Gerald F. Tuite

The effectiveness of papilledema as an indicator of raised intracranial pressure in children with craniosynostosis.

Craniosynostosis management partially depends on the detection and treatment of elevated intracranial pressure (ICP). Examination for papilledema is considered to be the most reliable screening method for identifying raised ICP, but its effectiveness has not been defined. One hundred and twenty-two children with craniosynostosis who underwent funduscopic examinations and then Camino ICP monitoring were studied. All eye examinations were performed by an ophthalmologist after pharmacological pupillary dilation. Fifteen patients (12%) had papilledema. Subsequent ICP monitoring showed that the median ICP was 12.7 mm Hg, with 41 patients (34%) having elevated ICPs (> 15 mm Hg). Those with papilledema had higher ICPs (17.5 +/- 3.2 versus 12.7 +/- 5.5 mm Hg), were older (5.9 +/- 4.7 versus 1.9 +/- 2.6 years), and were more likely to have craniofacial syndromes (73 versus 41%) than those without papilledema (P < 0.05). Patients with both elevated ICPs and papilledema were older (5.9 +/- 4.7 versus 1.6 +/- 1.4 years) and more likely to have multiple-suture synostosis (92 versus 61%) than those with elevated ICPs and no papilledema (P < 0.05). The presence of papilledema was a specific (98%) indicator of raised ICP, but its sensitivity was age-dependent. It was 100% sensitive in children older than 8 years, but it indicated elevated ICP in only 22% of younger patients. These results suggest that ICP monitoring to document elevated ICP is unnecessary in children older than 8 years who have detailed ophthalmological examinations. In the younger child, the presence of papilledema reliably indicates elevated ICP but its absence does not rule out elevated ICP; formal ICP measurement has a greater role in detecting elevated ICP in these patients.

Caspar plate fixation for the treatment of complex hangman's fractures.

This report details our recent experience with the surgical treatment of complex hangmans fractures after failure of closed reduction and immobilization in external orthosis. We have successfully treated hangmans fractures in 5 patients with anterior Caspar plate stabilization and C2-C3 interbody fusion. The specific anatomical features of these fractures were complex, rendering the spines of the patients highly unstable. The patients were considered surgical candidates when reduction could not be achieved or maintained with axial traction or halo immobilization. Each patient underwent anterior C2-C3 interbody bone fusion and Caspar plating from C2 to C3. All patients achieved adequate intraoperative reduction and were immobilized postoperatively with a halo vest. The follow-up period ranged from 3 to 28 months and provided a 100% fusion rate with no complications related to plating or nonunion. Our initial experience indicates that anterior C2-C3 interbody bone fusion and Caspar plate fixation is a suitable treatment option for patients with complex hangmans fractures who are not successfully managed nonoperatively.

Signals for proinflammatory cytokine secretion by human Schwann cells

Wallerian degeneration is a post-traumatic process of the peripheral nervous system whereby damaged axons and their surrounding myelin sheaths are phagocytosed by infiltrating leukocytes. Our studies indicate that Schwann cells could initiate the process of Wallerian degeneration by releasing proinflammatory cytokines involved in leukocyte recruitment and differentiation including IL-1beta, MCP-1, IL-8 and IL-6. A comparison of the secretory pattern between nerve explants and cultured Schwann cells showed that each cytokine was differentially regulated by growth factor deprivation or axonal membrane fragments. Since Wallerian-like degeneration occurs in a wide variety of peripheral neuropathies, Schwann cell-mediated cytokine production may play an important role in many disease processes.

Vertebral artery dissection related to basilar impression: case report.

A 50-year-old man with myelopathy secondary to basilar impression developed bilateral vertebral artery dissection after undergoing treatment with 8 pounds of cervical traction. The vertebral artery dissection resulted in vertebrobasilar insufficiency and posterior circulation stroke. In this report, the current management philosophies in the treatment of basilar impression are discussed, and the pertinent neurovascular anatomy is illustrated. This report suggests that vertebral artery injury may result from attempted reduction of severe basilar impression. Regardless of the cause of cranial settling, the risk of vertebral artery injury with cervical traction should be considered in patients with severe basilar impression.

Long-term growth and alignment after occipitocervical and atlantoaxial fusion with rigid internal fixation in young children

