Hypoglossal-facial anastomosis

Neurosurgical management of conus lipoma in Canada: a multi-center survey

OBJECT

Lipomyelomeningocele (LMM) is a congenital spinal cord anomaly. While patients with LMM may initially be asymptomatic, neurological sequelae secondary to LMM may become apparent as the patient ages. Consequently, some pediatric neurosurgeons have advocated for upfront neurosurgical interventions irrespective of the presence of symptoms at diagnosis. By contrast, others pursue a conservative approach when overt neurological symptoms are not yet evident. In light of the various practice styles to the heterogeneous anatomical locations, symptoms, and ages associated with LMM, we have conducted a multi-center survey of Canadian pediatric neurosurgeons using clinical vignettes representative of LMM patients.

METHODS

An online survey of the opinions of Canadian pediatric neurosurgeons was conducted using 5 separate cases with magnetic resonance imaging (MRI) scans of the lumbar spine. Each case was accompanied with the same three clinical vignettes, which varied in severity at time of presentation: asymptomatic, progressive somatic motor deficit, or longstanding overflow incontinence. Participants were asked the question, "Would you offer surgical management?" after each clinical vignette. After the five cases and their corresponding 3 clinical vignettes, participants were asked, "If you answered yes to any of the preceding questions, what type of surgery would you perform?". Options for surgical goals and techniques included complete removal, near-total removal, debulking, detethering, and expansile duroplasty. Surgical adjuncts included CUSA, LASER, and neurophysiologic monitoring.

RESULTS

Twenty-three responses were received from the 38 questionnaires sent out to all staff pediatric neurosurgeons across academic medical centers in Canada. This represented a response rate of 61%. Canadian pediatric neurosurgeons generally maintain a conservative approach to the surgical management of LMM as only 13% (n = 3) of surgeons indicated that they would operate in all scenarios. By contrast, 43% (n = 10) indicated surgical management in only those cases presenting with symptoms, and another 43% (n = 10) displayed a variable surgical approach. Nine percent (n = 2) of participants would not perform surgery for incontinence. The greatest level of disagreement among participants pertained to the management of asymptomatic sacral LMM where 43% of participants favored prophylactic surgery, while 57% of participants preferred conservative management.

CONCLUSIONS

The current study highlights the differences in management of LMM among Canadian pediatric neurosurgeons and provides further support for future prospective cohort studies to develop appropriate expert opinions and guidelines such that the care of LMM patients may be according to evidence-based best practice. This is especially true for the treatment of asymptomatic patients, a patient group that would benefit from a randomized controlled trial to assess the long-term outcomes of conservative and surgical management.

A comparative retrospective study: hypoglossofacial versus masseterofacial nerve anastomosis using Sunnybrook facial grading system

INTRODUCTION

The aim of our study is to compare the functional results between two surgical techniques for reanimation of facial paralysis: hypoglossal-to-facial versus masseteric-to-facial nerve anastomosis.

METHODS

This is a retrospective study of 13 patients treated for complete facial paralysis in two medical tertiary centers. The patients were classified into two groups. First group: masseteric-to-facial nerve anastomosis. Second group: hypoglossofacial nerve anastomosis. Sunnybrook facial grading system was used to evaluate the functional results. The mean scores were compared using Mann-Whitney test. The correlation between the age at surgery, the delay in time from the onset of the facial paralysis to the time of surgery and the results of Sunnybrook scores was studied using correlation and linear regression.

RESULTS

No significant statistical difference was found between the mean of total score of the two groups (first group = 38 ± 4.898, second group = 37.83 ± 4.956). All the patients treated by hypoglossofacial nerve anastomosis presented with hemiglossal atrophy. We found slight superiority for the masseterofacial nerve anastomosis in dynamic movements, whereas at rest the hypoglossofacial anastomosis is slightly better. All the differences were not statistically significant. No correlation was found between the age at surgery (age range included 32-73 years) and post-operative results. No correlation was found between the delays up to 24 months from the onset of the facial paralysis and post-operative results.

CONCLUSION

Our study showed that both types of anastomosis are effective with comparable results. The masseterofacial nerve anastomosis is preferred when possible to avoid the hemiglossal atrophy and its complications.

Pre- and postnatal imaging of Pai syndrome with spontaneous intrauterine closure of a frontal cephalocele

Pai syndrome is a rare congenital disorder characterized by cutaneous polyps of the face, pericallosal lipoma and median cleft lip. We report on a newborn girl with a variant of Pai syndrome presenting with all typical findings except a median cleft. In addition, fetal sonography and MRI showed the unique intrauterine evolution of a cephalocele into an atretic cephalocele.