Vesna Martich Kriss

SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) in Infants and Children

We review the biomechanics of the pediatric cervical spine and the clinical findings that pertain to SCIWORA (spinal cord injury without radiographic abnormality) in order to provide a more thorough understanding of this pediatric phenomenon of closed spinal trauma with significant neurologic sequelae but without bony injury. The unique hypermobility and ligamentous laxity of the pediatric bony cervical and thoracic spine predispose to a SCIWORA-type injury. In SCIWORA, the unusually elastic biomechanics of the pediatric bony spine allow deformation of the musculoskeletal structures beyond physiologic extremes, permitting direct cord trauma followed by spontaneous reduction of the bony spine. Potential mechanisms of the SCIWORA include hyperextension/ flexion, longitudinal distraction, and ischemic injury of the spinal cord.

Equine-related neurosurgical trauma: a prospective series of 30 patients.

Thirty million Americans ride horses; 50,000 of these riders are treated in emergency rooms annually. Equestrian activities are uniquely dangerous because the participant is unrestrained, often helmetless, and riding large, unpredictable animals capable of 40-mph speeds and kicking with up to 1 ton of force. Neurologic injuries in equestrians constitute the majority of severe injuries and fatalities. We prospectively studied all patients admitted to the University of Kentucky Medical Center with equine-related neurosurgical trauma from July 1992 to January 1996. Eighteen of 30 patients were male. Age ranged from 3 to 64 years. Five patients died (17%), and two suffered permanent paralysis. There were 24 head injuries (80%) and 9 spinal injuries (30%). The majority of injuries (60%) were caused by ejection or fall from the horse. Twelve patients (40%) were kicked by a horse, and four patients sustained crush injuries. Six patients underwent craniotomy, three had operative spinal stabilization, and five required ventriculostomy. Eleven patients (37%) were professional riders. Twenty-four patients (80%) were not wearing helmets, including all fatalities and craniotomy patients. Our data show that equine-related neurosurgical injuries can be severe and fatal because of the significant size, force, and unpredictability of these animals as well as the lack of proper headgear. We recommend that helmets be worn at all times around horses because a significant number of our patients (33%) were injured as bystanders. Risk of serious injury appears to be a function of cumulative exposure to horses, not level of expertise. Experience is not protective; helmets are.

Ultrasound assessment of spleen size in collegiate athletes

Objectives: To determine normal spleen dimensions in a healthy collegiate athletic population. Methods: 631 Division I collegiate athletes from one university participated in the study. During pre-participation examinations, demographic data collected were collected from volunteer athletes including sex, race, measurement of height and weight, and age. Subjects also completed a medical history form to determine any history of mononucleosis infection, platelet disorder, sickle cell disease (or trait), thalassaemia, or recent viral symptoms. Subjects then underwent a limited abdominal ultrasound examination, where splenic length and width were recorded. Results: Mean (SD) splenic length was 10.65 (1.55) cm and width, 5.16 (1.21) cm. Men had larger spleens than women (p<0.001). White subjects had larger spleens than African-American subjects (p<0.001). A previous history of infectious mononucleosis or the presence of recent cold symptoms had no significant affect on spleen size. In more than 7% of athletes, baseline spleen size met current criteria for splenomegaly. Conclusions: There is a wide range of normal spleen size among collegiate athletes. Average spleen size was larger in men and white athletes than in women and black athletes. A single ultrasound examination for determination of splenomegaly is of limited value in this population.

Symptomatic spinal intradural arachnoid cyst development after lumbar myelography. Case report and review of the literature.

Study Design. This case report describes the unique occurrence of acquired intradural spinal arachnoid cyst after lumbar puncture, which was proven radiographically and surgically. Objectives. To review and explore complications of lumbar puncture in the context of subsequent cyst development and to review the incidence, presentation, pathogenesis, and management of spinal intradural arachnoid cysts. Summary of Background Data. The etiology of the spinal intradural arachnoid cyst remains obscure; some such cysts are ascribed anecdotally to previous trauma or arachnoiditis, whereas the majority are idiopathic and assumed by many authors to be congenital. Methods. A 20‐year‐old woman with back and leg pain underwent lumbar myelography that yielded normal results with no evidence of arachnoid cyst at that time. Within 5 months, clinical symptoms of cauda equina compression and an S1 radiculopathy developed. Subsequent myelography and magnetic resonance imaging revealed a lumbar spinal arachnoid cyst. There was no history of intervening trauma or arachnoiditis. The lumbar puncture was thought to be the cause of the arachnoid cyst. Results. A laminectomy was performed with complete excision of the arachnoid cyst. The patient had an unremarkable postoperative course with excellent relief of her symptoms. Conclusions. This case provides supporting evidence for the traumatic etiology of spinal intradural arachnoid cyst. The development of an intradural spinal arachnoid cyst should be included as a possible complication of lumbar puncture.

