Donald H. Reigel

Lumbar lordosis measurement. A new method versus Cobb technique.

Study Design. A historic cross‐sectional study of lumbar lordosis in 199 healthy individuals aged 1‐30 years. Objective. To evaluate the magnitude and rate of the development of the normal lumbar lordotic curve with age using two methods of measurement. Summary of Background Data. There is no agreement among spine physicians on the range of the normal lumbar lordotic curve. In certain conditions, such as a tethered spinal cord, a change in lordotic curve may indicate or even precede the onset of neurologic symptoms. Reliable measurements of the lumbar lordotic curve may aid in the early diagnosis and management of these conditions, before irreversible neurologic change ensues. Methods. The lumbar lordotic curve was measured by the traditional Cobb technique and by a newly designed method, tangential radiologic assessment of lumbar lordosis. The data were subjected to the Morgan‐Pitman test for correlated variances to observe which of the two methods was more reliable in measuring the magnitude and rate of change in the lumbar lordotic curve. Results and Conclusions. The rate of development of the lumbar lordotic curve appears to be nonlinear, increases during first year of life and during puberty, and reaches a plateau of approximately 50° at maturity. The tangential radiologic assessment of lumbar lordosis method is more reproducible and more reliable in the lumbar lordotic curve, providing a smaller range of normal values (8°‐16° less) than the Cobb method.

The value of myelography in the management of childhood medulloblastoma.

Sixteen children with newly diagnosed medulloblastomas underwent myelography prior to radiotherapy. None had clinical evidence suggesting spinal cord involvement. Seven patients (43%) were discovered to have unsuspected metastases involving the cord. Cerebrospinal fluid (CSF) cytology results were inaccurate in predicting spinal cord involvement. Additional radiation was administered to the demonstrated lesions. Thirteen children (81%) are alive and well 7–53 months (average 26) from completion of therapy. One of nine children with a normal myelogram initially, and two of seven with initial spinal cord involvement have relapsed.

Posterior lumbar apophyseal fractures.

The radiographic findings in 4 patients with fractures of the lumbar vertebral ring apophysis are reported. All patients had a bony ridge or fragment projecting into the spinal canal, usually from the lower border of L4; a defect in the postero-inferior aspect of the vertebral body; and either an anterior extradural impression or complete blockage on the myelogram. Computed tomography was performed on one patient and appears to be helpful in demonstrating bone within the spinal canal. Preoperative diagnosis can facilitate selection of the appropriate surgical approach.

Tethered Spinal Cord Following Meningomyelocele Repair

Of 16 consecutive patients with tethered spinal cord studied, most had undergone repair of a meningomyelocele. All were evaluated using somatosensory evoked potentials at 6 to 12-month intervals. Other possibilities include tethered filum terminale, lipomeningocele, membrana reuniens, and miscellaneous conditions (diastematomyelia, neurenteric cysts, etc.). Metrizamide myelography with polytomography was superior to gas myelography in showing a low-lying cord, obtuse nerve root angles, and a thin subarachnoid space between the cord and the dorsal meninges cephalad to the tether. Surgery is generally helpful in these patients.

Myelography and cytology in the treatment of medulloblastoma

Abstract Eight of 22 children with newly diagnosed medulloblastoma had asymptomatic spinal cord involvement detected by myelography. Two additional patients had demonstrable spinal cord lesions at the time of relapse in the posterior fossa. Cerebral spinal fluid (CSF) cytology results were inaccurate in predicting cord involvement. Seven patients have relapsed 9–69 months from completion of radiotherapy. Three had initial cord involvement and also bad subsequent cord involvement at the time of intracranial relapse or afterwards. Frontal lobe involvement as the initial site of relapse occurred-in 3 patients. Computerized tomography has been valuable in the early detection of intracranial relapse. Three children are alive and well 10, 18, and 19 months respectively from time of relapse. All were retreated with radiotherapy in conjunction with misonidazole and subsequent chemotherapy.

