Vagal nerve stimulation for status epilepticus.

Refractory generalized convulsive status epilepticus in a 13-year-old boy was halted by left vagal nerve stimulation. Over the next 1.5 years, seizures have continued at a rate and severity which is significantly better than it had been in the year before insertion of the stimulator.

Pediatric neurosurgery: pride and prejudice.

Pediatric neurosurgery now exists as a member of the family of neurosurgery with its own training programs, process of accreditation, national and international conferences and scientific journals. The relentless expansion of science relevant to the practice of neurosurgery and the changing patterns of neurosurgical practice have driven and continue to drive the juggernaut of evolutionary process which sometimes necessitates the birth of new specialties of practice. The history and the development of neurosurgery as they relate to children are presented. There is no more reason to think that the established specialty of pediatric neurosurgery or the patients under the care of pediatric neurosurgeons would benefit from the collapsing of pediatric neurosurgery back into the general neurosurgical fold than to think that all of neurosurgery, and hence all patients cared for by neurosurgeons, would benefit from the return of organized neurosurgery to its general surgical parent. Just as mankind benefits from the steady advancement of all aspects of neurosurgery, children benefit from the existence and steady advancement of pediatric neurosurgery.

Efficacy of dural tenting sutures.

OBJECT: The goal of this study was to assess the necessity for the prophylactic use of dural tenting sutures. METHODS: Data that had been prospectively collected from 369 consecutive cranial operations in adults were analyzed. In this series of patients, dural tenting sutures were used on a judicious "as needed" basis. They were never used to satisfy a procedural routine or for use as a prophylaxis against epidural hemorrhage that was not apparent. Tenting sutures were used for the control of epidural bleeding in 33 patients (8.9%); no tenting was required in 336 patients (91.1%). Reoperation for postoperative epidural hematoma was not required in this series. CONCLUSIONS: Dural tenting sutures continue to have an important role in neurosurgery; however, there is no compelling evidence to support their traditional prophylactic use in every intracranial operation.

Cranial bone fixation in infants and children.

A technique is described for fixing cranial bone flaps with absorbable sutures and bone shims. This technique is a cost-efficient method of rapidly achieving rigid structural stability with excellent cosmetic results. The kerf created by the craniotome is bridged at multiple sites by bone chips harvested from the inner edge of the bone flap. Solid bony union is documented on histopathological analysis. The technique requires no special tools and avoids the problems associated with the use of plates, screws and wire.

Dural tenting sutures in pediatric neurosurgery.

Dural tenting sutures were used on a selective basis in 329 consecutive cranial operations in children; 16 (4.8%) required dural tenting sutures for the control of epidural bleeding and 313 (95.2%) required no dural sutures. Dural tenting sutures were never placed for prophylaxis or to satisfy a routine. Reoperation for postoperative epidural hematoma was required in 1 child (0.3%) and that child was subsequently discovered to have hemophilia. The author concludes that there is no compelling evidence for the prophylactic use of dural tenting sutures in children.

Balamuthia mandrillaris meningoencephalitis presenting with acute hydrocephalus.

The leptomyxid amoeba Balamuthia mandrillaris, previously believed to be a harmless soil-inhabiting organism, is now known to be a rare but consistently lethal cause of meningoencephalitis in humans. We report a case of amebic meningoencephalitis caused by B. mandrillaris which presented as a febrile illness with acute hydrocephalus.

Value-based formulas for purchasing. Employers shift to quality to evaluate and manage their health plans.

Employers have traditionally focused on cost and plan design in the management of their employees' health care programs. This cost focus has led most large employers to enroll employees in managed care programs and resulted in a new focus on the quality of care delivered by these plans. By evaluating cost and quality, employers attempt to understand the total value these health plans deliver. Hewitt Associates' Health Value Initiative, a health plan analysis based on employers' increased need for cost and quality information, is an example of a tool used by some employers to evaluate and strategically manage their health plans. A case study shows how one large employer used this information to shift to a more comprehensive cost and quality analysis, resulting ultimately in better health care costs and quality for its employees.

Transcranial migration of microfixation plates and screws. Case report.

