Chiazor U. Onyia

A short review on a complication of lumbar spine surgery: CSF leak

Cerebrospinal fluid (CSF) leak is a common complication of surgery involving the lumbar spine. Over the past decades, there has been significant advancement in understanding the basis, management and techniques of treatment for post-operative CSF leak following lumbar spine surgery. In this article, we review previous work in the literature on the various factors and technical errors during or after lumbar spine surgery that may lead to this feared complication, the available options of management with focus on the various techniques employed, the outcomes and also to highlight on the current trends. We also discuss the presentation, factors contributing to its development, basic concepts and practical aspects of the management with emphasis on the different techniques of treatment. Different outcomes following various techniques of managing post-operative CSF leak after lumbar spine surgery have been well described in the literature. However, there is currently no most ideal technique among the available options. The choice of which technique to be applied in each case is dependent on each surgeons cumulative experience as well as a clear understanding of the contributory underlying factors in each patient, the nature and site of the leak, the available facilities and equipment.

Forgotten? Not yet- Cardiogenic brain abscess in children - a case series based review.

BACKGROUND Brain abscess is a significant cause of morbidity in patients with uncorrected or partially palliated congenital cyanotic heart disease (CCHD). Unfortunately, in the developing world, the majority of patients with CCHD remain either uncorrected or only partially palliated. Furthermore, a risk of this feared complication also exists even among those undergoing staged corrective operations in the interval in between operations. There have been no recent articles in the literature on the outcomes of surgical management of cardiogenic brain abscess in children. In this study, we aimed to describe the clinical and demographic profile of patients with cardiogenic cerebral abscess and to highlight the fact that uncorrected or palliated CCHD continue to be at risk for brain abscess. METHODS This study was a retrospective analysis of 26 children (age <19 years) being managed for CCHD who were diagnosed with cerebral abscess managed surgically (26 of 39 of cases cerebral abscess in children), at Amrita Institute of Medical Sciences and Research Centre, Kochi, India between December 2000 and January 2014. Data collected retrospectively included demographic information, modes of presentation, diagnosis, location of abscess, details of the underlying heart disease, management of the cerebral abscess, and outcomes of management. RESULTS The patient cohort comprised 26 patients (16 males and 10 females), with a mean age of 7.19 years (range, 1.5-19 years). Ten of the 26 patients (38%) required reaspiration after the initial surgery. On follow-up, all the patients had improved symptomatically and demonstrated no signs of cerebral abscess. CONCLUSIONS Cardiogenic origin of cerebral abscess is the most common cause of cerebral abscess in children. Unresolved CCHD is a risk factor for the occurrence, persistence, and recurrence of cerebral abscess.

An Analysis of Outcome of Endoscopic Fenestration of Cavum Septum Pellucidum Cyst - More Grey than Black and White?

Background: Cavum septum pellucidum (CSP) and cavum vergae are actually fluid-filled, generally communicating midline cavities located between the third ventricle and corpus callosum. There have been various reports of their association with many behavioral and psychiatric disorders. Infrequently, they have been associated with an obstructive hydrocephalus-like picture. Although the structure and management of CSP has long been known, it has been an enigma as far as functional significance and management indications are concerned. The authors of this article try to analyze the significance of a persistent cavum and involvement of the same entity in varied presentations ranging from an incidental imaging finding to acute hydrocephalus, and propose a possible implication on the present surgical intervention paradigm. Purpose: To assess the surgical outcome of fenestration of a CSP cyst. Methods: Retrospective analysis of 3 patients who underwent endoscopic fenestration for CSP with obstructive hydrocephalus between 2012 and 2014 was done, and data were analyzed for symptomatic clinical improvement in particular behavior. Results: Pre- and postoperative brain MRI showed a significant decrease in the size of the cyst as well as the ventricles. There were no recurrences during follow-up. All of the patients improved. Conclusions: (1) Endoscopic fenestration of symptomatic CSP cysts is a safe treatment option. (2) Neurocognitive assessment is essential in the evaluation and outcome assessment of CSP.

Pediatric Neuropathology in Africa: Local Experience in Nigeria and Challenges and Prospects for the Continent

The present state of pediatric neuropathology practice is in rudimentary developmental stages in most parts of sub-Saharan Africa. We sought to determine the pattern of neurosurgical lesions in children diagnosed in southwestern Nigeria and briefly address issues surrounding the practice of this aspect of pathology in Africa. We performed a retrospective review of histopathologic results of biopsies obtained from pediatric patients with neurosurgical lesions at the Department of Pathology, Obafemi Awolowo University Teaching Hospitals Complex, Ile–Ife, Nigeria, between January 2001 and December 2011. Demographic and clinical data were extracted from the Ife-Ijesha cancer registry and histopathological diagnoses were confirmed. A total of 111 biopsies were reviewed with a maximum of 17 in 2001 and minimum of 3 in 2005. Patient ages ranged between 1 day and 16 years with a male:female ratio of 1.02:1. There were 53 spinal lesions, 15 intracranial lesions, 36 scalp masses, 6 skull lesions and 1 muscle biopsy. Most of the specimens were from myelomeningoceles. This documentation of the major types of pediatric neurological conditions encountered in clinical practice in this relatively resource-limited setting indicate the need for collaboration with better developed centers to improve training in neurosurgery and neuropathology to enhance the quality of clinical care for young patients in Africa.

