitute was observed in women. We report our radiographic and surgical findings, including an extensive review of the literature.

Periodontoid calcium pyrophosphate dihydrate deposition disease: "pseudogout" mass lesions of the craniocervical junction

Between 1984 and 1996, seven patients with symptomatic masses located posterior to the odontoid process and containing calcium pyrophosphate dihydrate crystals were evaluated by the senior author (A.H.M). All patients presented with distal paresthesias and myelopathy and underwent transoral-transpharyngeal resection of the anterior arch of C-I, the odontoid process, and the compressing mass. Histological examination revealed the characteristic changes of calcium pyrophosphate dihydrate (CPPD) deposition disease, with nodular deposits of birefringent rhomboid crystals. On magnetic resonance imaging, the masses appeared predominantly isointense with neural tissue on T1-weighted images and iso-to hyperintense on T2-weighted images. On computerized tomography scans, small area of calcifications within the masses were apparent in all cases. All patients improved postoperatively, with six of seven patients requiring posterior fixation for instability as a second procedure. Calcium pyrophosphate dihydrate deposition causing periodontoid mass lesions is a distinct clinical disease entity that probably is underdiagnosed. In the authors' l opinion, the diagnosis can often be established preoperatively by the distinctive neuroradiological appearance of the masses. Therefore, CPPD deposition disease should be considered in the differential diagnosis of masses of the craniocervical junction, because it is amenable to early surgical intervention. The consulting neuropathologist should be made aware of this diagnostic possibility at the time of surgery.

Sudden attacks of head pain in a young child

In the evaluation of headaches at any age, the clinical features of the episodes are the most important diagnostic information available. In the patient presented, the nature of the headaches suggests the need for further study as well as the most fruitful location in which to look.

Quantitative analysis of cerebrospinal fluid spaces in children with occipital plagiocephaly

The etiology of occipital plagiocephaly (OP) is not fully understood. The authors have observed that many infants with this condition have external hydrocephalus. This study was undertaken to quantify cerebrospinal fluid (CSF) space caliber in children with OP and to compare these measurements to those derived from normal age-matched controls to further elucidate the pathogenesis of this condition. Thirty-one infants with isolated unilateral OP (mean age 6 months) were studied. Infants with multiple cranial suture abnormalities, impaired neurological function, developmental delay, and associated craniofacial anomalies were excluded. Twenty normal infants were evaluated as controls. The volumes of the sylvian fissures, frontal and occipital subarachnoid spaces, as well as the cross-sectional areas of the suprasellar and perimesencephalic cisterns, were calculated from computerized tomography (CT) studies. Ventricular size was also assessed. Generalized subarachnoid space dilation was observed in 29 (93.5%) of the 31 children with OP. Head circumference was significantly greater in the case group (71.4 vs. 50.8 percentile; p = 0.0002 by analysis of variance). The sylvian fissure volume was significantly larger in the case group (5.8 ml vs. 0.7 ml in controls, p < 0.0001). The volume of the contralateral sylvian fissure was greater than that ipsilateral to the side of OP (7.1 ml vs. 4.5 ml, p = 0.001). Frontal subarachnoid space volume was greater in infants with OP (27.5 ml vs. 0.6 ml in controls, p < 0.0001). Both the suprasellar and perimesencephalic cisterns were of greater caliber in the case group (p = 0.007 and p < 0.0001, respectively). No difference in ventricular size or occipital subarachnoid space volume was noted between groups. The extraventricular CSF spaces in neurologically unimpaired infants with OP are significantly larger than those in age- and sex-matched controls. Enlarged subarachnoid spaces may increase the compliance and malleability of the calvaria and sutures, predisposing to positional deformity. External hydrocephalus may be a fundamental etiological factor in OP.

