Minimizing blood transfusions in the surgical correction of coronal and metopic craniosynostosis

OBJECTIVE

The current study was performed to determine the rate of allogeneic blood transfusion for coronal and metopic craniosynostosis surgery done by two experienced pediatric neurosurgeons and to identify factors associated with a need for transfusion.

METHODS

First operations for coronal and metopic craniosynostosis correction in children from 1996 to 2002 were reviewed retrospectively. For analysis, the primary endpoint was defined as either the receipt of a blood transfusion or a postoperative Hb level below 70 g/l, even if no blood was transfused. Univariate and multivariate analyses were done to examine the relationship of attaining the primary endpoint to extent of surgery, surgeons, surgery time, preoperative hemoglobin, craniosynostosis type, weight, and age.

RESULTS

Thirty-two patients were operated on: 17 with unicoronal; 9 with bicoronal, and 6 with metopic craniosynostosis. Median age at operation was 7.5 months. Blood transfusion rates were 0% for unicoronal, 44% for bicoronal, and 33% for metopic synostosis operations. Logistic regression revealed that the best predictor of having a postoperative hemoglobin level of <70 g/l or receiving a blood transfusion was the extent of surgery (beta=1.59, SE(beta)=0.57). The odds of reaching the primary endpoint for extensive surgery over basic surgery was 4.9 [95%CI=(1.6,15.0)]. Once extent of surgery was accounted for in the model, no other covariates significantly improved the model.

CONCLUSIONS

Low transfusion rates were achieved in primary operations for coronal and metopic craniosynostosis using simple intraoperative techniques and by accepting a low postoperative hemoglobin level.

Conservative Neurosurgical Management of Intracranial Epidural Abscesses in Children

OBJECTIVE

Traditional management of epidural abscesses caused by sinusitis in children involves neurosurgical drainage. With better techniques to drain affected sinuses, to identify causative organisms, and to guide medical therapy, some pediatric epidural intracranial abscesses may be treated effectively with sinus drainage and antibiotics, without an intracranial procedure.

METHODS

Charts and computed tomographic scans of children with isolated intracranial epidural abscess associated with sinusitis who were treated in a pediatric hospital were reviewed retrospectively.

RESULTS

Eight patients were treated between 1982 and 2002. All patients received antibiotic therapy appropriate to the causative organism(s). Four patients treated before mid-1997 had an intracranial procedure additionally (operative group, Group 1), and four patients treated thereafter did not (conservative group, Group 2). Abscesses had a mean size of 3 × 3 × 1 cm (length × width × depth) in both groups. All patients experienced clinical and radiographic resolution of the infection with treatment. In Group 1, neurosurgical management consisted of burr hole drainage in two patients and craniotomy in two patients. Extranasal otorhinolaryngological procedures for sinus drainage were performed in two patients. In Group 2, endonasal procedures were used in three patients for paranasal sinus infections to effect drainage and obtain specimens for culture. A radical mastoidectomy was required in the single patient with mastoiditis. Although two of four patients initially demonstrated transient worsening of headaches, all patients subsequently improved rapidly after the first week of treatment. Computed tomographic follow-up revealed minimal or no enlargement of the abscess or mass effect at 1 week, decrease or stable size at 2 weeks, and resolution by 6 weeks.

CONCLUSION

Sinus-related intracranial epidural abscesses in children may be managed without neurosurgical procedures in the setting of adequate sinus drainage, appropriate antibiotic therapy, and minimal extradural mass effect from the abscess. Symptomatic worsening without significant increase in mass effect during the first week of therapy is not necessarily an indication for an intracranial drainage procedure.

Mutism after posterior fossa tumour resection in children: incomplete recovery on long-term follow-up

INTRODUCTION

Mutism after posterior fossa tumour resection is generally said to be transient. Our experience suggested that speech did not usually normalise, and that mutism was associated with neurologic deficits that did not recover fully.

METHODS

Children with mutism after posterior fossa tumour resection, and alive more than 2 years post-operatively, were reviewed retrospectively. Charts were reviewed and parents contacted to ascertain details about mutism, associated neurologic deficits, and the most recent speech and neurologic status.

