Multiplanar spinopelvic fracture reduction and dual triangular osteosynthesis stabilization for complex multiplanar sacropelvic fractures.

BACKGROUND: Sacropelvic fractures with multidirectional instability require complex reduction and stabilisation techniques. Triangular osteosynthesis reconstruction is an established technique but hardware failure rates remain high and screw trajectories unfamiliar to spine surgeons. Our technique allows de-rotation of the pelvis, fracture reduction in both vertical and transverse planes, immediate weight bearing and is more reproducible for complex spine surgeons. OBJECTIVE: To describe our case series of dual triangular osteosynthesis reduction and stabilisation for complex sacropelvic fractures. METHODS: Retrospective case series of patients treated for unstable multiplanar sacropelvic fractures, at a level one trauma centre in the United Kingdom. Chart review was conducted to assess clinical features, radiology (plain radiographs, CT and MRI), surgical techniques and clinical and radiological outcomes. RESULTS: A total of six patients with four male and two females were included. Mean age of the cohort was 37.5 years (range 19-61 years) and average length of follow-up was 34.5 months (range 13-75 months). Three patients had neurological injury and three were intact. Four patients had associated thoraco-abdominal or lower limb injuries requiring intervention. All patients underwent surgery with reduction and stabilisation using dual triangular osteosynthesis constructs. At final follow-up, one patient had persistent bladder dysfunction (present preoperatively), one remained ASIA A from concomitant cord injury in the thoracic spine, and one patient with L5 and S1 weakness completely recovered. There were no metalwork complications and all patients achieved radiological fusion. CONCLUSION: Our technique of reduction and stabilisation of complex multidirectional sacropelvic fractures leads to a biomechanically strong construct with immediate stability, and without risk of hardware failure.

Management of Chiari 1 Malformation and Hydrocephalus in Syndromic Craniosynostosis: A Review.

Chiari 1 malformation and hydrocephalus are frequent findings in multi-suture and syndromic craniosynostosis patients. In this article, we review the pathogenesis, clinical significance, and management options for these conditions with comments from our own experience. The role of premature fusion of skull base sutures leading to a crowded posterior fossa and venous outflow obstruction resulting in impaired cerebrospinal fluid (CSF) absorption is highlighted. Management options are unique in this group and we advocate early (prior to 6 months of age) posterior vault expansion by distraction osteogenesis (DO) in the management of Chiari 1 malformation. Foramen magnum decompression is recommended for a select few either as part of posterior vault expansion or at a later date. Treatment of hydrocephalus, utilizing a ventriculoperitoneal (VP) shunt with preferably a programmable high-pressure valve and anti-siphon device, is required in a small percentage of cases despite successful posterior vault expansion. Patients need to be carefully selected and managed as hydrocephalus often serves as an important cranial vault growth stimulus. Further, they require careful monitoring and thought to ensure the management of these conditions and the timing of any intervention provides the optimal long-term outcome for the patient.

Management of multiloculated hydrocephalus in children with emphasis on role of CT ventriculography.

OBJECTIVE: The authors performed a retrospective review of children diagnosed with multiloculated hydrocephalus (MLH) in our institute. The goal was to analyze the different diagnostic and therapeutic modalities used with special emphasis on CT ventriculography (CTV). METHODS: Male and female patients below the age of 18 years diagnosed with MLH were included. Cases of uniloculated hydrocephalus like entrapped temporal horn or isolated fourth ventricle were excluded. We used iohexol for CTV and gadodiamide for MR ventriculography. Neuroendoscopic procedures performed were endoscopic fenestration, endoscopic third ventriculostomy (ETV), endoscopic septostomy, endoscopic aqueductoplasty, or a combination of the above. The cohort was divided into two groups (endoscopic or shunt) based on initial surgical intervention. RESULTS: A total of 52 patients were included, with 43 boys and 9 girls. The average age of presentation was 7.7 months. The most common predisposing factor for MLH was neonatal meningitis seen in 30 patients. Mean duration of follow-up was 39 months. CTV was used in 26 patients and MR ventriculography in three patients. In one patient, the diagnosis of MLH was ruled out after ventriculography. Patients who underwent ETV only had the best outcome with 71.4% success rate. At the end of follow-up, 14 patients (27%) were shunt independent. CONCLUSIONS: The present study indicates that CTV helps to accurately define the anatomy of the ventricles and determine the site of physiological CSF obstruction. This helps in therapeutic planning and in avoiding misdiagnoses. Further, neuroendoscopy has the potential to lead to shunt independence in some patients.