Management strategies for tumors of the axis vertebra

Primary and metastatic tumors of the axis vertebra pose difficult surgical problems. The authors report 14 cases of patients with axis tumors who underwent surgery between 1970 and 1993. The eight male and six female patients ranged in age from 9 to 70 years (mean 46 years). Presenting symptoms and signs included pain in 12, myelopathy in nine, radiculopathy in four, and cranial nerve deficits in two patients. Preoperative instability of the cervical spine was present in eight patients. The goal of surgery was to achieve diagnosis, decompression, and stabilization; the choice of operative intervention was based on tumor location and patient prognosis. Six transoral-transpalatal resections, two lateral extrapharyngeal approaches, four posterolateral decompressions, and 11 dorsal decompressions were performed. Eleven fusion procedures were required to achieve spinal stability. Patients with aggressive tumors requiring concomitant radiotherapy underwent fusion using contoured loop instrumentation or methyl methacrylate, whereas those with benign lesions underwent fusion using traditional techniques. With maximum medical and surgical intervention, 10 patients are alive and their tumors are in remission. In eight of these 10 patients, gross-total resection was achieved. Four patients died from tumor progression, and in three of these cases gross-total resection was not possible. There were no operative deaths and morbidity was minimal. Development of new surgical approaches to the axis has allowed resection of previously inoperable tumors. The extent of resection correlated with the duration of survival. A classification system for axis tumors is proposed to facilitate selection of appropriate surgical approaches that will maximize the extent of resection while achieving or maintaining spinal stability.

Posterolateral approach for anterior resection and posterior stabilization of the upper cervical spine: a case report

Surgical approaches to atlanto-axial lesions are generally accomplished by either anterior (transoral) or posterior approaches as dictated by the location of the lesion. In certain patients, these approaches are combined, either in a single or staged procedure. Mechanical stabilization is much more readily accomplished posteriorly, as this allows easy incorporation of the occiput. While the transoral approach allows excellent exposure of the bodies of C1 and C2, it entails substantial surgical trauma. We describe the case of a woman with destruction of the anterior portions of the C1 and C2 vertebrae by metastatic breast cancer addressed by simultaneous anterior tumor debulking and posterior instrumentation through a posterolateral approach to the upper cervical spine.

Pathogenesis and treatment of growing skull fractures

BACKGROUND

Growing skull fractures are poorly understood complications of pediatric skull fractures.

METHODS

A retrospective review of skull fractures at our institution from 1980-1993 revealed 10 patients with growing skull fractures. The age at injury ranged from 1-144 months, with 9 of 10 patients being under one year of age. The etiology of these fractures included falls, motor vehicle accidents, and child abuse. On average, growth of the fracture was diagnosed 14 months after the initial injury.

RESULTS

Six patients have had magnetic resonance imaging (MRI) with one demonstrating leptomeningeal cyst herniation, two having brain herniation, and three having both brain parenchyma and leptomeningeal cyst herniation. All patients had malacic cortex underlying the fracture, but there was no evidence of intracranial hypertension. Nine patients have undergone craniotomy with excision of granulation tissue and gliotic brain, dural repair, and cranioplasty using surrounding normal skull. There were no surgical complications or recurrences.

CONCLUSIONS

Brain/leptomeningeal cyst herniation through a dural rent, without MRI evidence of increased intracranial pressure, implicates physiologic growth and brain cerebrospinal fluid (CSF) pulsations as the cause of fracture enlargement.

Cervical epidural hematoma secondary to an extradural vascular malformation in an infant: case report

We present a report of a 22-month-old infant with a spontaneous spinal epidural hematoma arising from a purely epidural vascular malformation. Although often suspected as a cause of spontaneous epidural hemorrhage, vascular malformations have rarely been demonstrated. The important aspects of the presenting symptoms in this young age group are highlighted. We discuss the entity of spontaneous epidural hemorrhage and the characteristics that distinguish purely epidural from dural arteriovenous malformations.