RESULTS

There were 7 children, with follow-up ranging from 2.5 to 13.1 years (mean 6.8 years). Tumours were midline, with 4 astrocytomas and 3 medulloblastomas. Mutism was noted immediately after post-operative extubation in all patients. Speech reappeared 1-15 weeks post-operatively, except for 1 patient, who remained mute at 2.5 years. Speech returned to normal in only 1 patient. Mutism was always accompanied by new or worsened cerebellar ataxia, which resolved incompletely in the long term. Sixth nerve palsies occurred in 3 and recovered incompletely. Seventh nerve paresis occurred in 2 and recovered completely.

CONCLUSION

Mutism after posterior fossa tumour resection is associated with other neurologic deficits, particularly ataxia. Whereas speech usually returns, contrary to general opinion, speech rarely normalises. Other associated deficits rarely resolve completely. These findings have significant implications for counselling of family and patients.

The influence of surgical operative experience on the duration of first ventriculoperitoneal shunt function and infection

The relationship of surgeon experience, measured by operative volume, to the outcomes of ventricular shunt treatment of hydrocephalus in children is not clear. This paper explores this relationship based on first ventriculoperitoneal shunts (VPS) implanted in English-speaking Canada during the period from April 1989 to March 2001. Three thousand seven hundred and ninety-four first VPS insertions, performed by 254 surgeons, were reviewed. Surgical experience was represented by the number of shunt operations performed during the study period by each surgeon prior to the date of the operation. The 6-month shunt failure risk for less experienced surgeons was 38%, compared to 31% for more experienced surgeons. This difference decreased to 4% at 60 months and 3% at 120 months (p = 0.001). The infection rate for initial shunt insertions was 7% for patients treated by more experienced surgeons and 9.4% for those treated by less experienced surgeons (p = 0.006). A relationship between surgeon experience and shunt outcome that appears to be based on the operative experience that a surgeon brings to a procedure is in keeping with clinical experience. This observation has implications for public policy, service planning and surgical mentorship during the earlier years of a surgeon's career.

Lack of benefit of endoscopic ventriculoperitoneal shunt insertion: a multicenter randomized trial

OBJECT

Endoscopically assisted ventricular catheter placement has been reported to reduce shunt failure in uncontrolled series. The authors investigated the efficacy of this procedure in a prospective multicenter randomized trial.

METHODS

Children younger than 18 years old who were scheduled for their first ventriculoperitoneal (VP) shunt placement were randomized to undergo endoscopic or nonendoscopic insertion of a ventricular catheter. Eligibility and primary outcome (shunt failure) were decided in a blinded fashion. An intention-to-treat analysis was performed. The sample size offered 80% power to detect a 10 to 15% absolute reduction in the 1-year shunt failure rate. The authors studied 393 patients from 16 pediatric neurosurgery centers between May 1996 and November 1999. Median patient age at shunt insertion was 89 days. The baseline characteristics of patients within each group were similar: 54% of patients treated with endoscopy were male and 55% of patients treated without endoscopy were male; 30% of patients treated with and 26% of those without endoscopy had myelomeningocele; a differential pressure valve was used in 51% of patients with and 49% of those treated without endoscopy; a Delta valve was inserted in 38% of patients in each group; and a Sigma valve was placed in 9% of patients treated with and 12% of those treated without endoscopy. Median surgical time lasted 40 minutes in the group treated with and 35 minutes in the group treated without endoscopy. Ventricular catheters, which during surgery were thought to be situated away from the choroid plexus, were demonstrated to be in it on postoperative imaging in 67% of patients who had undergone endoscopic insertion and 61% of those who had undergone nonendoscopic shunt placements. The incidence of shunt failure at 1 year was 42% in the endoscopic insertion group and 34% in the nonendoscopic group. The time to first shunt failure was not different between the two groups (log rank = 2.92, p = 0.09).

CONCLUSIONS

Endoscopic insertion of the initial VP shunt in children suffering from hydrocephalus did not reduce the incidence of shunt failure.

