Surgical management of pediatric occipital neuralgia: a single-center experience of an uncommon pathology

OBJECTIVE

Occipital neuralgia (ON) is a rare headache disorder characterized by sharp pain in the distribution of the greater occipital nerve (GON), lesser occipital nerve, or third occipital nerve. ON is commonly associated with traumatic injury, and effective identification and diagnosis can be difficult given the infrequent presentation and similarities to other pediatric headache disorders. While GON decompression has been well described in adults for refractory pain, there is a paucity of data in the pediatric population, with no previously published series on ON. The primary aim of this study was to identify the characteristics of pediatric patients with ON prior to surgical intervention and to describe the natural history of postoperative outcomes after decompression or neurectomy in a pediatric population.

METHODS

A single-center retrospective case series was performed to evaluate factors predisposing children to refractory ON and the surgical efficacy of GON decompression or neurectomy. Six patients (mean age 15.0 ± 2.2 years) were identified for inclusion from October 2021 to October 2022. All patients had refractory ON as diagnosed by a pediatric neurologist. After medical therapy and repeated occipital nerve blocks failed, the patients were referred for GON decompression. Five patients had a history of trauma.

RESULTS

Six patients were identified and treated in our cohort, highlighting the infrequency of this pathology. All had at least one occipital nerve block, with 83% receiving varied relief. All underwent bilateral decompression or neurectomy of the GON and experienced relief, reporting improved visual analog scale scores (mean 8.3 ± 0.9 preoperatively to 1.0 ± 2.2 postoperatively, p = 0.0009). The patients were followed for an average of 10 months, and their mean number of medications decreased from 2.7 ± 0.5 preoperatively to 0.8 ± 0.7 postoperatively (p = 0.019). Each patient reported numbness or tingling in the GON distribution postoperatively, which spontaneously resolved over time. Two patients had recurrent pain in a delayed fashion.

CONCLUSIONS

GON decompression and neurectomy are efficacious treatments of refractory ON in the pediatric population.

Role of Immunotherapy in Down Syndrome Disintegrative Disorder (DSDD)

Objective

To describe case series of patients with DSDD, successfully treated with immunotherapy including Intravenous Immunoglobulin (IVIG) at a single academic center.

Background

Down syndrome is the most common chromosomal disorder, and in most cases, is due to trisomy of chromosome 21. DSDD is underrecognized, rapidly progressive neuropsychiatric syndrome with various postulated etiology including psychological stress, primary psychiatric disorder and autoimmunity.

Design/Methods

Case-1: A 20-year-old fun loving female with trisomy-21 and infantile spasms started having complex partial seizures, hallucinations, speech regression, tics, abnormal head movement and obsessive-compulsive behavior. Case-2: A 20-year-old female cheerleader with trisomy-21, started having rapid regression in language, cognition, social skills and agitation over one year. Case-3: A 22-year-old female dancer with trisomy-21, started having subacute onset depression, hallucinations, sleep changes, anorexia and speech regression over one year.

Results

Case-1: MRI brain and cerebrospinal fluid (CSF) studies were normal including negative autoimmune encephalitis panel. Serum thyroglobulin and thyroid peroxidase antibody were high. Prolonged oral steroid therapy helped but caused adverse effects. She was able to return to her premorbid baseline with chronic IVIG therapy every 10 weeks. Case-2: MRI brain and CSF were normal. Serum autoimmune encephalitis panel, thyroglobulin antibody and thyroid peroxidase antibody were negative. Pulse IV steroids improved symptoms, however she regressed after stopping steroids. IVIG every 6 weeks along with electroconvulsive therapy improved neurological symptoms. Case-3: MRI brain and EEG were normal. CSF showed elevated white blood cell count. Serum Thyroid antimicrosomal and thyroglobulin antibody were high. One dose of IVIG caused significant improvement in neurological symptoms for 6 weeks.

Conclusions

DSDD should be considered in patients with down syndrome with rapid regression. It is often associated with positive thyroid peroxidase antibody suggesting immune mediated etiology. Various immunotherapy treatments have been reported in literature including steroid, IVIG, mycophenolate and rituximab with significant improvement in selected patient with autoimmunity.

Multidisciplinary neurocutaneous syndrome clinics: a systematic review and institutional experience

OBJECTIVE

Neurocutaneous syndromes have variable multisystem involvement. The multiorgan involvement, potential pathologies, and various treatment options necessitate collaboration and open discussion to ensure optimal treatment in any given patient. These disorders provide quintessential examples of chronic medical conditions that require a lifelong, multidisciplinary approach. The objectives of this study were to 1) perform a systematic review, thoroughly assessing different multidisciplinary clinic layouts utilized in centers worldwide; and 2) characterize an institutional experience with the management of these conditions, focusing on the patient demographics, clinical presentation, complications, and therapeutic strategies seen in a patient population.

METHODS

A systematic review of studies involving multidisciplinary clinics and their reported structure was performed according to PRISMA guidelines using the PubMed database. Then a retrospective chart review of patients enrolled in the Oklahoma Children’s Hospital Neurocutaneous Syndromes Clinic was conducted.

RESULTS

A search of the PubMed database yielded 251 unique results. Of these, 15 papers were included in the analysis, which identified 16 clinics that treated more than 2000 patients worldwide. The majority of these clinics treated patients with neurofibromatosis (13/16). The remaining clinics treated patients with von Hippel–Lindau syndrome (n = 1), tuberous sclerosis complex (n = 1), and multiple neurocutaneous syndromes (n = 1). The most commonly represented subspecialties in these clinics were genetics (15/16) and neurology (13/16). Five clinics (31%) solely saw pediatric patients, 10 clinics saw a combination of children and adults, and the final clinic had separate pediatric and adult clinics. The retrospective chart review of the Neurocutaneous Syndromes Clinic demonstrated that 164 patients were enrolled and seen in the clinic from April 2013 to December 2021. Diagnoses were made based on clinical findings or results of genetic testing; 115 (70%) had neurofibromatosis type 1, 9 (5.5%) had neurofibromatosis type 2, 35 (21%) had tuberous sclerosis complex, 2 (1%) had von Hippel–Lindau syndrome, 2 (1%) had Gorlin syndrome, and the remaining patient (0.6%) had Aarskog-Scott syndrome. Patient demographics, clinical presentation, complications, and therapeutic strategies are also discussed.

CONCLUSIONS

To the best of the authors’ knowledge, this is the first detailed description of a comprehensive pediatric neurocutaneous clinic in the US that serves patients with multiple syndromes. There is currently heterogeneity between described multidisciplinary clinic structures and practices. More detailed accounts of clinic compositions and practices along with patient data and outcomes are needed in order to establish the most comprehensive and efficient multidisciplinary approach for neurocutaneous syndromes.