A case of transcranial, transdural migration of microplates and screws with damage to the subjacent cortex in an infant with craniosynostosis is described. The authors believe that plates and screws should be reserved for exceptional cases in which bony approximations are unstable or difficult to align by other means.

Spine and spinal cord injuries in downhill skiers.

Spine and spinal cord injuries are the most debilitating and costly of serious injuries sustained by downhill skiers. We present a series of 126 skiers with spine and spinal cord injuries drawn from 636 consecutive injured skiers evaluated at one center over an 11-year period. The incidence of spinal injury was very low (0.001/1000 skier-days). Eighteen (17%) patients had spinal cord injuries associated with their fractures; injuries in the cervical region were most likely to involve the spinal cord. The most commonly fractured levels were C6, T12 and L1; the most common fracture pattern was compression (38%). One-third of all patients had multisystem trauma; those with thoracolumbar injuries were much more likely to sustain torso and extremity trauma than those with cervical injuries. Information about injury patterns in skiers with spinal injuries should aid in the triage and initial evaluation of this blunt trauma population.

Severe snowboarding injuries.

Thirty-seven consecutive patients with severe snowboard-related injuries (defined by referral to a Level I trauma centre) were reviewed. The type and mechanism of each injury were examined and found to be similar to those reported for skiers. Mild closed head injuries were common (54 per cent). Head and abdominal injuries were more common among snowboarders than skiers, but chest and skeletal injuries were rare. There were no deaths. Serious snowboarding injury rates were similar to those for serious skiing injuries. The incidence of snowboarding injuries sufficiently severe to require tertiary referral was estimated at 0.03 injuries/1000 snowboarder days. Similar to reports of minor snowboarding injury, these data indicate that injury patterns in more serious snowboarding accidents are quite different from those of serious downhill skiing accidents. Injured snowboarders suffer splenic injuries more often and chest and spinal injuries less often than do skiers, and should be evaluated for blunt injuries with these statistical differences in mind.

Reduction cranioplasty.

Reduction cranioplasty can greatly improve the quality of life for selected patients with severe macrocephaly and can significantly diminish some of the difficulties in the long-term chronic care of others. Because of differences in age, cranial morphology and surgical goals, the surgical plan must be tailored to the individual patient. Three techniques for reduction cranioplasty, with the advantages and disadvantages of each, are described. Four patients, representing the spectrum of severe macrocephaly and also the problems associated with reduction cranioplasty, are presented. Surgical indications, tactical considerations and risks are discussed.

Normal sutural fusion and the etiology of single sutural craniosynostosis: the microspicule hypothesis.

Single sutural craniosynostosis is a disorder wherein a calvarial suture fuses prematurely, resulting in an abnormally shaped head. Children afflicted are normal neurologically, and the bone bridging the sutures is normal histologically. The mechanism of normal or pathologic sutural fusion is unknown. These facts prompted the authors to reexamine normal sutural anatomy and the concepts of skull growth in an animal model. Histochemical staining to identify osteoblasts and osteoclasts and tetracycline labeling were performed on neonatal rabbit calvarial sutures. Osteoblasts are found on all bony surfaces including the sutural edges, but do not extend across the sutural space. Thus the periosteum per se does not bridge the suture. Osteoclasts are found only in the diploic space. Thus, there is no mechanism to remove bone at/or within the suture. Tetracycline labeling revealed immense bone production at the suture as compared with dural and periosteal surfaces. Microscopic spicules of bone bridging the suture were identified. Based upon the above observations, we propose a new hypothesis for the mechanism of normal and pathologic sutural fusion. Bony microspicules normally and intermittently form and bridge the suture. As there is no mechanism to remove these spicules, we propose that normal mechanical forces cause them to fracture. A spicule that fails to fracture functions as a scaffold, upon which more bone is deposited, resulting in sutural fusion. Single sutural craniosynostosis results when a normal process occurs prematurely.

Temporal lobectomy for complex partial seizures that began in childhood.