Ventricular shunting for hydrocephalus in children: patients, procedures, surgeons and institutions in English Canada, 1989-2001

INTRODUCTION AND PURPOSE

Ventricular shunting remains the principle and most generally applicable method to treat hydrocephalus in children. This paper describes the demographics of this treatment in English Canada during the period of 1989 to March 2001.

METHODS

Hospital discharge records were obtained for patients less than 18 years who had a shunt inserted or revised. A database was constructed relating patients and procedures to hospital discharges based on scrambled patient identifiers, year of birth, sex, postal code and diagnoses.

OBSERVATIONS

5,947 patients underwent ventricular shunting procedures for hydrocephalus in this period. 261 surgeons working in 73 institutions provided 12,106 interventions (Shunt insertions: ventriculoperitoneal--5009, ventriculoatrial--119, ventriculopleural--28. Revisions: 6,950). Infection was deemed to have occurred in 1,059 procedures. Over the study period, the median number of procedures performed per surgeon per year was 2, with 75 % of surgeons performing 5 or fewer procedures in children per year. Although many surgeons operated on children throughout the thirteen years of the study, many did not acquire substantive cumulative experience. Overall infection rate was 8.6 %. Surgeon infection rates were greater than or equal to 20 % during the first four years of practice and thereafter they fell to and remained in the 10 % range. The mean shunt survival at 12 months of individual surgeons varied between 50 - 60 %, regardless of the number of years of experience of the surgeon; however, performance variability as measured by the standard deviation of 12 month survival rates for all surgeons, adjusted for years of experience, ranged widely until the fifth year of practice. The average number of procedures per year for treating hospitals was 2 with 75 %, providing 12 or fewer services annually. Over the entire study, 50 % of institutions provided 10 or fewer procedures. The mean institutional infection rate was 11.4 % (SD 23, median--6.0).

CONCLUSIONS

Quality monitoring of infection rate and duration of shunt function remains critical as many surgeons and hospitals provide care to children with hydrocephalus infrequently. Variability in infection rates and shunt survival at 12 months are a function of surgeon experience, measured by years in practice. Variability in outcome decreases with increasing surgeon experience.

Reduction of transfusion rates in the surgical correction of sagittal synostosis

Object. As public concern about the risks of blood transfusions increased in the mid-1990s, avoidance of transfusions became a goal of surgery for sagittal synostosis. This study was performed to confirm a hypothesized reduction in transfusion rates in recent years and to identify factors associated with both the need for transfusion and low postoperative levels of hemoglobin.

Methods. Sagittal synostosis operations performed in children between 1986 and 1999 were reviewed retrospectively. Patients underwent a minimum of vertex strip craniectomy and parietal craniectomies. There were 118 patients whose median age at surgery was 4.2 months. The primary end point for analysis was defined as either the receipt of a blood transfusion or a postoperative level of hemoglobin less than 70 g/L. Forty-two percent of patients (95% confidence interval [CI] 31–52%) treated before 1996 and 11% of patients (95% CI 0–23%) treated from 1996 onward received blood. The reduction in the blood transfusion rate in later years was, in part, related to the acceptance of a lower postoperative hemoglobin level, often below 70 g/L. A univariate analysis showed that the only patient or surgical factors that correlated with reaching the primary end point in a statistically significant manner were the year of surgery and the extent of surgery. A logistic regression of the age and weight of the child, length of surgery time (from skin opening to skin closure), preoperative hemoglobin level, extent of surgery, and surgeon against the primary end point revealed that the best predictor of the need for a blood transfusion or the presence of a postoperative hemoglobin level lower than 70 g/L was the extent of surgery (β = 1.4, standard error of the β statistic = 0.44). Once the extent of surgery was accounted for in the model, no other covariates significantly improved the model.

Techniques implemented to minimize blood loss since 1995 included the following: use of the Colorado needle for scalp incision, selection of the Midas Rex craniotome for cranial cuts, and application of microfibrillar collagen. Postoperative hemoglobin was allowed to decrease to 60 g/L if the child was stable hemodynamically, before blood was administered. There were no cardiovascular, wound healing, or infectious complications, and no surgeries were repeated for cosmetic reasons.