Customizable rigid head fixation for infants: technical note

IntroductionThe need and advantages of rigid fixation of the head in cranial surgeries are well documented (Berryhill et al., Otolaryngol Head Neck Surg 121:269-273, 1999). Head fixation for neurosurgical procedures in infants and in early years has been a challenge and is fraught with risk. Despite the fact that pediatric pins are designed, rigid head fixation involving direct application of pins to the head of infants and slightly older children is still generally not safe (Agrawal and Steinbok, Childs Nerv Syst 22:1473-1474, 2006). Yet, there are some surgeries in which some form of rigid fixation is required (Agrawal and Steinbok, Childs Nerv Syst 22:1473-1474, 2006). We describe a simple technique to achieve rigid fixation of the head in infants for neurosurgical procedures.Technical noteThis involves applying a head band made of Plaster of Paris (POP) around the head and then applying the fixation pins of the fixation frame directly on to the POP.ConclusionWe have used this technique of head fixation successfully for infants with no complications.

Paediatric day-case neurosurgery in a resource challenged setting: Pattern and practice

Background: It has been generally observed that children achieve better convalescence in the home environment especially if discharged same day after surgery. This is probably due to the fact that children generally tend to feel more at ease in the home environment than in the hospital setting. Only few tertiary health institutions provide routine day-case surgery for paediatric neurosurgical patients in our sub-region. Objective: To review the pattern and practice of paediatric neurosurgical day-cases at our hospital. Patients and Methods: A prospective study of all paediatric day-case neurosurgeries carried out between June 2011 and June 2014. Results: A total of 53 patients (34 males and 19 females) with age ranging from 2 days to 14 years were seen. Majority of the patients (77.4%) presented with congenital lesions, and the most common procedure carried out was spina bifida repair (32%) followed by ventriculoperitoneal shunt insertion (26.4%) for hydrocephalus. Sixty-eight percentage belonged to the American Society of Anesthesiologists physical status class 2, whereas the rest (32%) belonged to class 1. General anaesthesia was employed in 83% of cases. Parenteral paracetamol was used for intra-operative analgesia for most of the patients. Two patients had post-operative nausea and vomiting and were successfully managed. There was no case of emergency re-operation, unplanned admission, cancellation or mortality. Conclusion: Paediatric day-case neurosurgery is feasible in our environment. With careful patient selection and adequate pre-operative preparation, good outcome can be achieved.

Beckwith–Wiedemann syndrome and Chiari I malformation—a case-based review of central nervous system involvement in hemihypertrophy syndromes

BackgroundBeckwith–Wiedemann syndrome (BWS) is an unusual complex of abnormalities that includes mainly omphalocele, macroglossia, gigantism, visceromegaly, and neonatal hypoglycemia. Type I Chiari malformation, on the other hand, is defined as ectopia of the cerebellar tonsils below the plane of the foramen magnum. Only one case of association of BWS with Chiari I malformation has been previously reported in the literature.DiscussionSeveral conditions involving congenital hemihypertrophy have been previously reported in association with Type I Chiari malformation. The pathophysiological mechanism for most of these associations is thought to be quite complex and still remains unclear. However, the presence of tonsillar herniation in BWS has been explained by Tubbs and Oakes in the only one existing case report of BWS with Type I Chiari malformation in the literature, to be due to associated hemihypertrophy of the skull base. We additionally suggest that cerebellar hypertrophy may also contribute to the tonsillar herniation and fourth ventricular outlet obstruction.Illustrative caseWe now report our recent experience on this association following a review of the literature on association of other hemihypertrophy syndromes with the central nervous system anomalies.ConclusionWe believe that a common pathogenesis of Type I Chiari malformation occurs in conditions of hemihypertrophy including BWS, probably secondary to dysmorphology involving the posterior cranial fossa, and is not just an associated finding.

