Solid noninfectious growing masses over cerebrospinal fluid shunts: report of 3 cases.

The authors describe 3 children who presented with progressively enlarging skin-covered solid masses over the shunt catheter in the neck/clavicular region. The authors reviewed the clinical, laboratory, pathological, radiographic, and follow-up data for all 3 patients and reviewed the literature on the subject. The patients had no clinical evidence of an infectious process. Surgical exploration revealed that masses were surrounding and encasing the shunt tubing to which they were strongly attached. Pathological studies of the tissues demonstrated varying degrees of exuberant chronically inflamed granulation tissues, interstitial fibrosis, and dystrophic calcification. One patient had associated thinning of the skin overlying the mass and subsequently developed ulceration. No infectious organisms were observed. The cerebrospinal fluid aspirates from the shunts did not yield any organisms. There has been no recurrence of the masses. The presence of a growing mass over the shunt tube in the neck or the chest region without clinical evidence of infection does not indicate that the mass should be treated with antibiotics and complete shunt removal. Rather, the mass can be cured by extirpation and with "bypass" new shunt tubing locally.

Ultrasound-aided fixation of biodegradable implants in pediatric craniofacial surgery.

PURPOSE: Bioresorbable implant systems have been used for the rigid fixation of cranial and facial bones. A relatively recent advancement has been the fixation of these implants using an ultrasonic device. Published reports with such a device in pediatric craniofacial surgery have been limited. We report our experience with ultrasound-aided fixation of bioresorbable implants in the craniofacial surgery of children. METHODS: We retrospectively examined the clinical information, complications and outcome following the use of a commercially available ultrasound-aided bioresorbable implant system (SonicWeld Rx™, KLS Martin, Jacksonville, Fla., USA) during craniofacial surgery by University of Florida College of Medicine Jacksonville surgeons. Follow-up was obtained via clinical examination or telephone interview. RESULTS: Over a period of 3 years, 37 pediatric patients (age range: 2 months to 16 years) had placement of these implants for immediate bony fixation during craniofacial procedures. Pathology consisted mainly of craniosynostosis (n = 19), and trauma (n = 16). Twenty-eight had combined craniofacial procedures; 9 patients had facial procedures. Reoperation was performed for: wound infection (n = 1), plate extrusion (n = 1). Delayed subcutaneous plate-related swelling was seen in 5 patients (4 were infants) and had a benign clinical course. Good cosmetic outcomes were seen in all patients. CONCLUSIONS: The use of a bioresorbable implant system with ultrasound-aided pin fixation in pediatric craniofacial surgery achieves rapid fixation with minimal morbidity and good cosmetic outcome. This system is easy to use and provides reliable stability in the setting of pediatric trauma and craniosynostosis.

Advanced registered nurse practitioners and physician assistants in the practice of pediatric neurosurgery: a clinical report.

OBJECTIVE: This report addresses the clinical experience of the Division of Pediatric Neurosurgery with dedicated nurse practitioners and a physician assistant (PA) in outpatient and inpatient health care delivery, including surgical activities, as well as participation with the neurosurgery call schedule, quality improvement, teaching, and clinical research activities. METHODS: We report on the activities of allied health personnel in the Division of Pediatric Neurosurgery for the purpose of identifying the current and future role for health care delivery, related to the care of the child with a neurosurgical condition. This addresses the participation of 2 advanced registered nurse practitioners (ARNPs) and a PA in the outpatient and inpatient setting, call schedule, interventions in and out of the operating room, quality improvement sessions, continuing medical education, clinical research, clinical databases, presentations in meetings, teaching, and scientific publications. RESULTS: This report covers the period from September 2003 (when the division was initiated) to February 2011. The division currently consists of 3 pediatric neurosurgeons, 2 ARNPs and 1 PA. The ARNPs/PA have participated in the pediatric neurosurgery clinic held 5 half-days per week, the monthly multidisciplinary clinics (Spinal Defects Clinic, Pediatric Neurosciences Clinic, and the Fetal Diagnosis and Therapy Center working group), and inpatient care, as well as assisting in operative interventions. They participated in the on-call schedule and attended the monthly quality improvement sessions of the division in addition to presenting papers and topics in the monthly continuing medical education session. The PA maintained a computerized database of operative interventions, coding, morbidities, and outcomes. All were involved in teaching activities. They prepared preoperative and postoperative orders and practice guidelines, and they were also involved in the preparation of the database of institutional clinical research projects. They have presented posters in a total of 9 national and 2 international meetings, and have co-authored 8 manuscripts published in peer review journals. CONCLUSION: The ARNP/PA members have been active participants in all functions of the Division of Pediatric Neurosurgery. They have facilitated the work of the faculty in day-to-day activities and enhanced the scope of divisional activities, providing a team approach for the care of the patients, families, and caretakers.

Initiating, developing and evaluating a comprehensive spinal defects clinic: a clinical report.

