Curtis J. Rozzelle

Antimicrobial suture wound closure for cerebrospinal fluid shunt surgery: a prospective, double-blinded, randomized controlled trial

OBJECT Implantation of cerebrospinal fluid (CSF) shunting devices is associated with a 5-15% risk of infection as cited in contemporary pediatric neurosurgical literature. Shunt infections typically require complete removal of the device and prolonged antibiotic treatment followed by shunt replacement. Moreover, shunt infections are commonly associated with prolonged hospital stays, potential comorbidity, and the increased risk of neurological compromise due to ventriculitis or surgical complications. The authors prospectively evaluated the incidence of CSF shunt infection following shunt procedures performed using either antimicrobial suture (AMS) or conventional suture. METHODS In a single-center, prospective, double-blinded, randomized controlled trial, the authors enrolled 61 patients, among whom 84 CSF shunt procedures were performed over 21 months. Randomization to the study (AMS) or control (placebo) group was stratified to minimize the effect of known shunt infection risk factors on the findings. Antibacterial shunt components were not used. The primary outcome measure was the incidence of shunt infection within 6 months of surgery. RESULTS The shunt infection rate in the study group was 2 (4.3%) of 46 procedures and 8 (21%) of 38 procedures in the control group (p = 0.038). There were no statistically significant differences in shunt infection risk factors between the groups (procedure type and time, age < 6 months, weight < 4 kg, recent history of shunt infection). No suture-related adverse events were reported in either group. CONCLUSIONS These results support the suggestion that the use of AMS for CSF shunt surgery wound closure is safe, effective, and may be associated with a reduced risk of postoperative shunt infection. A larger randomized controlled trial is needed to confirm this association.

Intractable voiding dysfunction in children with normal spinal imaging: predictors of failed conservative management.

OBJECTIVES To identify the factors that might predict which individuals ultimately fail to resolve voiding symptoms by analyzing their presenting symptoms and video-urodynamic findings. Older children with intractable voiding dysfunction and no evidence of neurologic abnormality, who are recalcitrant to medical treatment, pose a management challenge. METHODS The charts of neurologically normal children with intractable voiding dysfunction, who had fluorourodynamic studies and normal lumbosacral magnetic resonance imaging, were reviewed. A database was created that included the urodynamics, presenting urinary symptoms, presence of soiling or constipation, age at onset of symptoms, cystogram and bladder ultrasound findings, and treatments given. Long-term follow-up was determined from chart review (all patients) or by a mailed survey (15 patients). Patients without symptoms and off medication were defined as normal. RESULTS A total of 50 children met the criteria mentioned earlier in the text, presented at a mean age of 9.4 years (range, 3.8-17.3) and were followed up for a mean of 4 years (range, 1-11) from their initial urodynamic evaluation. Of them, 33 (66%) remained symptomatic and 1 (34%) normalized. A total of 31 were found to have uninhibited bladder contractions (UBCs) with daytime wetting, of which 24 (77.4%) failed to normalize (P = .037). All 9 with UBCs and detrusor-sphincter dyssynergia remained symptomatic (P = .02). CONCLUSIONS The majority failed to resolve their voiding symptoms. Children who presented with daytime wetting, UBC, and detrusor-sphincter dyssynergia were the most likely to remain symptomatic. Patients with these characteristics might be considered for more aggressive alternative therapies, after a period of medical management.

Preoperative Predictors for Improvement after Surgical Untethering in Occult Tight Filum Terminale Syndrome

Background/Aims: An occult tight filum terminale syndrome has been described wherein clinical symptoms result from tension on the spinal cord despite nondiagnostic spinal magnetic resonance imaging (MRI). Recent reports have suggested a role for surgical untethering in this patient population; however, controversy remains regarding the surgical treatment of this condition. Owing to the various clinical presentations, the relationship of presenting signs and symptoms to postoperative outcomes might be useful in surgical selection. Methods: A retrospective review was conducted of 22 pediatric cases of surgical untethering for suspected occult tight filum terminale syndrome. All patients had nondiagnostic MRI findings, defined as a conus medullaris above the L3 vertebral body and a filum terminale diameter of less than 2 mm. Preoperative symptoms, signs and urodynamic test results were collected and compared with surgical outcomes determined by clinical notes and postoperative urodynamics reports. Abnormal findings on presentation were categorized as dermatologic, urologic, orthopedic and neurologic. Results: Patient age ranged from 7 months to 17 years, and 12 were female. Sixteen (73%) patients experienced subjective and/or objective improvement following surgical untethering. Fourteen patients had abnormal preoperative urodynamic testing, of which 12 underwent postoperative urodynamic testing. Five of these 12 (42%) demonstrated objective improvement postoperatively. Patients presenting with abnormal findings in at least 2 categories were more likely to improve following untethering (88%) than those with abnormalities in only 1 category (20%; p = 0.009). Conclusion: Spinal cord untethering is a treatment option for occult tight filum terminale syndrome. Further evaluation of the relationship between preoperative findings and surgical outcomes may facilitate the selection of surgical candidates.