Craniocervical intradural neurenteric cysts

Neurenteric cysts are rare lesions of the central nervous system that are lined by epithelium of intestinal nature. They result from abnormal separation of germ cell layers in the 3rd week of embryonic life, leading to persistence of entodermal elements in the spinal canal. The common location is cervical and ventral to the spinal cord. The lesions have been recognized as being entodermal in origin by such markers as vertebral anomalies, gut cysts, bowel reduplication and the presence of keratin markers. Three unusual cases of childhood craniocervical intradural neurenteric cysts in patients aged 4-8 years are described. These cysts were located in the ventral aspect of the spinal canal ranging from the craniocervical junction to the C6 level and were associated with bony anomalies such as a bifid clivus, hemivertebrae and blocked vertebrae. Two patients presented with signs of cervical cord compression and 1 with recurrent meningitis. One child with an anterior cervicomedullary region mass had undergone unsuccessful transoral transpalatal exploration and subsequently required excision with a dorsolateral approach. The second patient, after two successful attempts at drainage via laminectomies, required myelotomy of the spinal cord to allow excision. Thus the patient with the lesion from C4 through C6 underwent vertebrectomy and anterior excision with a C4 through C7 strut graft fusion. There were bony and vascular anomalies which would have complicated a dorsal approach. Pathological diagnosis of neurenteric cysts was based on the findings of nonciliated mucin producing small cuboidal or columnar epithelium lining a cystic cavity. Neurenteric cysts are uncommon congenital anomalies which may become symptomatic in the pediatric population.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary craniovertebral anomalies and the hindbrain herniation syndrome (Chiari I): data base analysis

This prospective study analyzes 100 patients with Chiari malformation and primary craniovertebral junction (CVJ) anomalies (3-66 years). Neurodiagnostic investigations employed tomography, gas myelography, CT and CT myelography, and MRI. Factors considered were reducibility, mode of encroachment, cerebrospinal fluid (CSF) dynamics and syringohydromyelia. Sixty-six patients with irreducible pathology underwent ventral or ventrolateral decompression and dorsal stabilization. Dorsal occipitocervical fixation was performed in reducible lesions that also required dorsal decompression (n = 34). Proatlas remnants were identified in 8 and atlas assimilation in 92 patients. Paramesial invagination was present in 20, syringohydromyelia in 46, and vertebral segmentation defects in 66 others. Completely reducible abnormalities were identified in 16 of 20 patients aged 2-14 years, and partially reducible abnormalities in 4 of 16 patients aged 14-20 years, 8 of 48 patients aged 20-40 years and 6 of 16 patients aged 40-60 years. The critical sagittal canal diameter at the foramen magnum was 19 mm. Twenty-two patients had previous posterior decompression and 27 had previous syrinx to subarachnoid shunt with delayed deterioration. Improvement occurred in all after ventral or ventrolateral decompression with resolution of the syringohydromyelia and normalization of CSF flow. We conclude that: (1) hindbrain herniation syndrome is frequently seen with fourth occipital sclerotome abnormalities; (2) Chiari malformation with craniovertebral abnormalities become symptomatic with a canal diameter of < 19 mm; (3) abnormal ventral bony pathology is reducible in children wit atlas assimilation and later becomes irreducible invagination, therefore early operation with fusion is recommended; (4) ventral decompression relieves brain stem, cerebellar symptoms and syringohydromyelia; (5) CSF studies with cine MRI shows reversal of craniospinal CSF dissociation after ventral CVJ decompression and; (6) craniovertebral anomalies associated with Chiari malformations must be addressed early and appropriately.

Myelinoclastic diffuse sclerosis (Schilder's disease): report of a case and review of the literature

The clinical, neuroimaging, and neuropathologic features of Schilder's disease in a 17-year-old girl are presented and compared to 11 well-documented cases reported since 1912. The evolution of knowledge about Schilder's disease and the confusion in nomenclature are reviewed. Signs and symptoms in this case and others reported in the literature are nonspecific and may mimic mass lesions. Neuroimaging studies also may mimic brain tumor or abscess; however, the absence of significant edema, the irregular and incomplete ring enhancement, the discrepancy between size of the lesions and the associated mass effect, and the absence of other lesions elsewhere in the brain may help differentiate Schilder's disease from neoplasm, infection, and other demyelinating lesions. Although frozen sections of these lesions are often interpreted as astrocytoma, the inflammatory, primarily histiocytic, nature of Schilder's disease is more easily recognized in paraffin-embedded material. Unique features of this case include multiple unilateral lesions and the cyst-like degeneration present in both lesions. Multiple lesions in Schilder's disease are characteristically bilateral. The examination of aspirated fluid is the first such report in Schilder's disease. The limitation of multiple lesions in our case to one hemisphere calls for reexamination of the restrictive 1985 criteria of Poser for the diagnosis of Schilder's disease.