OBJECT The long-term consequences of atlantoaxial (AA) and occipitocervical (OC) fusion and instrumentation in young children are unknown. Anecdotal reports have raised concerns regarding altered growth and alignment of the cervical spine after surgical intervention. The purpose of this study was to determine the long-term effects of these surgeries on the growth and alignment of the maturing spine. METHODS A multiinstitutional retrospective chart review was conducted for patients less than or equal to 6 years of age who underwent OC or AA fusion with rigid instrumentation at 9 participating centers. All patients had at least 3 years of clinical and radiographic follow-up data and radiographically confirmed fusion. Preoperative, immediate postoperative, and most recent follow-up radiographs and/or CT scans were evaluated to assess changes in spinal growth and alignment. RESULTS Forty children (9 who underwent AA fusion and 31 who underwent OC fusion) were included in the study (mean follow-up duration 56 months). The mean vertical growth over the fused levels in the AA fusion patients represented 30% of the growth of the cervical spine (range 10%-50%). Three different vertical growth patterns of the fusion construct developed among the 31 OC fusion patients during the follow-up period: 1) 16 patients had substantial growth (13%-46% of the total growth of the cervical spine); 2) 9 patients had no meaningful growth; and 3) 6 patients, most of whom presented with a distracted atlantooccipital dislocation, had a decrease in the height of the fused levels (range 7-23 mm). Regarding spinal alignment, 85% (34/40) of the patients had good alignment at follow-up, with straight or mildly lordotic cervical curvatures. In 1 AA fusion patient (11%) and 5 OC fusion patients (16%), we observed new hyperlordosis (range 43°-62°). There were no cases of new kyphosis or swan-neck deformity, evidence of subaxial instability, or unintended subaxial fusion. No preoperative predictors of these growth patterns or alignment were evident. CONCLUSIONS These results demonstrate that most young children undergoing AA and OC fusion with rigid internal fixation continue to have good cervical alignment and continued growth within the fused levels during a prolonged follow-up period. However, some variability in vertical growth and alignment exists, highlighting the need to continue close long-term follow-up.

Computer-assisted measurement of lumbar spine radiographs

RATIONALE AND OBJECTIVES The authors evaluated a method for obtaining reproducible, reliable measurements from standard lumbar spine radiographs for determining the degree of spondylolisthesis, vertebral body height, intervertebral disk space height, disk space angle, and degree of vertebral body wedging. MATERIALS AND METHODS Four to six easily defined points were identified on each vertebral body on anteroposterior and lateral plain radiographs of the lumbosacral spine of patients. From these points, the degree of spondylolisthesis, the vertebral body height, the intervertebral disk space height, the disk space angle, and the degree of vertebral body wedging were easily calculated by using well-known geometric relationships. This method requires the use of a personal computer and a standard spreadsheet program but does not require the use of any other specialized radiographic equipment, computer hardware, or custom software. RESULTS Calculations of intra- and interobserver variability for the measurement of spondylolisthesis, disk space height, disk space angle, and vertebral body height measurement showed that the technique is extremely reproducible. CONCLUSION This technique may prove useful in the prospective evaluation of potential candidates for lumbar spinal stenosis surgery.

Vertebral Artery Dissection Related to Basilar Impression

A 50-year-old man with myelopathy secondary to basilar impression developed bilateral vertebral artery dissection after undergoing treatment with 8 pounds of cervical traction. The vertebral artery dissection resulted in vertebrobasilar insufficiency and posterior circulation stroke. In this report, the current management philosophies in the treatment of basilar impression are discussed, and the pertinent neurovascular anatomy is illustrated. This report suggests that vertebral artery injury may result from attempted reduction of severe basilar impression. Regardless of the cause of cranial settling, the risk of vertebral artery injury with cervical traction should be considered in patients with severe basilar impression.

Neural reconstruction methods of restoring bladder function

During the past century, diverse studies have focused on the development of surgical strategies to restore function of a decentralized bladder after spinal cord or spinal root injury via repair of the original roots or by transferring new axonal sources. The techniques included end-to-end sacral root repairs, transfer of roots from other spinal segments to sacral roots, transfer of intercostal nerves to sacral roots, transfer of various somatic nerves to the pelvic or pudendal nerve, direct reinnervation of the detrusor muscle, or creation of an artificial reflex pathway between the skin and the bladder via the central nervous system. All of these surgical techniques have demonstrated specific strengths and limitations. The findings made to date already indicate appropriate patient populations for each procedure, but a comprehensive assessment of the effectiveness of each technique to restore urinary function after bladder decentralization is required to guide future research and potential clinical application.

Sources of Human Schwann Cells and the Influence of Donor Age

We evaluated several tissues as possible sources for culturing human Schwann cells. The average cell yield (total cell number/mg of nerve fascicle) obtained from adult autopsy cases and transplant organ donors was similar (2 x 10(4) and 2.9 x 10(4), respectively), but significantly higher yields were obtained from dorsal roots of pediatric patients undergoing selective dorsal rhizotomy (6.1 x 10(4)). Fresh tissue was not essential since cells isolated from 0 to 20 h postmortem were equally viable. However, we found evidence that donor age affects the intrinsic growth rate of Schwann cells and perineurial fibroblasts in culture.

Evaluation and management of tethered cord syndrome in occult spinal dysraphism: Recommendations from the international children's continence society

As awareness and frequency of tethered spinal cord (TSC) related to occult spinal dysraphism (OSD) has increased with magnetic resonance imaging (MRI), variability exists in its evaluation and management. Due to no published level I data, we summarize the current International Childrens Continence Society (ICCS) recommendations for diagnosis and treatment of OSD.