Transumbilical approach for shunt insertion in the pediatric population: an improvement in cosmetic results

Objective In spite of the recent interest in endoscopic third ventriculostomy, ventriculoperitoneal (VP) shunt is still the gold standard in treating non-obstructive hydrocephalus in children. The peritoneal cavity remains the optimal site for cerebrospinal fluid (CSF) diversion. Shunt insertion and re-interventions carry a high risk of inaesthetic abdominal scars and long-term morbidity. We report a technique of transumbilical shunt insertion, which provides better cosmetic results and without many more complications. This approach has been performed for a long period in a wide variety of intra-abdominal conditions by pediatric surgeons.Methods Between March and October 2003, we inserted 12 VP shunts in children. For eight consecutively treated children the follow-up is more than 3 months. All the shunts were inserted through the umbilicus. These eight children are the subjects of this study. Indications for shunting were: communicating hydrocephalus (6 cases), subdural hematoma (1 case), and hygroma associated with an arachnoid cyst (1 case). The population consisted of 7 boys and 1 girl, ranging in age between 6 weeks and 47 months (mean age: 15 months), and their body weights varied between 2,110 g and 18,000 g (mean weight: 8,470 g). All children were examined twice a day for 3 days, and wounds were examined daily to check for the absence of sepsis or dehiscence. Clinical controls were performed 1 month after discharge. The operating surgeon was invited to comment on any difficulties encountered in making or closing this incision afterwards.Results The average length of clinical follow-up was 6 months (range 4–7 months). One infection of the VP shunt occurred. It was treated with external drainage and antibiotics. After 1 week, a second VP shunt was inserted using the same technique without particular difficulty and with a nice cosmetic result. Concerning the seven other children, the cosmetic results were optimal, with no puckered abdominal scars or wound dehiscence, and with no perioperative or long-term complications related to the umbilical approach.Conclusion At this early follow-up, umbilical incision for shunt insertion is a safe and easy technique. It provides an optimal cosmetic result, even in cases of re-intervention. This minimally invasive surgery does not require long specialized training. We have not shown an increase in complications associated with a learning curve. Longer follow-up is needed to evaluate the risk of infection.     

Deep brain stimulation for refractory obsessive-compulsive disorder.

BACKGROUND: Neurosurgery (anterior capsulotomy) has been beneficial to many patients with debilitating, refractory obsessive-compulsive disorder (OCD), but the irreversibility of the procedure is an important limitation to its use. Nondestructive, electrical stimulation (deep brain stimulation; DBS) has proven an effective alternative to ablative surgery for neurological indications, suggesting potential utility in place of capsulotomy for OCD. METHODS: The effects of DBS for OCD were examined in four patients in a short-term, blinded, on-off design and long-term, open follow-up. The patients had incapacitating illness, refractory to standard treatments. Hardware developed for movement disorder treatment was surgically implanted, with leads placed bilaterally in the anterior limbs of their internal capsules. Patients received stimulation in a randomized "on-off" sequence of four 3-week blocks. Ongoing, open stimulation was continued in consenting patients after the controlled trial. RESULTS: Patients tolerated DBS well. Dramatic benefits to mood, anxiety, and OCD symptoms were seen in one patient during blinded study and open, long-term follow-up. A second patient showed moderate benefit during open follow-up. CONCLUSIONS: It appears that DBS has potential value for treating refractory psychiatric disorders, but additional development work is needed before the procedure is utilized outside of carefully controlled research protocols.     