Intra‐operative Evoked Potential Studies of Newborn Infants with Myelomeningocele

Somatosensory evoked potentials were studied in seven infants during surgery for repair of thoraco‐lumbar myelomeningocele. All were operated on during the first 24 hours of life. Because anaesthetics were known to suppress somatosensory evoked potentials, narcotics and muscle relaxants were used for anesthesia.

Posterior lumbar apophyseal fractures

The radiographic findings in 4 patients with fractures of the lumbar vertebral ring apophysis are reported. All patients had a bony ridge or fragment projecting into the spinal canal, usually from the lower border of L4; a defect in the postero-inferior aspect of the vertebral body; and either an anterior extradural impression or complete blockage on the myelogram. Computed tomography was performed on one patient and appears to be helpful in demonstrating bone within the spinal canal. Preoperative diagnosis can facilitate selection of the appropriate surgical approach.

Growth hormone treatment of children with neural tube defects: Results from 6 months to 6 years☆☆☆★

OBJECTIVE Patients with neural tube defects (myelomeningocele) have severe growth retardation, and treatment with recombinant human growth hormone (rHGH) for 6 months accelerates growth velocity. We examined patients treated for longer periods to determine whether accelerated growth persists, and whether patients demonstrated to be growth hormone deficient have a greater response to rHGH therapy. METHODS We retrospectively evaluated the growth rate and length standard deviation score (SDS) of 22 patients in response to treatment with 0.3 mg/kg per week of rHGH for 7 to 72 months. Nine of 22 patients were growth hormone deficient (nocturnal and provocative growth hormone responses < 7 ng/ml). Treatment success was defined as an increase of length SDS of > 0.2 SD per year. RESULTS Fourteen patients (64%) had treatment successes, and eight had treatment failures. Length SDS improved from a pretreatment value of -2.9 (+/- 1.2) to the most recent length SDS of -1.9 (+/- 1.4) (p < 0.001). The growth rate was significantly increased through year 4 of treatment. The annualized growth rate after 6 months of rHGH treatment was significantly different for the success and failure groups (11.0 +/- 2.6 cm/yr vs 5.1 +/- 3 cm/yr, p < 0.001). The annualized 6-month growth rate during treatment was related to the probability of treatment success. CONCLUSION Treatment with rHGH significantly improves the growth rate and length SDS of children with neural tube defects. The 6-month annualized growth velocity during treatment was predictive of long-term treatment response. The effect on adult stature is unknown.

External drainage for ventricular infection following cerebrospinal fluid shunts.

57 children with shunt-related ventricular infection were treated with external ventricular drainage and a combination of systemic and intraventricular antibiotics. For persistent infection or inadequate drainage volume the external ventricular drain was promptly changed. Cerebrospinal fluid cultures of 54 (95%) of the children became sterile within an average of 5.1 days. As soon as three consecutive 48-hour cultures of the cerebrospinal fluid were negative, the external ventricular drainage was removed and a new ventriculoperitoneal shunt was inserted. Provided that three consecutive 48-hour cultures of the cerebrospinal fluid were negative at the time of reinstitution of ventriculoperitoneal shunting, low cerebrospinal fluid glucose readings were not associated with any greater risk of recurrent infection than following primary ventriculoperitoneal shunting.

Cricopharyngeal Achalasia Associated with Arnold-Chiari Malformation in Childhood

Six patients with myelomeningocele and the Arnold-Chiari malformation developed cricopharyngeal achalasia and lower cranial nerve deficits. Diagnosis is established by cine-esophagram. Distortion of the brain stem or cranial nerves secondary to the Arnold-Chiari malformation may produce the autonomic imbalance necessary for cricopharyngeal achalasia. Treatment is supportive and includes verification of cerebral spinal fluid shunt function. Suboccipital craniectomy may reverse progressive lower cranial nerve deficits and reduce cricopharyngeus spasm. Cricopharyngeal myotomy may be considered when the cranial nerve deficits and cricopharyngeal achalasia are fixed, irreversible, and continue to cause disability.