John Shillito

Medulloblastoma at the joint center for radiation therapy between 1968 and 1984. The influence of radiation dose on the patterns of failure and survival

In order to assess the efficacy of high‐dose irradiation to the posterior fossa and low‐dose irradiation to the spinal axis, we reviewed the results of 60 patients with biopsy‐proven medulloblastoma treated at the Joint Center for Radiation Therapy (JCRT) between 1968 and 1984. The 5‐ and 10‐year actuarial survival rates for all patients were 68% and 44%, respectively. The median time to recurrence was 19 months. Extent of surgery, age, and radiation dose to the posterior fossa all were of prognostic value. Complete or subtotal gross resection appeared to be a favorable prognostic indicator compared with biopsy only (P < 0.05), with a 69% versus 40% actuarial survival rate at 5 years, respectively. Infants 2 years of age or less had a diminished 5‐year actuarial survival rate of 48% (P < 0.05) compared with older age groups. The posterior fossa was the predominant site of recurrence and accounted for 78% of all failures. Local control in the posterior fossa was dose dependent. Seventy‐nine percent of the tumors that received 5000 cGy or greater were controlled versus only 33% of the tumors that received less than 5000 cGy (P < 0.02). There were no supratentorial failures, and there was only one isolated spinal cord failure. There were no solitary spinal failures in 24 patients who received a median dose of only 2400 cGy to the spinal axis. We concluded that low‐dose irradiation to the spine and whole brain may be indicated with maintenance of a posterior fossa dose of greater than 5000 cGy.

Neurourological Implications of the Changing Approach in Management of Occult Spinal Lesions

Occult lesions of the spine in children are a rare but recognizable cause of neurogenic dysfunction involving the lower extremities, and lower urinary and gastrointestinal tracts. We report the preoperative and postoperative urodynamic findings in 40 children with varying spinal abnormalities. Of these patients 28 were neonates or infants (average age 8.7 months) and 12 were older children (average age 11.7 years). Preoperative urodynamic testing revealed normal function in 18 of 28 children (64 per cent) in the younger age group in contrast to 1 of 12 (8 per cent) in the older age group. Of the 10 infants with abnormal studies postoperative urodynamic findings returned to normal in 6, while 2 others remained abnormal but were improved. In contrast, of 11 older children with abnormal preoperative evaluations 3 (27 per cent) reverted to normal postoperatively. The neurourological changes seen in these occult lesions are variable, may occur at any age, are progressive and are potentially reversible by surgical correction but this reversibility diminishes with age.

Bladder Functional Changes Resulting from Lipomyelomeningocele Repair

From 1986 to 1991, 12 boys and 23 girls underwent surgery for lipomyelomeningocele removal. Of these patients 29 were 15 months old or younger (average age 3 months), while 6 were 4.5 to 19 years old (average age 10 years). Preoperative and postoperative urodynamic studies, including external urethral sphincter electromyography, were done on everyone. All 29 infants had a cutaneous lesion overlying the lower back and 14 had an abnormal neurological examination. Preoperative urodynamic studies were abnormal in 11 patients, consisting of an upper motor neuron lesion in 6, and a mixed upper and lower motor neuron lesion in 5. Postoperatively, 10 of 14 children with an abnormal neurological examination improved, while 9 of 11 with abnormal lower urinary tract function normalized. In 1 of 18 children (6%) with normal preoperative urodynamic studies detrusor-sphincter dyssynergia developed postoperatively. In all 6 older children urinary incontinence developed, and this led to the diagnosis. Everyone had an abnormal neurological examination and abnormal preoperative urodynamic studies. One child had a lower motor neuron lesion, and 5 had a mixed upper and lower motor neuron lesion. Postoperatively, the neurological examination improved in only 1 patient (16%), and the urological symptoms and urodynamic findings improved in another child. Lipomyelomeningocele has a progressive effect on lower spinal cord function because infants tend to present with fewer urinary manifestations and physical findings than older children. Individuals who escape early detection tend to have a more subtle cutaneous abnormality. As a result, older children are more likely to present with urological and neurological complaints. Surgical correction in infancy provides a degree of reversibility not seen in older children. It is imperative that early identification, evaluation and treatment be undertaken to prevent this progression and permanency of neurological changes and urinary dysfunction.

Pediatric lumbar disc surgery: 20 patients under 15 years of age

BACKGROUNDnPatients in their first or second decades of life who present with back pain without sciatica or painless scoliosis have been found to have a central lumbar disc protrusion. This study was elected to determine the difference between pediatric and adult disc symptomatology, surgical findings, and the results of surgery.nnnMETHODSnReview of office and Childrens Hospital records from 1958 through 1995 yielded a total of 60 patients under the age of 20 years who had lumbar discectomy by the author. Twenty were under the age of 15. This group is reported herein. All but 3 have been followed for up to 20 years. RESULTS The youngest was a boy 10 years and 8 months at operation. Only 20% complained initially of sciatic pain; 60% had it by the time of surgery; 20% never had it. The offending disc was at L5-S1 in 75%. The disc protrusion was central in 75%; no disc had ruptured. The posterior spinal ligament had ossified in the protruded position in 40%. Computed tomography (CT) scans were particularly useful. Significant antecedent trauma was present in 45%. Sixty percent were males. There was a family history of disc disease in 60%. The whereabouts of 3 of the 20 patients is unknown; their operations were 20-36 years ago.nnnCONCLUSIONSnLumbar disc disease in the first 2 decades may be missed because of the absence of sciatica. Once diagnosed, conservative therapy for as long as 2 years has failed. Lumbar discectomy in children under 15 years was safe in all cases and known to be successful in 88%.