Cervicomedullary compression in achondroplasia

Six patients with achondroplasia and symptoms suggestive of cervicomedullary junction compression are reviewed; these included three females and three males, with an average age of 8 years (range 7 months to 30 years). The mean duration of symptoms prior to intervention was 1.9 years. Symptoms included occipitocervical pain, ataxia, incontinence, apnea, and respiratory arrest. Radiological investigations consisted of plain films with flexion and extension views, pluridirectional tomography, thin-section computerized tomography, and magnetic resonance imaging. Typical findings included marked foramen magnum stenosis, ventrolateral cervicomedullary junction compression secondary to central and paramesial basilar invagination, and dorsal cervicomedullary junction compression secondary to ligamentous hypertrophy and invagination of the posterior atlantal arch. All patients underwent posterior fossa decompression and atlantal laminectomy. Surgery consistently revealed marked dorsal and paramesial overgrowth of the rim of the rim of the foramen magnum, with thickening and invagination of the atlantal posterior arch and a dense fibrotic epidural band resulting in dorsal cervicomedullary compression. Intraoperative ultrasonography was used to determine the extent of decompression required. Three patients required duraplasty. Three patients had concurrent hydrocephalus, two of whom had undergone ventriculoperitoneal shunting prior to surgical decompression of the posterior fossa. One patient developed a pseudomeningocele postoperatively, requiring serial lumbar punctures before it resolved. No patient developed craniovertebral instability following decompression. Improvement or resolution of symptoms was noted in all patients, with an average follow-up period of 4.8 years. Thus, cervicomedullary compression in patients with achondroplasia can be successfully treated with dorsal decompression of the craniovertebral junction. Dense epidural fibrotic bands are frequently noted in these cases and must be aggressively released to ensure satisfactory decompression.

Nonrheumatoid cranial settling

Cranial settling is a condition in which erosive changes of the atlantal lateral masses result in downward telescoping of the atlas onto the axis body, anterior displacement of the atlantal posterior arch, and subsequent ventral and dorsal cervicomedullary compression. Cranial settling is described in conjunction with rheumatoid basilar invagination and atlanto-axial instability, possibly representing the most life-threatening abnormality associated with rheumatoid arthritis. The authors describe a case of symptomatic cranial settling in a nonrheumatoid patient with chronic, severe, spasmodic torticollis resulting in erosive changes in the occipito-atlanto-axial complex.

Combined anti-fungal therapy and surgical resection as treatment of disseminated aspergillosis of the lung and brain following BMT

This report describes a 6-year-old girl with pre-B ALL who developed systemic aspergillosis following BMT. She was successfully treated with a combination of amphotericin B, itraconazole and surgery. This report emphasizes the importance of surgical resection in the management of disseminated aspergillosis.

Cervicomedullary compression by separate atlantal lateral mass

Compression of the cervicomedullary junction can result from a variety of congenital craniovertebral anomalies. We report an unusual case of cervicomedullary compression by a free lateral atlantal mass associated with contralateral occipito-atlantal fusion.

Botulinum toxin enhancement of postoperative immobilization in patients with cervical dystonia. Technical note

Postoperative immobilization in patients with cervical dystonia requiring fusion presents a unique management problem. Two patients with severe degenerative cervical spine disease secondary to chronic repetitive motion are reported. Both required a surgical fusion and postoperative immobilization. Botulinum toxin was injected intramuscularly to assist in immobilization. The technique used is described.

Ganglioglioma: 13 years of experience

A 13-year retrospective review of 17 patients with gangliogliomas treated at the University of Iowa was conducted to investigate the association between tumor location, extent of resection, pathological findings, and patient prognosis. Thirteen were in the cerebral hemispheres and 4 in the midline. The mean ages at diagnosis and symptom onset were 16 and 8.8 years, respectively. The most common presenting symptom was seizures (11 patients); focal neurological deficit was seen in 5 patients and headache in 1. Patients with hemispheric tumors had an older age at time of diagnosis and a longer duration of symptoms. Pathologically, they had more microcalcifications, lymphocytic infiltration, microcystic degeneration, and eosinophilic bodies. Cerebral hemispheric tumors were more amenable to total resection than midline neoplasms, 77% versus 25%, respectively. In the patients with hemispheric tumors, 10 patients were tumor-free after total resection. Two of the 3 patients with partial resection had stable residual tumors. The third died of tumor progression. In the 4 patients with midline neoplasms, one was tumor-free after total resection. The other 3 had subtotal resection and radiation therapy. Two died within 2 years; the third is still alive with progressive tumor. Five of 9 patients who had seizure disorders and who underwent total tumor removal were seizure-free postoperatively. The other 4 patients and the 2 with partial surgical resection continued to have seizures.