Forty-six consecutive patients who underwent surgery for intractable temporal lobe seizures originating in childhood are reported; invasive preoperative monitoring (e.g., depth electrodes and subdural arrays) was not used in the selection process. Our results, with respect to the control of seizures and improvement in behavior, are comparable to those of series in which invasive monitoring was used in the selection process. Eighty-five percent of the 46 patients (96% of the 28 operated after the introduction of long-term electroencephalographic monitoring) became either seizure free or experienced near total control of their seizures. Our results indicate that many patients can be selected successfully for temporal resection without exposure to the risk and expense of invasive presurgical procedures. A long duration of epilepsy prior to surgery in patients with neoplasia portended a less satisfactory outcome. Our results strengthen the argument for early operation in children with intractable epilepsy.

Cerebral hemicorticectomy for epilepsy.

Hemicorticectomy resulted in total or near-total control of seizures in 10 of 11 children with chronic epilepsy. During a median follow-up period of 5.5 years, there have been no deaths or delayed complications. The surgical outcome after hemicorticectomy compares favorably with that of more extensive surgical procedures, yet is associated with significantly less risk. The technique for hemicorticectomy is described and illustrated.

Hair and neurosurgery.

The value of removing hair in preparation for neurosurgery is addressed in detail. One neurosurgeon's series, accrued over 40 consecutive months, of 638 prospectively examined, consecutive cases is the basis of this report. The overall surgical wound infection rate was 1.1%. The infection rate for the 313 cranial cases was 0.3% and 2.8% for the 218 procedures involving cerebrospinal fluid diversion (shunts). These data are discussed in the context of extensive nonneurosurgical and microbiological literature. It is concluded that the removal of hair by shaving does not lower the risk of surgical wound infection and may increase the risk. A technique for preparing skin and hair for neurosurgery and for the management of hair during neurosurgical procedures is discussed.

Hydraulic regulation of brain parenchymal volume.

A mechanism for the hydraulic regulation of brain parenchymal volume is hypothesized. Ventricular fluid pressure is transmitted to parenchymal capillaries and affects the pressure difference across the capillary wall, thereby influencing the rate of movement of fluid from the capillary lumen to interstitial fluid. The tendency for brain parenchyma to expand results from the resistance encountered by interstitial fluid as it slowly passes through the complex interstices of extracellular space. The tendency for the brain parenchyma to become smaller results, not from compression of tissue by ventricular fluid, but from an inherent elasticity of brain tissue. The parenchymal volume is stable only when the opposing tendencies are balanced. The critical site of action for the hydraulic control of parenchymal volume is the capillary wall, and the fundamental relationship governing this can be expressed mathematically.

Results of surgery for extratemporal partial epilepsy that began in childhood.

Thirty-five consecutive patients who underwent surgery for intractable extratemporal seizures originating in childhood are described. Candidates for surgery were selected on the basis of clinical criteria, neurodiagnostic imaging, and an electroencephalographic investigation that included the use of sphenoidal electrodes and long-term monitoring. Invasive preoperative monitoring was not used. Our results, with respect to the control of seizures and behavioral improvement, are comparable with series in which data from invasive recordings were used in the selection process. Sixty-three percent of the 35 patients (76.5% of those operated on after the introduction of long-term electroencephalographic monitoring) became either seizure free or experienced a reduction in their frequency of seizures by at least 75%. The favorable outcome in this group of patients strengthens the argument for early operation in children with intractable epilepsy, even when the seizure focus is outside the temporal lobe.

Craniopharyngiomas in children. Long-term effects of conservative surgical procedures combined with radiation therapy.

Thirty-seven patients with craniopharyngioma were treated at Children's Hospital, Boston, between 1972 and 1981, the mean follow-up period now being 10.5 years. Twenty of these patients are old enough to have finished high school and have been queried about their college or job activity. None of the four patients who had undergone radical excision of their tumor and who had reached the age of finishing high school was able to work independently. Among the 16 patients who reached this age and who were treated by more conservative operations and irradiation or irradiation alone, job performance or college attendance varied considerably, indicating that psychosocial impairment occurred in this group, but suggesting that the risk was less. The rate of tumor recurrence or of failure to respond to treatment was 57% (four of a total of seven survivors) following radical surgery and 7% (two of 27 survivors) after conservative operations and irradiation. The overall mortality rate was 8%; the causes of the three deaths were: "hypothalamic crisis" 1 year after radical resection; progressive tumor growth despite two attempts at resection and irradiation; and a brain-stem glioma in the field of irradiation 8 years after treatment.