The modernization of pediatric neurosurgery

Introduction It might be presumed that the discipline of pediatric neurosurgery is as youthful as the patients it serves. But this subspecialty of neurosurgery is at least 50 years old.Discussion This 2003 Donald D. Matson Memorial Lecture will examine the growth and development of childrens neurosurgical care from the aspects of its identity and continuing educational activity, the impact of technology, outcome measures, and the role of public advocacy.Presented at the Pediatric Sections of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, San Diego, Calif., 30 April 2003     

C-reactive protein levels following standard neurosurgical procedures

Summary ¶Background. The aim of the present study was to establish the magnitude and time-course of C-reactive protein increases following routine neurosurgical procedures in the absence of clinical and laboratory signs of infection. Method. C-reactive protein levels were studied daily following ventriculo-peritoneal shunt implantation, anterior cervical fusion, vestibular schwannoma operation, supratentorial glioma surgery, endovascular intracranial aneurysm treatment and open cerebral aneurysm surgery. Findings. The magnitude of the C-reactive protein increase depended on the extent of surgical trauma and peak-levels were recorded between postoperative day one and four after which the levels tapered off. Interpretation. Increases occurring after the fourth postoperative day are likely to be caused by complications of surgery, e.g. infection.Published online July 23, 2003     

Risk factors for the occurrence of chronic subdural haematomas after neurosurgical procedures

Summary ¶Chronic subdural haematoma (CSDH) is a rare clinical complication of neurosurgical procedures. CSDH occurs sporadically after aneurysm clipping surgery and revascularisation surgery but the risk factors are not known. The present study reviewed 6613 consecutive neurosurgical procedures performed from January 1987 to July 2001, and identified 621 cases of CSDH. Fifty of these 621 cases had a past history of neurological disorders treated by neurosurgery. This study evaluated these 50 cases in order to elucidate the clinical and radiological characteristics of CSDH after neurosurgery and to investigate the etiology for identifying in the risk factors of CSDH as a postoperative complication. The incidence of CSDH after neurosurgery was 0.8% (50/6613). Twenty-seven of the 50 patients with a past history of neurosurgery had undergone aneurysm clipping surgery. The incidence after clipping surgery was 2.4%. Twelve of these 27 cases also underwent ventriculoperitoneal shunting. Three patients had postoperative CSDH after arachnoid cyst opening and/or shunting. The incidence was highest at 7.5%. Three patients had postoperative CSDH after brain tumour surgery. The incidence was low at 0.4%. However, the ventricular cerebrospinal fluid (CSF) space was opened during tumour removal in 2 of these 3 patients.Communication of the subarachnoid space to the subdural space is considered to be one of the causative factors and excessive CSF shunting facilitates formation of CSDH after neurological surgery. Repair of arachnoid tearing during neurosurgery and avoidance of excessive CSF shunting may reduce the risk of CSDH after neurosurgery.Published online May 19, 2003     

CSF shunt infections in children: experiences from a population-based study

Summary.  The objective was to identify risk factors for shunt infections, and establish the rate of infection for shunt procedures carried out under standardized conditions in a well-defined population. All (407) paediatric shunt operations (primary and revisions) performed within a total population of 630000 inhabitants between January 1, 1986 and December 31, 1996, were analysed retrospectively. 11 shunt infections were diagnosed in 10 patients, giving an overall infection rate of 2.7% per procedure and 6.2% per patient. Infections were significantly correlated with age, type of operation, and a etiology of hydrocephalus. Thus, infections occurred more frequently during the first 6 months of life, more often following primary shunt insertions compared with revisions, and children with myelomeningocele had a higher infection risk than children with hydrocephalus due to other causes. There was a highly significant male preponderance in the patient material.  Conclusion: The overall infection rate was relatively low. The risk factors for shunt infections appear to relate to epidemiological characteristics rather than to surgical factors. Published online April 28, 2003  Correspondence: Professor Knut Wester, Department of Neurosurgery, Haukeland University Hospital, N 5021 Bergen, Norway.     

