Ian K. White

Transfer of children with isolated linear skull fractures: is it worth the cost?

OBJECTIVE Children with skull fractures are often transferred to hospitals with pediatric neurosurgical capabilities. Historical data suggest that a small percentage of patients with an isolated skull fracture will clinically decline. However, recent papers have suggested that the risk of decline in certain patients is low. There are few data regarding the financial costs associated with transporting patients at low risk for requiring specialty care. In this study, the clinical outcomes and financial costs of transferring of a population of children with isolated skull fractures to a Level 1 pediatric trauma center over a 9-year period were analyzed. METHODS A retrospective review of all children treated for head injury at Riley Hospital for Children (Indianapolis, Indiana) between 2005 and 2013 was performed. Patients with a skull fracture were identified based on ICD-9 codes. Patients with intracranial hematoma, brain parenchymal injury, or multisystem trauma were excluded. Children transferred to Riley Hospital from an outside facility were identified. The clinical and radiographic outcomes were recorded. A cost analysis was performed on patients who were transferred with an isolated, linear, nondisplaced skull fracture. RESULTS Between 2005 and 2013, a total of 619 pediatric patients with isolated skull fractures were transferred. Of these, 438 (70.8%) patients had a linear, nondisplaced skull fracture. Of these 438 patients, 399 (91.1%) were transferred by ambulance and 39 (8.9%) by helicopter. Based on the current ambulance and helicopter fees, a total of

Comparison Perioperative Factors During Minimally Invasive Pre-Psoas Lateral Interbody Fusion of the Lumbar Spine Using Either Navigation or Conventional Fluoroscopy

1,834,727 (an average of

Risk of deep venous thrombosis in elective neurosurgical procedures: a prospective, Doppler ultrasound–based study in children 12 years of age or younger

4188.90 per patient) was spent on transfer fees alone. No patient required neurosurgical intervention. All patients recovered with symptomatic treatment; no patient suffered late decline or epilepsy. CONCLUSIONS This study found that nearly

Sequential imaging demonstrating os odontoideum formation after a fracture through the apical odontoid epiphysis: case report and review of the literature

2 million was spent solely on transfer fees for 438 pediatric patients with isolated linear skull fractures over a 9-year period. All patients in this study had good clinical outcomes, and none required neurosurgical intervention. Based on these findings, the authors suggest that, in the absence of abuse, most children with isolated, linear, nondisplaced skull fractures do not require transfer to a Level 1 pediatric trauma center. The authors suggest ideas for further study to refine the protocols for determining which patients require transport.

346 Temporary Inferior Vena Cava Filter to Prevent Pulmonary Embolism in Thrombophilic Neurosurgery Patients.

Study Design: Retrospective clinical study. Objectives: The aim of this study was to compare intraoperative conditions and clinical results of patients undergoing pre-psoas oblique lateral interbody fusion (OLIF) using navigation or conventional fluoroscopy (C-ARM) techniques. Methods: Forty-two patients (22 patients by navigation and 20 by fluoroscopy) underwent the OLIF procedure at 2 medical centers, and records were reviewed. Clinical data was collected and compared between the 2 groups. Patients were followed-up with a range of 6 to 24 months. Results: There were no significant differences on demographic data between groups. The navigation group had zero radiation exposure (RE) to the surgeon and radiation time compared to the C-ARM group, with total RE of 44.59 ± 26.65 mGy and radiation time of 88.30 ± 58.28 seconds (P < .05). The RE to the patient was significantly lower in the O-ARM group (9.38 mGy) compared to the C-ARM group (44.59 ± 26.65 mGy). Operating room time was slightly longer in the navigation group (2.49 ± 1.35 hours) compared to the C-ARM group (2.30 ± 1.17 hours; P > .05), although not statistically significant. No differences were found in estimated blood loss, length of hospitalization, surgery-related complications, and outcome scores with an average of 8-month follow-up. Conclusions: Compared with C-ARM techniques, using navigation can eliminate RE to surgeon and decrease RE to the patient, and it had no significant effect on operating time, estimated blood loss, length of hospitalization, or perioperative complications in the patients with OLIF procedure. This study shows that navigation is a safe alternative to fluoroscopy during the OLIF procedure in the treatment of degenerative lumbar conditions.