Conclusions. Low blood transfusion rates were achieved using simple intraoperative techniques and by accepting a low level of postoperative hemoglobin.

A cost-effectiveness analysis of endoscopic third ventriculostomy

OBJECTIVE

Endoscopic third ventriculostomy (ETV) is currently the principal alternative to cerebrospinal fluid shunt placement in the management of pediatric hydrocephalus. Cost-effectiveness analysis can help determine the optimal strategy for integrating these different approaches.

METHODS

All patients (n = 28) who underwent ETV at British Columbia's Children's Hospital between 1989 and 1998 were matched for age, pathogenesis, and number of previous shunt procedures, with patients treated with cerebrospinal fluid shunts. To perform a cost-effectiveness analysis, hydrocephalus-related resource consumption and outcome (determined as the number of hydrocephalus treatment-free days during follow-up) were then retrospectively identified. Cost data were linked to resource use to provide a total cost for all resources used. Costs and outcomes were discounted annually at 5% by standard economic analysis methods.

RESULTS

Twenty-four of 28 ETV patients had obstructive hydrocephalus. Over equivalent follow-up periods (median, 35 mo), the ETV success rate (defined by need for reoperation) was 54%. One hydrocephalus-related death and one hemiparesis occurred in the ETV group. No permanent procedure-related morbidity or mortality was seen in the shunt group. The cost/effect ratios for the two groups were similar. The additional incremental resource use by the shunt group included six readmissions and eight reoperations. ETV mean costs per patient were $10,570 +/- $7628, versus $10,922 +/- $8722 for the shunt group (Canadian dollars for the year 2000). Costs accrued more quickly for the shunt group as time passed. The additional incremental outcome benefit to the endoscopy group was 86 treatment-free days (3.07 d per patient [95% confidence interval, -7.56 to 13.70 d]). Neither of these differences was statistically significant.

CONCLUSION

In this matched cohort, ETV was not significantly less costly or more effective over a median 35 months of follow-up, with a 54% initial ETV success rate, even before the additional morbidity and mortality encountered were taken into account. The time course for the accrued costs suggests that a larger cohort, longer follow-up, or higher success rates are needed to demonstrate the cost-effectiveness of this therapy.

Management of optic chiasmatic/hypothalamic astrocytomas in children

OBJECTIVE

The management of optic chiasmatic gliomas is controversial, partly related to failure to separate out those tumors involving the optic chiasm only (chiasmatic tumors) from those also involving the hypothalamus (chiasmatic/hypothalamic tumors). The purpose of this study was: (i) to analyze the outcomes of chiasmatic and chiasmatic/hypothalamic tumors separately; and (ii) to determine the appropriateness of recommending radical surgical resection for the chiasmatic/hypothalamic tumors.

METHODS

A retrospective chart review of all newly diagnosed tumors involving the optic chiasm from 1982-1996 at British Columbia's Children's Hospital was performed.

RESULTS

There were 32 patients less than 16 years of age, 14 with chiasmatic and 18 with chiasmatic/hypothalamic astrocytomas, with an average duration of follow-up of 5.8 years and 6.3 years, respectively. Ten of the patients with chiasmatic tumors and none with chiasmatic/hypothalamic tumors had neurofibromatosis I. Thirteen of the 14 chiasmatic tumors were managed with observation only, and none had progression requiring active intervention. For the chiasmatic/hypothalamic tumors, eight patients had subtotal resections (>95% resection), six had partial resections (50-95%), three had limited resections (<50%), and one had no surgery. There were fewer complications associated with the limited resections, especially with respect to hypothalamic dysfunction. There was no correlation between the extent of resection (subtotal, partial, or limited) and the time to tumor progression (average 18 months).

CONCLUSIONS

In conclusion, chiasmatic and chiasmatic/hypothalamic tumors are different entities, which should be separated out for the purposes of any study. For the chiasmatic/hypothalamic tumors, there was more morbidity and no prolongation of time to progression when radical resections were compared to more limited resections. Therefore, if surgery is performed, it may be appropriate to do a surgical procedure that strives only to provide a tissue diagnosis and to decompress the optic apparatus and/or ventricular system.

