The Use of Distraction Osteogenesis in the Treatment of Rickets-Associated Craniosynostosis.

BACKGROUND: Craniosynostosis has a known association with rickets. Because of abnormal bone development and a tendency for patients with rickets to present at an older age than most patients with craniosynostosis, repair may be complicated by inadequate cranial expansion and greater risk of sutural re-fusion. We present 2 cases of rickets-associated sagittal craniosynostosis and show the effectiveness of distraction osteogenesis in the surgical management of this condition. CASE DESCRIPTION: Two 3-year-old boys with rickets presented with sagittal synostosis and marked scaphocephalic deformity. Cranial osteotomies were performed followed by placement of 2 internal distractors. The devices were activated daily for 30 days to achieve a target transverse cranial distraction of 30 mm. A subsequent period of 10-12 weeks allowed for adequate bone consolidation. At the time of device removal, the final breadth of distraction and the quality of new bone formed was assessed. Distraction distance in both cases was verified intraoperatively to be 30 mm. Clinical examination confirmed that the distraction gaps were bridged by solid bone. The treatment protocol resulted in a significant improvement in cranial proportion in both patients, which was maintained at long-term follow-up. Estimated blood loss was high in both cases, presumably related to the hyperemic nature of rickets bone. CONCLUSIONS: Distraction osteogenesis promotes bone growth and cranial remodeling in patients with craniosynostosis caused by rickets. The technique allows for continuous incremental expansion of both bone and scalp tissue. We recommend consideration of distraction osteogenesis in the treatment of older children with severe deformity related to craniosynostosis, including those with rickets.

A prospective natural history study of nonoperatively managed Chiari I malformation: does follow-up MRI surveillance alter surgical decision making?

OBJECT Chiari malformation Type I (CM-I) in children is a common incidental finding. Resolution of cerebellar tonsil ectopia has been reported, but no studies have followed tonsil position over regular intervals throughout childhood. To better elucidate the clinical and radiological natural history of CM-I in children, the authors prospectively followed up children with nonoperatively managed CM-I for up to 7 years. METHODS The study included all children evaluated for CM-I over a period of 12 years for whom surgery was not initially recommended. The study excluded patients with associated conditions, including syringomyelia and hydrocephalus. For all patients, initial management was nonoperative, and follow-up management consisted of annual cervical spine or brain MRI and clinical examination. At each follow-up examination, the neurological examination findings, subjective symptoms, and the position of the cerebellar tonsils on MR images were recorded. An alteration in tonsillar descent of 2 mm or greater was considered a change. RESULTS Neurological examination findings did not change over the course of the study in the 52 children who met the inclusion criteria. Although radiological changes were common, no surgeries were performed solely because of radiological change. Overall, tonsil position on radiological images remained stable in 50% of patients, was reduced in 38%, and increased in 12%. Resolution was seen in 12% of patients. Radiological changes in tonsil position were seen during every year of follow-up. On average, in any given year, 24% of images showed some form of change in tonsil position. A total of 3 patients, for whom no changes were seen on MR images, ultimately underwent surgery for subjective clinical reasons. CONCLUSIONS CM-I in children is not a radiologically static entity but rather is a dynamic one. Radiological changes were seen throughout the 7 years of follow-up. A reduction in tonsillar descent was substantially more common than an increase. Radiological changes did not correlate with neurological examination finding changes, symptom development, or the need for future surgery. Follow-up imaging of asymptomatic children with CM-I did not alter treatment for any patient. It would be reasonable to follow these children with clinical examinations but without regular surveillance MRI.

Postoperative Mycoplasma hominis infections after neurosurgical intervention.

OBJECT: Mycoplasma hominis is a rare cause of infection after neurosurgical procedures. The Mycoplasma genus contains the smallest bacteria discovered to date. Mycoplasma are atypical bacteria that lack a cell wall, a feature that complicates both diagnosis and treatment. The Gram stain and some types of culture media fail to identify these organisms, and typical broad-spectrum antibiotic regimens are ineffective because they act on cell wall metabolism. Mycoplasma hominis commonly colonizes the genitourinary tract in a nonvirulent manner, but it has caused postoperative, postpartum, and posttraumatic infections in various organ systems. The authors present the case of a 17-year-old male with a postoperative intramedullary spinal cord abscess due to M. hominis and report the results of a literature review of M. hominis infections after neurosurgical procedures. Attention is given to time to diagnosis, risk factors for infection, ineffective antibiotic regimens, and final effective antibiotic regimens to provide pertinent information for the practicing neurosurgeon to diagnose and treat this rare occurrence. METHODS: A PubMed search was performed to identify reports of M. hominis infections after neurosurgical procedures. RESULTS: Eleven cases of postneurosurgical M. hominis infection were found. No other cases of intramedullary spinal cord abscess were found. Initial antibiotic coverage was inadequate in all cases, and diagnosis was delayed in all cases. Multiple surgical interventions were often needed. Once appropriate antibiotics were started, patients typically experienced rapid resolution of their neurological symptoms. In 27% of cases, a suspicious genitourinary source other than urinary catheterization was identified. CONCLUSIONS: Postoperative M. hominis infections are rarely seen after neurosurgical procedures. They are typically responsive to appropriate antibiotic therapy. Mycoplasma infection may cause prolonged hospitalization and multiple returns to the operating room due to delay in diagnosis. Early clinical suspicion with appropriate antibiotic coverage could help prevent these significant complications.

Confocal microscopy for the histological fluorescence pattern of a recurrent atypical meningioma: case report.

BACKGROUND AND IMPORTANCE: Fluorescence-guided resection with 5-aminolevulinic acid (5-ALA), which has shown promising results in the resection of malignant gliomas, has been used for meningioma resection in an attempt to more clearly delineate the tumor margin. However, no article has investigated the fluorescence pattern of meningiomas on a histological level. Understanding the microscopic pattern of fluorescence could help assess the precision and utility of using 5-ALA for these tumors. We present the case of a recurrent atypical meningioma operated on with 5-ALA fluorescence-guided resection for delineation of tumor tissue from surrounding uninvolved dura. CLINICAL PRESENTATION: A 53-year-old woman presented with recurrent atypical meningioma of the falx. Prior treatment included surgical resection 6 years earlier with subsequent fractionated radiation therapy and radiosurgery for tumor progression. The patient was given 5-ALA 20 mg/kg body weight dissolved in 100 mL water 3 hours before induction of anesthesia. Intraoperative fluorescence was coregistered with preoperative imaging. Neuropathological analysis of the resected falx with confocal microscopy enabled correlation of fluorescence with the extent of tumor on a histological level. CONCLUSION: Fluorescence guidance allowed clear intraoperative delineation of tumor tissue from adjacent, uninvolved dura. On a microscopic level, there was a very close correlation of fluorescence with tumor, but some tumor cells did not fluoresce.