Etiology of lateral rectus palsy in infancy and childhood

The etiologies of lateral rectus palsy in 132 infants and children seen over a period of 22 years in a university medical center were retrospectively reviewed and compared with similar reports in the literature. Unlike most reports, which lump children with adults, this study focuses on childhood etiologies of lateral rectus palsy. In contrast to the only two studies in the literature on childhood lateral rectus palsy, which reflect a purely ophthalmologic perspective, this study reflects experiences of pediatric neurology and pediatric neurosurgery, as well as ophthalmology. Most lateral rectus palsies were unilateral, almost equally distributed between right and left sides. Trauma, tumor, and congenital etiologies were the most prevalent. The relative frequency of each of these etiologies varies by service (neurology, neurosurgery, ophthalmology). In 10.6% of patients, etiology could not be determined. The majority of patients had an isolated lateral rectus palsy. Association of lateral rectus palsy with other cranial nerve palsies and/or long tract signs characterized trauma and tumor. The majority of tumors were primary and infratentorial. A small number of patients had benign recurrent lateral rectus palsy.

Scoliosis in pediatric Chiari malformations without myelodysplasia

A prospective study was undertaken in 1985 to better understand how the surgical manipulation of hindbrain herniation affected abnormal spinal curvature. Eleven patients under 16 years of age with Chiari malformation (not associated with myelodysplasia) and scoliosis of at least 15 degrees were studied. The mean curve angle at the time of original treatment was 29 degrees, with the convexity to the right in seven patients. The curvature was rapidly progressing in four patients. The most common presenting signs were myelopathy and weakness. Investigative procedures included spine radiographs with the patient standing and magnetic resonance (MR) imaging of the brain, spinal cord, and craniovertebral junction. Eight children had associated hydrosyringomyelia. Surgical intervention consisted of a dorsal posterior fossa decompression in all patients and a transoral ventral decompression of the cervicomedullary junction in five. All patients were followed at 3, 6, and 12 months, and at yearly intervals thereafter with clinical evaluations, spine radiographs in the standing position, and postoperative MR imaging. The mean follow-up period was 35 months. The scoliosis improved in eight patients, stabilized in one, and progressed in two. Only one child required postoperative spinal fusion and instrumentation for progression of scoliosis. Hematomyelia or hematobulbia was associated with persistent scoliosis in two patients. The presence of hydrosyringomyelia and bone erosion did not preclude curve improvement. All patients under 10 years of age had resolution of their scoliosis, despite preoperative curves of more than 40 degrees. These findings emphasize the importance of early surgical intervention, with the restoration of normal cerebrospinal fluid dynamics at the craniovertebral junction in children with symptomatic Chiari malformations.

Pediatric spinal cord and vertebral column injury

Between January 1, 1970, and December 31, 1988, 179 children (birth to age 16) were treated for spinal cord and/or vertebral column injury by the Neurosurgical Service at the University of Iowa Hospitals and Clinics. Pediatric injuries accounted for 9% of all spinal trauma seen during this period. The mean age was 10.2 years. Sixty-two children were between birth and 8 years of age and 117 were between ages 9 and 16. The cause, distribution, type of injury, and severity of neurological injury varied with age. Neurological outcome was dependent on the severity of the initial neurological injury. Children with complete or severe incomplete myelopathy uniformly remained with severe neurological dysfunction; children with mild to moderate injuries recovered normal or nearly normal neurological function. Surgical versus nonoperative management had no bearing on neurological outcome. Twelve percent of the children with severe spinal cord injuries developed posttraumatic spinal deformity. We conclude that spinal injury patterns differ between preadolescent and older children. Most injuries can be successfully managed with nonoperative therapy. Prognosis is primarily correlated with the severity of the initial neurological insult. Finally, children with severe spinal cord injury must have close, long-term follow-up to monitor the development of posttraumatic spinal deformity.