Clinical outcomes that fetal surgery for myelomeningocele needs to achieve

INTRODUCTION

The development of techniques to close open neural tube malformations prior to birth has generated great interest and hope for fetal interventions and their outcomes. To plan a randomized trial, as is being discussed at three centres in the United States, the determination of what constitutes a clinically significant improvement in outcome is critical. To date, preliminary observations from two centres suggest that improvements may occur, not in spinal cord function as originally postulated, but in the extent of the hindbrain hernia and the frequency that shunting is required to control hydrocephalus.

PURPOSE

The determination of what outcome would constitute an important and clinically significant difference in outcome to be achieved by fetal intervention for myelomeningocele.

METHOD

Parents of patients and patients treated in our myelomeningocele clinic were surveyed using a structured and validated tool. From the perspective of a recommendation to a close friend or family member, the interviewees were asked to quantify on a scale from 0 to 100 the chance of specific outcomes (need for a shunt, need for a wheelchair, change of urinary incontinence) that a fetal operation would need to predictably achieve.

RESULTS

Responses were obtained from 77 patients/families. The fifty percentile response in each study dimension was as follows: the chance of needing a shunt was 12 % (range 0 - 50 %), the chance of needing a wheelchair was 8 % and the chance of being incontinent was 5 % (range 0 - 25 %).

CONCLUSIONS

Fetal interventions will have to achieve significant improvements in the control of hydrocephalus, mobilization and continence over postnatal treatment to be justified.

The patterns of late deterioration in patients with transitional lipomyelomeningocele

INTRODUCTION

Tethering is assumed to be the primary cause of deterioration seen in children with transitional lipomyelomeningocele as they age. The inevitability of deterioration has led to recommendations for prophylactic interventions to stabilize or prevent further clinical deterioration.

OBJECTIVE

Determine the frequency and patterns of functional deterioration observed after successful untethering in patients with transitional lipomyelomeningocele and compare functional outcomes with what is known regarding untreated patients.

METHODS

Fifty patients having transitional LMMC, treated at a single institution and followed in a multidisciplinary clinic were retrospectively reviewed to determine their clinical status prior to untethering, and the time to development of new symptoms or signs following untethering.

RESULTS

82% of patients were diagnosed and 78% underwent untethering prior to one year of age. All patients had a cutaneous lumbosacral lipoma, 22 patients were considered normal at presentation and 28 showed abnormalities on clinical examination. Forty-nine patients were untethered successfully and all were available for follow-up ranging from 2 to 138 months (mean 39 months). Acute morbidity was limited to transient neurogenic bladder dysfunction and minor wound complications. Late clinical deterioration occurred in the majority of patients. Orthopedic and neurological deterioration occurred over the first 60 months following untethering and urological deterioration occurred thereafter.

CONCLUSIONS

Functional loss after untethering is common and the pattern of loss is likely a reflection of the ability to detect abnormalities in this infant population. Untethering does not usually result in permanent acute morbidity, and does not prevent longer-term functional deterioration. The ratio of asymptomatic to symptomatic patients at follow-up in this operative series is similar to age-matched historical series of untreated patients.

Cervical myelocystoceles and meningoceles: long-term follow-up

Little is known about the long-term prognosis of patients with cervical myelocystoceles and meningoceles. In this study, we report the long-term follow-up (average 10 years and 8 months) of 8 patients with cervical myelocystoceles and meningoceles. Neurologic, orthopedic, urologic and psychosocial status was assessed on long-term follow-up. The results indicate that in patients with cervical myelocystoceles, neurologic deficits become noticeable in the first year of life as the infant matures. Motor deficit was common in these patients, whereas sensory and urologic deficits did not occur. We believe that this is related to underlying myelodysplasia. In addition, patients with cervical myelocystoceles tend to have significant orthopedic problems. In contrast, patients with cervical meningoceles do not have neurologic deficits, but do develop mild orthopedic problems.