OBJECTIVE: The Division of Pediatric Neurosurgery of the University of Florida College of Medicine - Jacksonville developed a multidisciplinary clinic for the better management of pediatric patients with spinal defects. The purpose of this report is to assist neurosurgeons in those regions and countries where there are no spinal defects clinics (SDC). METHODS: We induced a staged process to develop a comprehensive multidisciplinary clinic for pediatric patients with spinal defects: phase I - during December 2003 to June 2004, the organizational planning, multiinstitutional recruitment of health care personnel and location of clinic space occurred; phase II - the SDC sessions initiated in June 2004 and have consequently been held on a monthly basis; phase III - this consisted of a quality improvement program during which parents/caregivers were surveyed. RESULTS: Between June 2004 and February 2009, 139 patients/families were evaluated. Diagnoses included: myelomeningocele (102), lipomeningocele (18), meningocele (1), myelocystocele (3), spina bifida occulta (9), spinal trauma (2), spasticity of cerebral origin (2), spinal arachnoid cyst (1) and syringomyelia (1). During this period, 110 parents/caregivers were questioned on how the SDC assisted in the care of their child. A total of 62% (of 53 responders) indicated the SDC allowed them to be better informed about their child's medical conditions and short/long-term health care plans, 52% stated health care needs were better coordinated than prior to their participation in the SDC, and 26% responded that the initiation of the clinic had reduced their medical care travel. CONCLUSIONS: Pediatric neurosurgeons may take the lead in organizing a multidisciplinary clinic for the betterment of these children. Multidisciplinary care settings facilitate health care delivery and lead to better patient care as perceived by parents/caregivers.

Ultrasound-aided fixation of a biodegradable cranial fixation system: uses in pediatric neurosurgery.

OBJECT: Bioresorbable implant systems have been used in neurosurgery for the rigid fixation of cranial and facial bones. A relatively recent advancement has been the fixation of these implants using an ultrasonic device. The experience with such a device in neurosurgical practice has been limited. The authors report on their experience with ultrasound-aided fixation of bioresorbable implants in pediatric neurosurgical practice. METHODS: The study consisted of 2 parts. The retrospective portion consisted of a chart review of pertinent clinical information, complications, and outcomes after the use of a commercially available ultrasound-aided bioresorbable implant system (SonicWeld Rx, KLS Martin L.P.). Follow-up was obtained in all patients via clinical examination or telephone interview. The prospective portion of the study consisted of video analysis of the implantation technique in a routine craniotomy. Implantation times were measured, and delays during treatment were noted. RESULTS: Over a period of 2 years, 28 consecutive patients underwent placement of these implants for bone fixation during craniotomies or craniofacial reconstructions. The only complication was seen in a child with Crouzon syndrome, who had a wound infection caused by Serratia sepsis from a central venous line infection. There were no repeated operations for implant-related swelling, and no cases of premature plate resorption, bone instability, or settling. In vivo, the average time required to implant a resorbable pin with this system was 22 seconds. CONCLUSIONS: The use of a bioresorbable implant system with ultrasound-aided pin fixation in pediatric neurosurgery cases achieved adequate stability with few complications. This system was easy to use and provided rapid fixation of implants.

Ventriculogallbladder shunts in pediatric patients.

OBJECT: The authors report a clinical protocol for the application of ventriculogallbladder (VGB) shunts in children who may be unable to maintain or receive ventriculoperitoneal (VP) shunts. METHODS: Eighteen patients underwent placement of VGB shunts as an alternative to VP shunt therapy for the following reasons: malfunction of the VP shunt due to suspected failure of the peritoneum to absorb cerebrospinal fluid (17 cases) and multiple intraabdominal general surgical procedures (1 case). The patients ranged in age from 4 months to 17 years (mean 6.5 +/- 6.1 years [standard deviation {SD}]). All patients underwent preoperative imaging of the gall-bladder either by ultrasonography or computed tomography scanning. A team consisting of a pediatric neurological surgeon and a pediatric general surgeon performed all operative procedures. The procedures were conducted by open laparotomy to precisely place the appropriate length of distal catheter and to anchor it to the gallbladder wall. RESULTS: There were 2 early shunt malfunctions, both obstructions due to "sludge" (1 in the biliary duct and 1 in the common bile duct). A late-onset (5-year) malfunction occurred secondary to gallbladder stones. In all 3 cases of malfunction, the devices were successfully converted to VP shunts. In 1 patient a conversion to a VP shunt was chosen following a general surgical intervention. There were 2 shunt infections (Staphylococcus epidermidis and Haemophilus influenzae). These were successfully treated. Two patients underwent conversion to a VGB shunt on 2 occasions. Thirteen patients had functional VGB shunts at the time of their last follow-up assessment. The follow-up for these 13 patients ranged from 1 to 8 years (mean 2.1 +/- 2.0 years [SD]). CONCLUSIONS: Ventriculogallbladder shunts may be considered for the treatment of hydrocephalus in children when the peritoneal cavity cannot be used as a distal terminus.