Craniovertebral abnormalities in Down's syndrome

The ligamentous laxity associated with atlantoaxial subluxation has been assumed as a normal occurrence in 15-20% of Down's syndrome patients. The occipitoatlantoaxial instability that accompanies this entity has been poorly recognized. The medical records and radiographic findings of 18 symptomatic patients with Down's syndrome and cervicomedullary compromise were reviewed (1979-1991). All patients were evaluated prospectively under protocol for abnormalities of the cranial vertebral junction. There were 11 males and 7 females (age 3-42). 'Fixed' atlantoaxial luxation was seen in 8 (5 developed precipitous onset of cervical medullary compression). Occipitoatlantoaxial instability was present in 9 and associated rotary luxation in 9. The average predental space was 8 mm in the neutral position in 18 individuals. Two adolescents had previously undergone atlantoaxial dorsal fusion with subsequent progressive basilar invagination due to unrecognized occipitoatlantal instability. An os odontoideum was seen in 3 patients. Irreducible invagination in 2 was treated with anterior decompression followed by dorsal occipital cervical fixation. The occipital cervical fixation was utilized in 10 individuals. Atlantoaxial dorsal fusion was made in 7 and 2 patients with acute rotary luxation of C1 and C2 were treated with immobilization. Halo immobilization in two individuals following a dorsal occipital cervical fixation produced an anterior fusion at the cranial vertebral complex indicating active vertebral ligamentous pathology. The review focuses on increased incidence of occiput cervical instability in the spectrum of craniovertebral junction abnormalities associated with Down's syndrome. A large percentage has an odontoid ossicle probably as a result of repeated minor trauma. The results of surgical stabilization have been shown to be excellent.

Diagnosis and management of the Dandy-Walker malformation: 30 years of experience

Thirty-seven patients with Dandy-Walker malformation were treated between 1959 and 1989. Eighty percent of patients became symptomatic by 3 years of age, with 70% presenting within the 1st year of life. Hydrocephalus was present in 91% of patients at the time of diagnosis. Clinical presentation was most often heralded by symptoms and signs of hydrocephalus with focal neurological findings being a less prominent feature. One third of children demonstrated developmental delay. Associated congenital anomalies were present in 48% of children. Contemporary neuroimaging including computed tomography and magnetic resonance imaging facilitated diagnosis obviating the need for invasive studies such as pneumoencephalography and ventriculography. Patients were initially managed by posterior fossa craniectomy with membrane excision (8), lateral ventricle shunt alone (13), shunting of the cyst alone (4), or combined shunting of the cyst and lateral ventricles (12). Combined shunting proved superior to the other methods, being successful in alleviating hydrocephalus and posterior fossa symptoms in 92% cases. The overall mortality was 24%, the majority occurring before 1970. Of the 28 survivors, 27 (96%) are shunt-dependent, with 19 having a combined shunt system in place. Therefore, we currently favor combined shunting of the cyst and lateral ventricles as the initial procedure for patients with Dandy-Walker malformation.

Pediatric pituitary tumors

This retrospective review of pediatric patients with pituitary tumors causing onset of symptoms by 17 years of age was done to define their pathological distribution, clinical presentation, treatment, and prognosis. Eighteen patients were evaluated and treated from 1979 to 1989. Five had Cushing's disease and 13 had prolactin-secreting tumors. The mean age at the onset of symptoms was 14.7 years, with a range of 7 to 17 years. The mean follow-up period was 4.6 years, and the series consisted of 15 girls and 3 boys. Four of the 5 patients with tumors secreting adrenocorticotropic hormone were girls. The five patients exhibited obesity, hypertension, and growth retardation. The mean age of this group of patients at diagnosis was 12.2 years, and all had intrasellar lesions removed by the transsphenoidal approach. Adenoma was documented in 4 cases by histopathology. There was complete resolution of the endocrinological and clinical abnormalities in each case. The group of patients with prolactinomas comprised 11 girls and 2 boys, and their mean age at diagnosis was 15.7 years. The girls exhibited either primary or secondary amenorrhea. Seven had macroadenomas and 4 had microadenomas. Nine of the 11 girls underwent transsphenoidal resection, and surgery failed in 6, based on hormonal or radiological data. The two boys had suprasellar tumor extension and required multiple surgical procedures plus radiation therapy for control of the tumor mass.