Spontaneous resolution and recurrence of a Chiari I malformation and associated syringomyelia. Case report

The spontaneous resolution of syringomyelia has been reported infrequently. In patients with Chiari I malformations, resolution of the syringomyelia has sometimes been associated with improvement of their malformation. The authors present a case of spontaneous resolution followed by recurrence of syringomyelia and a corresponding change in the Chiari malformation. This case is of interest in light of the theories postulated to explain spontaneous resolution of syringomyelia.

Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus

OBJECTIVE

Forty percent of standard cerebrospinal fluid shunts implanted for the treatment of pediatric hydrocephalus fail within the first year. Two new shunt valves designed to limit excess flow, particularly in upright positions, were studied to compare treatment failure rates with those for standard differential-pressure valves.

METHODS

Three hundred-forty-four hydrocephalic children (age, birth to 18 yr) undergoing their first cerebrospinal fluid shunt insertion were randomized at 12 North American or European pediatric neurosurgical centers. Patients received one of three valves, i.e., a standard differential-pressure valve; a Delta valve (Medtronic PS Medical, Goleta, CA), which contains a siphon-control component designed to reduce siphoning in upright positions; or an Orbis-Sigma valve (Cordis, Miami, FL), with a variable-resistance, flow-limiting component. Patients were monitored for a minimum of 1 year. Endpoints were defined as shunt failure resulting from shunt obstruction, overdrainage, loculations of the cerebral ventricles, or infection. Outcome events were assessed by blinded independent case review.

RESULTS

One hundred-fifty patients reached an endpoint; shunt obstruction occurred in 108 (31.4%), overdrainage in 12 (3.5%), loculated ventricles in 2 (0.6%), and infection in 28 (8.1%). Sixty-one percent were shunt failure-free at 1 year and 47% at 2 years, with a median shunt failure-free duration of 656 days. There was no difference in shunt failure-free duration among the three valves (P = 0.24).

CONCLUSION

Cerebrospinal fluid shunt failure, predominantly from shunt obstruction and infection, remains a persistent problem in pediatric hydrocephalus. Two new valve designs did not significantly affect shunt failure rates.

Functional deterioration following placode untethering in myelomeningocele

Placode untethering in myelomeningocele patients can result in improvement and/or stabilization of neurological function, spinal curvature and pain. This paper reviews the outcome of untethering procedures in 24 patients to determine the frequency of subsequent functional deterioration. Decreased range of movement, joint stiffness and changes in muscle tone were the commonest indications for surgical intervention, occurring in 15 patients. Untethering resulted in improvement in 8 patients, stabilization of progression in 6 and continued deterioration in 1 patient. Two patients previously untroubled with spasticity became symptomatic within 3 months of the procedure. Changes in ambulation were present preoperatively in 9 patients. Stabilization was observed in 4 and improvement in 5. One of the patients, who had improved, deteriorated during the 1st year of follow-up. Alterations in bladder capacity and continence occurred in 7 patients. Improvement was seen in 2 patients, deterioration in 2 and no change in 3. Of the patients who improved, 1 subsequently deteriorated again within the 2nd postoperative year. Of those patients who had stable bladder function preoperatively, 6 subsequently deteriorated despite untethering. Pain was a less frequent symptom, occurring in 6 patients. Six patients became pain-free within 3 months of untethering. Two patients who did not have pain preoperatively had pain at the operative site persisting for up to 3 months postoperatively. Of the 20 patients having a single untethering procedure to date, 11 have further symptoms that can be attributed to retethering.