Anterior Spinal Column Augmentation Techniques

OBJECTIVE The risk of venous thromboembolism (VTE) from deep venous thrombosis (DVT) is significant in neurosurgical patients. VTE is considered a leading cause of preventable hospital deaths and preventing DVT is a closely monitored quality metric, often tied to accreditation, hospital ratings, and reimbursement. Adult protocols include prophylaxis with anticoagulant medications. Childrens hospitals may adopt adult protocols, although the incidence of DVT and the risk or efficacy of treatment is not well defined. The incidence of DVT in children is likely less than in adults, although there is very little prospectively collected information. Most consider the risk of DVT to be extremely low in children 12 years of age or younger. However, this consideration is based on tradition and retrospective reviews of trauma databases. In this study, the authors prospectively evaluated pediatric patients undergoing a variety of elective neurosurgical procedures and performed Doppler ultrasound studies before and after surgery. METHODS A total of 100 patients were prospectively enrolled in this study. All of the patients were between the ages of 1 month and 12 years and were undergoing elective neurosurgical procedures. The 91 patients who completed the protocol received a bilateral lower-extremity Doppler ultrasound examination within 48 hours prior to surgery. Patients did not receive either medical or mechanical DVT prophylaxis during or after surgery. The ultrasound examination was repeated within 72 hours after surgery. An independent, board-certified radiologist evaluated all sonograms. We prospectively collected data, including potential risk factors, details of surgery, and details of the clinical course. All patients were followed clinically for at least 1 year. RESULTS There was no clinical or ultrasound evidence of DVT or VTE in any of the 91 patients. There was no clinical evidence of VTE in the 9 patients who did not complete the protocol. CONCLUSIONS In this prospective study, no DVTs were found in 91 patients evaluated by ultrasound and 9 patients followed clinically. While the study is underpowered to give a definitive incidence, the data suggest that the risk of DVT and VTE is very low in children undergoing elective neurosurgical procedures. Prophylactic protocols designed for adults may not apply to pediatric patients. Clinical trial registration no.: NCT02037607 (clinicaltrials.gov).

Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4

IntroductionThe mechanism of formation of an os odontoideum is controversial and likely multifactorial. One theory states that the apex of the odontoid separates from the body because of a fracture. The intact alar and apical ligaments pull the fractured segment superiorly. The independent vascular supply of the apex allows the fractured bone to remain viable and remodel into the smooth, corticated bone characteristic of an os odontoideum. However, there are no publications with direct radiographic evidence supporting the theory.Case reportIn this paper, the authors present a 7-year-old child with a fracture through the apical odontoid epiphysis, extending into the body of the dens. Serial imaging studies demonstrate progressive separation of the apex from the body of the odontoid. The fractured segment begins to remodel and assume the classic form of an os.ConclusionThe authors consider this case to be radiographic evidence supporting an acquired/traumatic origin of os odontoideum. Further, the mechanism of fracture through a cartilaginous epiphysis may explain the formation of an os after “normal” x-ray images or following seemingly minor trauma.

Risk of radiation-induced malignancies from CT scanning in children who underwent shunt treatment before 6 years of age: a retrospective cohort study with a minimum 10-year follow-up

INTRODUCTION Patients with symptomatic thrombophilia are treated with therapeutic anticoagulation. These patients can require neurosurgery. The patient must have their anticoagulation reversed before, during, and after surgery. After surgery they must be anticoagulated again. This entails a risk of embolic and hemorrhagic complications. Eighty-seven of these patients underwent neurosurgery between 2003 and 2015. Forty-two had a retrievable inferior vena cava filter before surgery and 45 had no filter placed. We report our results on this novel approach. METHODS Prospective analysis of 87 thrombophilic patients. The author had his thrombophilic patients get an inferior vena cava (IVC) filter before elective spine/cranial surgery. The filter was left in for 2 weeks after surgery and then removed and anticoagulated. Other neurosurgeons did not have a filter placed in their thrombophilic patients. These patients were normalized a few days before surgery and anticoagulated at various time points after surgery. χ analysis of the results was performed. RESULTS In the 45 patients with no filter, there were 6 pulmonary embolisms (PEs) of which 3 (10%) died acutely. There were 4 reoperations for spinal/cranial epidural hemorrhage after resumption of anticoagulation. Of the 41 patients with temporary IVC filters placed, there were no PEs, postoperative hemorrhages, or deaths. The filter was removed 2 weeks after surgery, when the patient was ambulatory and therapeutically anticoagulated. In 10, there was clot on the filter at removal. There were no complications due to the filter. χ analysis documented a significant reduction in the risk of PE, mortality, and postoperative hemorrhage (P < .01). CONCLUSION A temporary IVC filter in thrombophilic neurosurgery patients is safe and significantly lessens the risk of PE, mortality, and perioperative hemorrhage.

Computed-tomography-based anatomical study to assess feasibility of pedicle screw placement in the lumbar and lower thoracic pediatric spine

With the aging population, osteoporotic compression fractures have become increasingly common throughout the United States. Many of these patients are not suitable for open surgery, but suffer from substantial pain. It has been found that through the injection of polymethylmethacrylate cement into these fracture sites (vertebroplasty), pain can be alleviated quickly and easily with little recovery time by the patient and low rates of complications. Since the development of vertebroplasty, many other augmentation techniques, including balloon-assisted peek implant-assisted techniques, have been invented. Along with new techniques, new indications for augmentation have come about both in tumor and trauma domains. In this chapter, the expanded indications and techniques involved in vertebral augmentation will be described.