Veronica J. Rooks

Cervical spine injury in child abuse: report of two cases

Abstract Pediatric cervical spine injuries have rarely been reported in the setting of child abuse. We report two cases of unsuspected lower cervical spine fracture-dislocation in twin infant girls who had no physical examination findings to suggest cervical spine injury. Classic radiographic findings of child abuse were noted at multiple other sites in the axial and appendicular skeleton. Magnetic resonance (MR) imaging proved to be valuable in both the initial evaluation of the extent of cervical spine injury and in following postoperative changes. The unexpected yet devastating findings in these two cases further substantiate the importance of routine evaluation of the cervical spine in cases of suspected child abuse.

Comparison of probe sheaths for endovaginal sonography

Objective To compare the effectiveness of commercially available probe covers with less expensive condoms. Methods During a 10-month period, sonographers performed endovaginal ultrasound examinations on patients by randomly testing either commercially available probe covers or condoms on the vaginal probe. After use, the sheaths were tested for damage by filling them with water to observe for leakage and thereby determine the breakage rate. Results Perforations were noted in 15 of 180 probe covers and three of 180 condoms (8.3 versus 1.7%, P < .05; relative risk [RR] 5.4, 95% confidence interval [CI] 1.4-18.5). Potential contamination of the endovaginal probe occured during nine of 174 examinations and one of 178 examinations in which probe covers and condoms, respectively, were used (P < .05; RR 9.7, 95% CI 1.2–67.7). Conclusion Condoms are less expensive and superior to commercially available probe covers for covering the ultrasound probe during endovaginal examinations.

Magnetic Resonance Imaging of the Fetal Central Nervous System, Head, Neck, and Chest

Magnetic resonance imaging (MRI) has become an important tool in the assessment of fetal anomalies. Although ultrasound remains the modality of choice for screening, MRI offers several advantages that permit optimal characterization of anomalies in certain situations. Accurate recognition and characterization of fetal anomalies guides decisions about pregnancy management and coordination of postnatal care. This article will briefly review safety and practical aspects of fetal MRI. We will then provide a concise summary of the most common indications for fetal MRI, and discuss the differential diagnosis and role of MRI in assessment of fetal brain, head, neck, spine, and chest anomalies.

Spinal epidural abscess due to tropical pyomyositis in immunocompetent adolescents

Pyomyositis, a suppurative infection of skeletal muscle, is a disease not frequently encountered by neurosurgical providers. While previously considered an infection localized to tropical and semitropical locations, clinical reports of pyomyositis in temperate climates have increased over the past decade. Paraspinal involvement is uncommon in pyomyositis; however, the potential exists for spread into the epidural space resulting in a spinal epidural abscess (SEA). Early diagnosis of an SEA is frequently hampered by the absence of specific signs, unfamiliarity with the disease, atypical manifestations, and a broad differential diagnosis that includes more common causes of back pain. To date, 1 such case of paraspinal pyomyositis associated with an SEA has been reported in the neurosurgical literature. The authors present 2 cases of pyomyositis with an SEA and review the epidemiology, pathophysiology, diagnostic workup, and management of this disorder.

Head and Neck Ultrasound in the Pediatric Population

Ultrasound, as a diagnostic modality, has been developing rapidly. High-resolution ultrasound machines have been reduced to the size of a laptop computer. Ultrasound can be adopted by otolaryngologists for use within the clinic and the operating room. Ultrasound offers several advantages to the pediatric patient population. It is well tolerated and adds a degree of precision to the physical examination. It can be done repeatedly as lesions evolve and treatment is performed. It is valuable for guidance and therapeutic treatment of lesions in the operating room. It is likely that ultrasound use will continue to rapidly grow and evolve as a tool within the field of otolaryngology.

Sonographic Evaluation of Hydronephrosis in the Pediatric Population Is Well-Tempered Sonography Necessary?

Standardized protocols exist for diuretic renography. There are no specific guidelines regarding hydration before renal sonography. This study assessed the importance of the hydration status by sonographic measurements of the anteroposterior diameter and its effect on Society for Fetal Urology (SFU) hydronephrosis grading.