A Comparative Analysis Between Four-Quadrant Osteoplastic Decompressive Craniotomy versus Conventional Decompressive Craniectomy for Traumatic Brain Injury.

OBJECTIVE: Primary decompressive craniectomy (DC) is indicated to evacuate the hematoma and reduce intracranial pressure in traumatic brain injury (TBI). However, there are a myriad of complications because of absence of the bone flap. A novel technique, four-quadrant osteoplastic decompressive craniotomy (FoQOsD) retains the bone flap while achieving adequate cerebral decompression. METHODS: A single-center randomized controlled trial of 115 patients with TBI needing decompressive surgery was conducted. Of these patients, 59 underwent DC and 56 underwent FoQOsD. The primary outcome determined was functional status at 6 months using the Glasgow Outcome Scale-Extended. RESULTS: No significant differences were identified in baseline characteristics between both groups. Mean Glasgow Outcome Scale-Extended score was comparable at 6 months (4.28 in DC vs. 4.38 in FoQOsD; P = 0.856). Further, 22 of 58 patients in the DC group had died (38%) compared with 25 of 55 patients in the FoQOsD group (44.6%) (odds ratio [OR], 1.19; 95% confidence interval [CI], 0.6-2.36; P = 0.6) (1 patient lost to follow-up in each group). A favorable outcome was seen in 56.8% of patients in the DC group versus 54.4% of patients in the FoQOsD group (P = 0.74). Presence of intraventricular hemorrhage and subarachnoid hemorrhage (OR, 7.17; 95% CI, 1.364-37.7; P = 0.020), opposite side contusions (OR, 3.838; 95% CI, 1.614-9.131; P = 0.002) and anisocoria (OR, 3.235; 95% CI, 1.490-7.026; P = 0.003) preoperatively were individual factors that played a significant role in final outcome. CONCLUSIONS: FoQOsD is as efficacious as conventional DC with the added benefit of avoiding a second surgery. The procedure is associated with better cosmesis and fewer complications.

Radiation-induced Supratentorial Osteosarcoma Following Curative Treatment of Infratentorial Ependymoma in a Child.

The development of secondary neoplasms following therapeutic cranial irradiation is rare and quite often lethal. Meningiomas, sarcomas, and high-grade gliomas are the most common tumors that manifest as a result of radiation therapy. We report the case of an 11-year-old child who presented with symptoms of supratentorial space-occupying lesion 7 years after curative surgery and cranial irradiation for a posterior fossa ependymoma. Magnetic resonance imaging of the brain revealed a right-sided temporoparietal dural-based contrast-enhancing lesion with evidence of overlying bone and skin involvement. The histological report of ependymoma from the previous surgery led us to suspect that we were dealing with a recurrence until the histopathology of the second surgery revealed highly malignant osteosarcoma. The child recovered fully and underwent chemotherapy, but ultimately succumbed to the disease. We report this case to highlight the importance of recognizing these neoplasms and to review its management.

Do Glioblastomas with Syndromic Association Have Better Prognosis? A Case of Supratentorial Glioblastoma with Embryonal Tumor Differentiation in a Child with Multiple Enchondromatosis.

Glioblastoma (GBM) is an aggressive cancerous neoplasm of the brain that has numerous morphological subtypes. Primitive neuroectodermal differentiation (hereafter, referred to as embryonal tumor [ET] differentiation) in GBM is one of them and is known to occur in adults. Their presentation in pediatric population is rare and can be a source of diagnostic confusion. The dual pathology leads to doubts where one could ask whether it is ET differentiation in GBM specimen or glial differentiation in ET specimen. This histological discrimination has a bearing on the treatment regimens and prognosis. We report a case of a 10-year-old boy presenting with a supratentorial GBM, isocitrate dehydrogenase wild type with ET differentiation, and multiple benign bony lesions of both extremities. He underwent surgical excision for the brain neoplasm followed by radiotherapy and has shown prolonged survival with no recurrence. In this article, we discuss prognostic factors associated with long-term survival of these tumors.

Penetrating orbital trauma leading to trans-orbital brain herniation.