Intrathecally administered baclofen for treatment of children with spasticity of cerebral origin

Management of severe spasticity in children is often a difficult problem. Orally administered medications generally offer limited benefits. This study examines the value of intrathecally administered baclofen in the treatment of 19 children with severe spasticity of cerebral origin: eight of whom sustained brain injury associated with trauma, near drowning, or cardiac arrest; 10 with cerebral palsy (spastic quadriplegia); and one child with Leigh's disease. At the time of entry into the study, patients ranged from 4 to 19 years of age, and all were completely dependent on caretakers for activities of daily living. Children who responded positively to a trial dose of intrathecal baclofen underwent insertion of a drug delivery system for continuous infusion. This was followed by a double-blind trial of baclofen or placebo and follow-up review at 3 and 6 months, and yearly thereafter. Seven children did not undergo pump implantation because of excess sedation or poor response. The 12 remaining children have been followed for a period of 1 to 5 years. Favorable responses were present in all 12 children as determined by the Ashworth Scale, with the greatest benefit being reduction of lower limb tone. Except in the case of one child who had reduction in lower limb tone that resulted in difficulty with transfers, the caretakers all reported significant benefits from intrathecal baclofen, with improvement in muscle tone, behavior, sitting, and general ease of care being most commonly noted. Central side effects were seen in some children who received continuous intrathecal baclofen infusion and included hypotension (two patients), bradycardia (two), apnea or respiratory depression (two), and sedation (one). During a total of 568 months of pump operation there were 10 mechanical complications, including two related to pump or side port failure and eight related to catheter kinks, extrusions, or dislodgment. Pump pocket effusion occurred in five children and a cerebrospinal fluid fistula was seen in one child. Local infection occurred in three children and meningitis in two children. The results demonstrate the potential value of continuous intrathecal baclofen infusion for treatment of severe spasticity of cerebral origin. However, this treatment can result in significant complications and more experience is required before the long-term benefits can be determined.

A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy

A randomized controlled single-blind trial was performed to compare lumbo-sacral selective posterior rhizotomy (SPR) followed by intensive physiotherapy, with intensive physiotherapy alone in improving motor function in children with spastic diplegic cerebral palsy. Fifteen patients were randomly assigned to each treatment modality. Patients in the SPR group had rhizotomy within 1 month, followed by intensive outpatient physiotherapy for 9 months. Patients assigned to physiotherapy alone had identical intensive physiotherapy. There was a statistically significant and clinically important difference in improvement in motor function in favor of the SPR group, with a mean increase in total Gross Motor Function Measure (GMFM) score of 11.3% at 9 months for the SPR group compared with 5.2% for the physiotherapy-only group (P = 0.007). Significant improvements in spasticity (P < 0.001) and range of movement (P < 0.001) were noted in the SPR group compared to the physiotherapy-only group. The results indicate that the improvement in motor function after SPR is more than can be explained by the associated intensive physiotherapy.

Value of postoperative surveillance imaging in the management of children with some common brain tumors

The rationale for obtaining surveillance computerized tomography (CT) scans or magnetic resonance (MR) images in pediatric patients with brain tumors is that early detection of recurrence may result in timely treatment and better outcome. The purpose of this study was to investigate the value of surveillance cranial images in a variety of common pediatric brain tumors managed at a tertiary care pediatric hospital. A retrospective chart review was performed of children with astrocytoma of the cerebral hemisphere, cerebellum, optic chiasm/hypothalamus, or thalamus; cerebellar or supratentorial high-grade glioma; supratentorial ganglioglioma; posterior fossa or supratentorial primitive neuroectodermal tumor (PNET); and posterior fossa ependymoma. Data were analyzed to determine the frequency with which recurrences were identified on a surveillance image and how the type of image at which recurrence was identified related to outcome. In 159 children, 17 of 44 recurrences were diagnosed by surveillance imaging. The percentage of recurrences identified by surveillance imaging was 64% for ependymoma, 50% for supratentorial PNET, 43% for optic/hypothalamic astrocytoma, and less than 30% for other tumors. The rate of diagnosis of recurrence per surveillance image varied from 0% to 11.8% for different tumor types. Only for ependymomas did there appear to be an improved outcome when recurrence was identified prior to symptoms. Our results indicate that, using the protocols outlined in this study, surveillance imaging was not valuable in identifying recurrence of cerebellar astrocytoma or supratentorial ganglioglioma during the study period, but was probably worthwhile in identifying recurrence of posterior fossa ependymoma and optic/hypothalamic astrocytoma and, possibly, medulloblastoma. Surveillance protocols could be made more effective by individualizing them for each type of tumor, based on current data on the patterns of recurrence.