Hemichorea-Hemiballism Secondary to Non-Ketotic Hyperglycemia

Non-ketotic hyperglycemia is an unusual and rare cause of hemichorea-hemiballismus. Correction of the hyperglycemia usually results in total resolution of the signs and symptoms. We present the case and medical imaging findings of a 66-year-old female who presented with steadily worsening choreiform and ballistic movements of the right upper and lower extremities over a 2-week period. Her serum glucose was greater than 600 mg/dL, and no ketones were present. CT scan and MR demonstrated left basal ganglia abnormalities suggesting hyperglycemia-related hemichorea-hemiballismus syndrome. Restoration of euglycemia led to eventual resolution of all symptoms. Knowledge of this disorder is paramount so as to rule out other causes of intracranial pathology.

Paraspinal Tropical Pyomyositis and Epidural Abscesses Presenting as Low Back Pain

We present the case of a 13-year-old patient who presented to the Emergency Department with low back and flank pain. Cross sectional imaging revealed paraspinal pyomyositis and epidural abscess. A detailed patient history revealed a recent lower extremity skin infection consistent with tropical pyomyositis. Review of this case shows the importance for recommending either contrast enhanced computed tomography (CT) imaging of the spine and/or magnetic resonance imaging (MRI) in patients with a recent skin infection and acute onset of back pain.

Vitamin D deficiency versus non-accidental trauma: comment on "Rickets or abuse? A histologic comparison of rickets and child abuse-related fractures"

We read with great interest the study by Kepron and Pollanen [1] concerning a histologic comparison of rickets and child abuse-related fractures. Recently, numerous studies have attempted to find a reliable method of differentiating vitamin D deficiency from traumatic causes of fracture in young children, with some studies concluding that vitamin D insufficiency was not associated with multiple fractures or the diagnosis of child abuse [2], and that fractures seen in overt rickets do not resemble non-accidental trauma [3]. Despite this, determining the underlying cause of fractures in young children is still a clinical dilemma, as the metaphyseal abnormalities of rachitic bones can be difficult to distinguish from classic metaphyseal lesions, which are highly specific for non-accidental trauma. Moreover, both diagnoses can co-exist. We recently studied the relationship between vitamin D deficiency and cause of fracture in young children. After IRB approval, we retrospectively reviewed all skeletal surveys performed over the last 10 years at our center. Of the 396 skeletal surveys performed, 99 were read to have possible non-accidental trauma. 25-hydroxyvitamin D levels were sent in 11 of these 99 cases, all in children under 1 year of age (Table 1). The prevalence of vitamin D deficiency was 12.5 % in the children with no clinical suspicion of vitamin D deficiency (95 % binomial CI 0.003–0.524, 1 of 8 cases), and was likely not related to the underlying cause of fracture in that single case. Three of the children were highly suspected of having vitamin D deficiency from their clinical course (prolonged NICU stay, or documented rickets of prematurity). Thus it appears that routine screening of vitamin D levels after suspected non-accidental trauma with fracture is not routinely useful in children for whom there is low clinical suspicion of vitamin D deficiency, although on occasion there is overlap in the diagnoses (1 of our 8 cases). While not currently accessible in the routine hospital setting, a histologic comparison of bone changes, as performed by Kepron and Pollanen [1], could be of great value in helping clinicians determine the underlying cause of fracture in infants and children.

Diffusion-Weighted Magnetic Resonance Imaging of an Intramedullary Epidermoid Cyst with Dorsal Dermal Sinus Tract in a Toddler

We report the use of diffusion-weighted magnetic resonance imaging to diagnose and manage a rare case of a symptomatic thoracic intramedullary congenital epidermoid cyst with associated dermal sinus in a girl. Congenital intramedullary epidermoid cysts with associated dermal sinuses are very rare occurrences and seldom present symptomatically in very young children. We present a case of a 32-month old with a draining dimpled skin lesion. Magnetic resonance images demonstrated an intramedullary epidermoid with a dorsal dermal sinus tract opening to the skin surface which was confirmed surgically. The patient was treated with debulking to prevent recurrent infection and progression of neurological symptoms. This case demonstrates the use of diffuse-weighted MRI to assist in the diagnosis and surgical management of an atypical presentation of a rare developmental abnormality, which is not well documented in the pediatric radiological literature. Failure to diagnosis may have significant neurological permanent debilitating consequences.