The accuracy of abnormal lumbar sonography findings in detecting occult spinal dysraphism: a comparison with magnetic resonance imaging

OBJECT The purpose of this study was to correlate lumbar ultrasound (LUS) and MRI findings in patients suspected of having occult spinal dysraphism (OSD). METHODS Over a 5-year period, 1273 consecutive infants underwent an LUS study at a major pediatric tertiary referral center. Of these, 106 patients had abnormal LUS findings suggestive of an OSD, and 103 underwent subsequent MRI studies. The anatomical descriptions of the 2 studies were compared for agreement. RESULTS The average age of the infants was 34 days at the time of the LUS study; OSD was suspected in these patients because of the presence of cutaneous stigmata and congenital defects. The most common anatomical descriptions from the LUS study included a thickened or fatty filum (32 cases), filum cyst (11 cases), and presence of a terminal ventricle or syrinx (9 cases). Using MRI findings as the standard reference, the sensitivity of LUS in detecting a thickened or fatty filum was 20%. The sensitivity of detecting an abnormal conus level at or below L-3 was 76.9%. CONCLUSIONS In the patient population chosen to undergo LUS studies, abnormal findings had poor sensitivity at detecting anatomical findings consistent with OSD.

Pediatric Neurosurgical Practice Patterns Designed to Prevent Cerebrospinal Fluid Shunt Infection

Background/Aims: Various factors have been associated with cerebrospinal fluid (CSF) shunt infection risk, leading to many recommendations intended to reduce that risk. We sought to assess current North American pediatric neurosurgical practice patterns in this regard via a web-based survey. Particular attention was paid to the use of antibiotic-impregnated materials and prophylactic perioperative antibiotics. Methods: The membership of the section on pediatric neurological surgery of the American Association of Neurological Surgeons and Congress of Neurological Surgeons was invited to complete a survey of current practices intended to minimize CSF shunt infection risk. To be eligible for participation in this study, the respondent had to maintain an active neurosurgical practice within North America and place or revise at least 25 shunts in pediatric patients (<21 years) per year. Responses to the questionnaire were then analyzed. Results: A total of 100 responses were analyzed. All respondents were familiar with antibiotic-impregnated shunt catheters, and 61 of 100 had actually used them. Eleven of 61 respondents use them universally, 20 of 61 in >50% of cases, and 30 of 61 in <50% of cases. Antibiotic-impregnated suture material was known to 59% of respondents, of whom 28% (14 of 59) reported having actually used antimicrobial suture. All respondents use perioperative intravenous antibiotics with vancomycin, first-generation cephalosporins, and then second-generation cephalosporins being the most common. Routine use of intraventricular antibiotics was reported by 27%. An assessment of surgical techniques revealed that 90% limit shunt contact with patient’s skin, 62% use the double-gloving technique, 45% handle shunt components only with instruments, and 34% use an antiseptic shampoo preoperatively. Conclusion: Our survey reveals a wide range of practices intended to prevent shunt infection and captures, in particular, current trends in the use of antibiotic-impregnated materials and perioperative antibiotics for CSF shunting procedures.

Risk factors for surgical site infection following nonshunt pediatric neurosurgery: a review of 9296 procedures from a national database and comparison with a single-center experience