Cavernous Sinus Thrombophlebitis: Case Report

OBJECTIVE AND IMPORTANCE Cavernous sinus thrombophlebitis is a rare, dangerous, and historically difficult condition to diagnose and treat. Knowledge of the imaging findings and the importance of early diagnosis and treatment are emphasized. CLINICAL PRESENTATION We present a case of cavernous sinus thrombo-phlebitis caused by sphenoid sinusitis. Previously undescribed magnetic resonance imaging findings of cavernous sinus thrombophlebitis include enlargement of the cavernous sinus, abnormal enhancement and increased T2 signal of the petrous apex and clivus, and marked narrowing of the cavernous portion of the internal carotid artery. Resolution of cavernous sinus thrombophlebitis is also documented by magnetic resonance imaging. INTERVENTION The anatomy of the cavernous sinus dictates the natural history and diagnosis of cavernous sinus thrombophlebitis. We review the literature regarding the clinical diagnosis, differential diagnosis, and treatment of cavernous sinus thrombophlebitis. CONCLUSION We emphasize the importance of a high index of suspicion, the potentially rapid and fatal course of the disease process, and the subsequent need for antibiotic therapy and selective surgery.

Mononucleosis and athletic participation: an evidence-based subject review.

Infectious mononucleosis (IM) is a common medical condition that afflicts thousands of young athletes each year. Despite the self-limited nature of this disorder, the variability of the clinical presentation and the rare risk of splenic rupture routinely present sports medicine clinicians with difficult return-to-play decisions. Currently there are no evidence-based guidelines regarding the management of the athlete with IM. This review discusses the available research data pertaining to the management of IM in young athletes and develops questions for future clinical research.

Occult Spinal Dysraphism in the Infant Clinical and Sonographic Review

The progressive neurologic dysfunction caused by occult spinal dysraphism can be prevented with early clinical recognition, radiographic diagnosis, and neurosurgical treatment. However, detection of occult spinal dysraphism in the infant is difficult because neurologic symptoms often are not apparent until the child becomes ambulatory. Occult spinal dysraphism, however, can be suspected in the asymptomatic neonate when cutaneous stigmata, such as hemangiomas, hairy patches, deep and/or eccentric dimples, or subcutaneous masses are seen over the lumbosacral spine. Because of the serious, often irreversible, sequelae of a delayed diagnosis, spinal sonography of high-risk infants with midline, lumbosacral, cutaneous stigmata should be considered as an effective, noninvasive screening method.

Hiatus/paraesophageal hernias in neonatal Marfan syndrome

We report on an infant with neonatal Marfan syndrome (NMS) and hiatus/paraesophageal hernia who presented to a university hospital with an unusual early complication of this connective tissue disorder. An abnormal course of the nasogastric tube was noted on the first day of life by a radiograph of the chest and abdomen performed for bloody gastric drainage. The question of esophageal perforation was raised. Subsequent contrast study demonstrated a large hiatus/paraesophageal hernia with pronounced gastroesophageal reflux (GER). A part of the hernia was positioned posterior and to the right of the gastroesophageal junction (GEJ), presumably the location of the nasogastric tube as noted on the initial films. Although characterized by cardiac/aortic abnormalities, NMS can be a difficult diagnosis and should be considered in any infant with hiatus/ paraesophageal hernia with or without GER.

Abdominal Manifestations of Cystic Fibrosis in Older Children and Adults

OBJECTIVE Cystic fibrosis (CF) is a disorder of exocrine gland function of which the gene mutation has been existing for thousands of years. With recent medical advances, neonates presently affected have a life expectancy of 40 years. The common gastrointestinal presentations of CF patients, including pancreatic, hepatobiliary, and bowel manifestations, are thus important to recognize. CONCLUSION Gastrointestinal manifestations of CF are varied yet common and thus increasingly important to recognize. The sonographic, CT, and MRI abdominal findings in older children and adults with CF are presented.

Hyperdense posterior falx in the neonate

Objective. Hyperdense posterior falx and/or torcula on unenhanced CT scans is associated with sagittal sinus thrombosis in adults. However, the validity of this finding in newborns is unknown. Materials and methods. A prospective review was performed from September 1995 to November 1996, evaluating head CT scans of infants during their first week of life. Results. Eleven neonatal head CT scans revealed a hyperdense posterior falx, suggestive of sagittal sinus thrombosis. Further imaging (7 ultrasound and 4 magnetic resonance imaging examinations) revealed no evidence of venous thrombosis in 10 of the 11 infants. Conclusion. Predominantly unmyelinated neonatal brain and increased hematocrit of neonatal blood probably contribute to the false impression of hyperdense posterior falx/torcula on neonatal head CT scans.