INTRODUCTION: Development of a posttraumatic herniation of brain parenchyma through the orbit is a rare complication of orbital roof fracture. Mostly, the injury is due to a direct impact to the frontal region resulting in orbital roof fracture with dural defect and herniation of cerebrospinal fluid or brain parenchyma. These patients present with acute or gradually progressive proptosis with impending risk of loss of vision and mandate surgical decompression of optic nerve with watertight closure of the dural defect. Bony reconstruction may be required to achieve normal contour of the orbit. MATERIALS AND METHODS: We encountered an interesting pediatric patient who presented to us with altered sensorium and progressive proptosis 3 days after a penetrating trauma to his left orbit by falling on the handle of a bicycle. The plain computerized tomography of the head (NCCT) showed a left orbital roof defect with herniation of brain matter into the orbit displacing the globe inferolaterally. A craniotomy was performed and watertight closure of the dural rent was achieved with use of autologous bone to cover the defect. CONCLUSIONS: The child improved gradually, and at 6 months follow-up, he had good cosmetic outcome with improvement of vision.

Spinal cord abscess secondary to infected dorsal dermal sinus in an infant: uncommon presentation of a known entity.

Infection along the congenital dermal sinus tract is well known. However, congenital dorsal dermal sinus presenting with intramedullary abscess is quite rare. The sinus tract usually presents in the midline and acts as a portal of entry for infection that may manifest as meningitis, extradural or subdural abscess and may further involve the cord. Surgical drainage of pus and complete excision of the sinus tract is the standard treatment. Here we describe an infant with an infected congenital dorsal dermal sinus with atypical presentation as large paracentral abscess in the upper back. We further highlight the importance of recognising and treating these skin dimples even when clinically silent to avoid catastrophic complications.

Spontaneous Umbilical CSF Fistula Due to Migration of the Peritoneal End of VP Shunt: A Case Report and Review of Pathogenesis.

Abdominal complications after ventriculoperitoneal (VP) shunt surgery for hydrocephalus have been known to occur. The more common complications include peritoneal pseudocyst, obstruction of the lower end, and shunt infection. Perforations of the intra-abdominal hollow viscera leading to spontaneous extrusions of the peritoneal catheter via the natural orifices have also been reported. A rarer phenomenon still is the migration of the lower end of the VP shunt through the anterior abdominal wall, leading to the formation of a spontaneous umbilical fistula at a site unrelated to the surgical site. Eight cases have been described in the literature so far with various causes elucidated. We report this condition in a child 4.5 years after his shunt surgery and postulate different mechanisms for both early and late presentations of this condition.

Linear undisplaced fracture of temporoparietal bone acting as spontaneous early decompressive craniotomy in a neonate.

Decompressive craniotomy (DC) is used to treat intracranial hypertension associated with traumatic brain injury. Early DC is associated with better outcomes. We present a neonate with a history of fall with computed tomography scan showing a large frontoparietal contusion and associated parietal and temporal bone fracture. This acted as a spontaneous DC causing bony segment to separate due to which the edematous brain could be accommodated. Despite the presence of a large contusion, the child was neurologically intact and medically managed. The neonate presented with a posttraumatic leptomeningeal cyst 2 months later, which had to be repaired surgically. We discuss how a linear undisplaced fracture acts as spontaneous DC and the role of early DC in improving outcomes.

A Successful Strategy for Surgical Treatment of Boerhaave's Syndrome Sans Thoracotomy.

Boerhaave's syndrome is a rare life threatening condition that is often misdiagnosed and fatal if not treated promptly. While the gold standard is early surgical intervention, recent studies have showed success with conservative management. We report a case of Boerhaave's syndrome that was managed conservatively by decompressive gastrostomy, feeding jejunostomy, bilateral intercostal drainage tubes with added proximal diverting cervical esophagostomy. The patient recovered completely and stoma closure was done two months later.

Small intestinal obstruction secondary to jejunal trichobezoar removed per anum without an enterotomy: a case report.

Trichobezoars can rarely present with obstruction. This is usually due to collection of a hair ball in the stomach. We encountered an interesting case of small bowel obstruction due to a jejunal trichobezoar. The treatment generally is an enterotomy with removal of the hair ball. We report a case of a 29-year-old post partum female who presented to us with sub acute intestinal obstruction. Exploratory laparotomy revealed an impacted mass in the distal jejunum which was removed per anum without an enterotomy. Postoperative gastroscopy did not show trichobezoar in the stomach. This case highlights the importance of trichobezoar as a differential diagnosis in young women with small bowel obstruction that can be treated without an enterotomy and avoiding the risks and morbidities associated with it.