OBJECTIVE Surgical site infection (SSI) following CSF shunt operations has been well studied, yet risk factors for nonshunt pediatric neurosurgery are less well understood. The purpose of this study was to determine SSI rates and risk factors following nonshunt pediatric neurosurgery using a nationwide patient cohort and an institutional data set specifically for better understanding SSI. METHODS The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS NSQIP-P) database for the years 2012-2014, including all neurosurgical procedures performed on pediatric patients except CSF shunts and hematoma evacuations. SSI included deep (intracranial abscesses, meningitis, osteomyelitis, and ventriculitis) and superficial wound infections. The authors performed univariate analyses of SSI association with procedure, demographic, comorbidity, operative, and hospital variables, with subsequent multivariate logistic regression analysis to determine independent risk factors for SSI within 30 days of the index procedure. A similar analysis was performed using a detailed institutional infection database from Childrens of Alabama (COA). RESULTS A total of 9296 nonshunt procedures were identified in NSQIP-P with an overall 30-day SSI rate of 2.7%. The 30-day SSI rate in the COA institutional database was similar (3.3% of 1103 procedures, p = 0.325). Postoperative time to SSI in NSQIP-P and COA was 14.6 ± 6.8 days and 14.8 ± 7.3 days, respectively (mean ± SD). Myelomeningocele (4.3% in NSQIP-P, 6.3% in COA), spine (3.5%, 4.9%), and epilepsy (3.4%, 3.1%) procedure categories had the highest SSI rates by procedure category in both NSQIP-P and COA. Independent SSI risk factors in NSQIP-P included postoperative pneumonia (OR 4.761, 95% CI 1.269-17.857, p = 0.021), immune disease/immunosuppressant use (OR 3.671, 95% CI 1.371-9.827, p = 0.010), cerebral palsy (OR 2.835, 95% CI 1.463-5.494, p = 0.002), emergency operation (OR 1.843, 95% CI 1.011-3.360, p = 0.046), spine procedures (OR 1.673, 95% CI 1.036-2.702, p = 0.035), acquired CNS abnormality (OR 1.620, 95% CI 1.085-2.420, p = 0.018), and female sex (OR 1.475, 95% CI 1.062-2.049, p = 0.021). The only COA factor independently associated with SSI in the COA database included clean-contaminated wound classification (OR 3.887, 95% CI 1.354-11.153, p = 0.012), with public insurance (OR 1.966, 95% CI 0.957-4.041, p = 0.066) and spine procedures (OR 1.982, 95% CI 0.955-4.114, p = 0.066) approaching significance. Both NSQIP-P and COA multivariate model C-statistics were > 0.7. CONCLUSIONS The NSQIP-P SSI rates, but not risk factors, were similar to data from a single center.

Combined occipitoatlantoaxial rotatory fixation.

Occipitoatlantoaxial rotatory fixation (OAARF) is a rare condition involving fixed rotational subluxation of the atlas in relation to both the occiput and axis. Atlantoaxial rotatory fixation (AARF) appears to precede OAARF in most cases, as untreated AARF may cause compensatory counter-rotation and occipitoaxial fixation at an apparently neutral head position. We report a case of OAARF in an 8-year-old girl with juvenile idiopathic arthritis. Cervical imaging demonstrated slight rightward rotation of the occiput at 7.63° in relation to C-2 and significant rightward rotation of C-1 at 65.90° in relation to the occiput and at 73.53° in relation to C-2. An attempt at closed reduction with halo traction was unsuccessful. Definitive treatment included open reduction, C-1 laminectomy, and occipitocervical internal fixation and fusion.

Rate of shunt revision as a function of age in patients with shunted hydrocephalus due to myelomeningocele

OBJECTIVE It is generally accepted that cerebrospinal fluid shunts fail most frequently in the first years of life. The purpose of this study was to describe the risk of shunt failure for a given patient age in a well-defined cohort with shunted hydrocephalus due to myelomeningocele (MMC). METHODS The authors analyzed data from their institutional spina bifida research database including all patients with MMC and shunted hydrocephalus. For the entire population, the number of shunt revisions in each year of life was determined. Then the number of patients at risk for shunt revision during each year of life was calculated, thus enabling them to calculate the rate of shunt revision per patient in each year of life. In this way, the timing of all shunt revision operations for the entire clinic population and the likelihood of having a shunt revision during each year of life were calculated. RESULTS A total of 655 patients were enrolled in the spina bifida research database, 519 of whom had a diagnosis of MMC and whose mean age was 17.48 ± 11.7 years (median 16 years, range 0-63 years). Four hundred seventeen patients had had a CSF shunt for the treatment of hydrocephalus and thus are included in this analysis. There were 94 shunt revisions in the 1st year of life, which represents a rate of 0.23 revisions per patient in that year. The rate of shunt revision per patient-year initially decreased as age increased, except for an increase in revision frequency in the early teen years. Shunt revisions continued to occur as late as 43 years of age. CONCLUSIONS These data substantiate the idea that shunt revision surgeries in patients with MMC are most common in the 1st year of life and decrease thereafter, except for an increase in the early teen years. A persistent risk of shunt failure was observed well into adult life. These findings underscore the importance of routine follow-up of all MMC patients with shunted hydrocephalus and will aid in counseling patients and families.

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

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

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

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