Letter to the Editor. Treatment of thoracolumbar burst fractures: extended follow-up of a randomized clinical trial comparing orthosis versus no orthosis

TO THE EDITOR: I read with interest the recent article by Urquhart et al.4 (Urquhart JC, Alrehaili OA, Fisher CG, et al: Treatment of thoracolumbar burst fractures: extended follow-up of a randomized clinical trial comparing orthosis versus no orthosis. J Neurosurg Spine 27:42–47, July 2017). The authors report that there was no loss of spinal alignment, no increased risk of neurological deterioration, nor any worsening of pain and functional outcome between patients with thoracolumbosacral orthosis (TLSO) and those with no orthosis (NO) over the 2-year follow-up period in this study. Overall results appear not to demonstrate any superiority of the TLSO group over the NO group, even with a theoretically higher risk of developing deficits as a result of the early ambulation of patients in the NO group. Avoidance of early ambulation to prevent further axial loading within the cast has been the recommendation for patients being treated conservatively for thoracolumbar burst fractures.3 This raises the question as to whether the use of an orthosis in the management of this group of spine patients really has any benefit, especially in view of its own challenges, with extra cost to the patient, long duration of discomfort from the splinting effect, and even development of ulcers over pressure points within the TLSO cast, and so on. The work of Urquhart et al., in a way, represents an important and significant contribution to our understanding of the pathophysiology of burst fractures in the thoracolumbar segment of the spine, and thus should be taken into consideration in the creation of future guidelines for managing these patients.1,2 Unfortunately, however, the patient sample size in this study is quite small. Additionally, the authors did not clearly define exactly how immediate the mobilization by the physiotherapist was for the early ambulation of patients in the NO group. A larger cohort and randomized controlled study will probably be required to objectively validate this interesting finding.

Letter to the Editor. Tumors of the fourth ventricle

TO THE EDITOR: I read with interest the recent article by Ferguson et al.1 (Ferguson SD, Levine NB, Suki D, et al: The surgical treatment of tumors of the fourth ventricle: a single-institution experience. J Neurosurg [epub ahead of print April 14, 2017. DOI: 10.3171/2016.11. JNS 161167]). I would like to commend the authors on this series of cases involving fourth ventricle lesions, which is the largest so far in the literature, particularly because of the extensive comparison between the 2 key surgical approaches to these lesions. As one would expect, overall results generally appear to demonstrate superiority of the telovelar approach over the transvermian approach, especially in terms of complication profile. Interestingly, however, the authors report that their use of MRI-guided intraoperative navigation, ultrasonography, and neurophysiological monitoring did not significantly affect neurological outcome in this 18-year retrospective review of 55 patients, despite previous documentation in the literature on the usefulness of these adjuncts.2–4 This is quite a remarkable finding from this review because it then raises the question as to the extent of impact of the intraoperative use of these adjuncts in reducing unwanted neurological sequelae during the resection of fourth ventricle tumors. Perhaps this may be suggesting that the management strategy for surgical treatment should be based on other more important factors such as the experience of the surgeon, more meticulous microsurgical dissection, and better understanding of the anatomy of each lesion on the one hand, and less dependence on these adjuncts on the other hand, for optimal neurological outcomes. A high-quality comparative observational cohort and randomized controlled study may be required to objectively prove this.

Letter to the Editor. Ventriculoperitoneal shunts after abdominal surgery

TO THE EDITOR: I read with interest the recent article by Burks et al.1 (Burks JD, Conner AK, Briggs RG, et al: Risk of failure in pediatric ventriculoperitoneal shunts placed after abdominal surgery. J Neurosurg Pediatr 19:571–577, May 2017). The authors report that their retrospective review of 141 patients revealed that shunt surgery performed within 2 weeks of abdominal surgery was associated with time to failure, whereas shunt surgery performed 2 weeks after abdominal surgery was not associated with time to failure. They then concluded that when feasible, patients who require shunt placement within the first 2 weeks after an abdominal surgery would probably benefit from either atrial or pleural termini instead.1 However, I wish to point out that the suggestion of using the pleura in their conclusion would only be applicable to children who are older than 4 years of age.4 This is because the absorptive capacity of the pleura is variable and may be insufficient for children who are younger than this age, predisposing them to the development of pleural effusions and respiratory difficulties. For this group of patients, the subgaleal space may probably be considered as a much safer alternative for shunt placement, even though it is commonly used for posthemorrhagic hydrocephalus in premature infants, in addition to the atrium.2–4 Additionally, their study demonstrates an association between shunt placement for hydrocephalus due to spinal dysraphism and shunt failure. This further confirms and strengthens previous findings that suggest that the underlying etiology of hydrocephalus is an important predictor of shunt failure.2 The incidence of shunt-related complications following shunting for hydrocephalus due to myelomeningocele alone has been documented to be as high as 22.8%. Unfortunately, most of these risk factors for shunt failure can’t be modified. This needs to be taken into consideration during preoperative counseling on the possibility of shunt failure, even with the best of optimal conditions.