Brain tumors occurring before 1 year of age: a retrospective reviews of 22 cases in an 11-year period (1977-1987)

Congenital brain tumors have been reported infrequently and their management remains ill defined. An 11-year review (1977-1987) of all children with brain tumors with the onset of symptoms before 1 year of age was completed. Twenty-two children with the following histological diagnoses were treated: astrocytoma (7 patients), primitive neuroectodermal tumor (6 patients), papilloma or carcinoma of the choroid plexus (3 patients), malignant teratoma (2 patients), dermoid tumor (2 patients), embryonal rhabdomyosarcoma (1 patient), and chloroma (1 patient). Fifteen tumors were supratentorial in location, and 7 were infratentorial. Initial symptoms were hydrocephalus (32%), focal neurological deficit (23%), asymptomatic increase in head circumference (18%), failure to thrive (14%), and seizures (4.5%). The goal of treatment was a radical excision when possible, with primary chemotherapy in the last 6 years of the review period. Radiation therapy was the adjunct to surgery in the initial 5-year period. All patients with papillomas of the choroid plexus and dermoid lesions underwent a total resection with no recurrence. All 7 astrocytomas were supratentorial, with 6 occurring in the diencephalon. Five of the seven patients with astrocytomas survived more than 5 years. The 6 primitive neuroectodermal tumors were located equally between the supra- and infratentorial spaces. Four of the 6 infants with these tumors received chemotherapy (2 received chemotherapy alone; 2 received chemotherapy and radiation therapy) and are tumor free 2 to 9 years later. A fifth child received radiation therapy alone early in the series and survived only 4 months. The family of the other child refused adjunctive treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Chiari I malformations and hydromyelia--complications

The Chiari I malformation is associated with a hydromyelic cavity in 55-75% of patients. In the author's series (1977-1991), hydromelia occurred in 111 of 131 patients (85%). There were 35 children. Posterior fossa decompression with duraplasty and fourth ventricle to subarachnoid shunt was made in all patients with Chiari I malformation with hydromyelia. The obex connection to the cervical cord central canal was closed with muscle, if widely patent. Eighty-five percent showed sustained objective improvement. The precautions taken to avoid complications and a literature review are tabulated for easy reference.

Complications of surgery at the craniovertebral junction--avoidance and management

The pathology encountered at the craniovertebral junction is extensive. It includes congenital, developmental and acquired abnormalities which ultimately compromise the cervicomedullary junction. The pediatric age group is particularly vulnerable as the muscular support is not fully developed. Numerous surgical approaches have been developed to relieve compression, as well as to stabilize this region. The complications described are from a review of the literature and the author's personal experience.

Atlanto-axial instability secondary to solitary eosinophilic granuloma of C2 in a 12-year-old girl

Involvement of the axis by solitary eosinophilic granuloma is rare. We report a 12-year-old girl who presented with a unifocal eosinophilic granuloma of C2 that resulted in a pathologic fracture and atlanto-axial subluxation. She had no other skeletal or systemic manifestations of histiocytosis X. She was successfully treated with posterior spinal fusion and transoral excisional biopsy. Because solitary lesions may mimic malignant tumors, biopsy is advised in atypical cases. The prognosis for solitary eosinophilic granuloma is almost always favorable in terms of symptomatic improvement and restoration of vertebral height.

Diagnosis and management of pyogenic vertebral osteomyelitis in adults

Management of vertebral osteomyelitis remains controversial regarding optimum duration of antibiotic therapy and the role of surgery. Forty adults with vertebral osteomyelitis were reviewed. Staphylococcus aureus was the most common pathogen isolated. Disk space narrowing with end-plate erosion was the earliest finding, followed by progressive vertebral body destruction. Magnetic resonance imaging proved extremely valuable in detecting spinal cord compression in patients with neurologic deficit. Treatment should include at least 8 weeks of intravenous antibiotics combined with immobilization for pain reduction. Surgical intervention is indicated for all patients with neurologic deficit. Serial erythrocyte sedimentation rates are valuable for following response to therapy. The value of magnetic resonance imaging in diagnosis is emphasized.