Early antithrombotic prophylaxis with low molecular weight heparin in neurosurgery

Summary> ¶Background. Despite the high risk of venous thromboembolic events (VTE) in neuro-surgical patients, heparin prophylaxis has not been routinely established due to concern about bleeding complications. After initiating early low molecular weight heparin (LMWH) prophylaxis, we reviewed our patients in order to examine the viability of this practice. Method. Over a 3 year period, the records of patients admitted for elective neuro-surgery (ES), head injury (HI) or spontaneous intracranial haemorrhage (ICH) were analysed. Prophylaxis was performed with certoparin (3000 U anti-factor Xa s.c.) on the evening before ES and within 24 hours after surgery or admission whenever a CT did not show a progress-sive haematoma. Contraindications for LMWH were prothrombin time <70%, partial thrombo-plastin time >40s, platelet count <100.000/ml, and platelet aggregation test sum <60%. The incidence of bleeding complications, VTE, and resulting morbidity/mortality was assessed. Findings. 294 patients were admitted for ES, 344 for HI, and 302 for ICH. 155 of these were excluded because of contraindications. Intracranial bleeding was recorded in 1.5% (ES 1.1%, HI 3.5%, ICH 0%) and operative revision was performed in 1.1% (ES 0.7%, HI 2.8%) of patients. One case of moderate disability and no mortality occurred. The incidence of VTE and pulmonary embolism was documented in 0.2% and 0.1% of patients, with no associated mortality. No heparin induced thrombocytopenia was observed. Interpretation. In neurosurgical patients, antithrombotic prophylaxis with certoparin was determined to be safe and efficacious when contraindications are carefully considered and a 12-hour time interval before and after surgery was guaranteed. This retrospective analysis should encourage a prospective trial of early LMWH prophylaxis.     

Comparison of the effects of sevoflurane and propofol on cooling and rewarming during deliberate mild hypothermia for neurosurgery

Background. Because the time available for cooling and rewarmingduring deliberate mild hypothermia is limited, studies of therate of the cooling and rewarming are useful. The decrease incore hypothermia caused by heat redistribution depends on theanaesthetic agent used. We therefore investigated possible differencesbetween sevoflurane and propofol on the decrease and recoveryof core temperature during deliberate mild hypothermia for neurosurgery. Methods. After institutional approval and informed consent,26 patients were assigned randomly to maintenance of anaesthesiawith propofol or sevoflurane. Patients in the propofol group(n=13) received propofol induction followed by a continuousinfusion of propofol 3–5 mg kg^–1 h^–1.Patients in the sevoflurane group (n=13) received propofol inductionfollowed by sevoflurane 1–2%. Nitrous oxide and fentanylwere also used for anaesthetic maintenance. After inductionof anaesthesia, patients were cooled and tympanic membrane temperaturewas maintained at 34.5°C. After surgery, patients were activelyrewarmed. Results. There was no difference in the rate of decrease andrecovery of core temperature between the groups. There was alsono difference in skin surface temperature gradient (forearmto fingertip), heart rate and mean arterial blood pressure betweenthe groups. Conclusions. Sevoflurane-based anaesthesia did not affect coolingand rewarming for deliberate mild hypothermia compared withpropofol-based anaesthesia. Br J Anaesth 2003; 90: 32–8     

Vascular Decompression of Trigeminal and Facial Nerves in the Posterior Fossa under Endoscope-Assisted Keyhole Conditions

Objective: The aim of this study was to determine the use and safety of the endoscope as an adjunct during trigeminal and facial nerve decompression procedures performed under keyhole conditions in the posterior fossa. Method: We performed 67 surgeries in 65 patients with symptomatic trigeminal and facial nerve compression syndromes. The diagnosis was made mainly on the basis of clinical history, examination, and magnetic resonance imaging scans. Surgery was performed in all cases under endoscope-assisted keyhole conditions. The follow-up was 1 week postoperatively, 6 months, and then yearly up to 7 years. All 34 patients with trigeminal neuralgia received preoperative medication treatment and experienced failure with it. Eighteen patients out of 30 with hemifacial spasm had been previously treated with botulinum toxin injections. One patient suffered from both trigeminal neuralgia and facial spasm, because of a megadolichobasilar and vertebral artery with compression of both cranial nerves. Results: Sixty-four of the 65 patients became symptom free after surgical treatment; one revision surgery was necessary because of disappearance of the decompression muscle piece. No mortalities or minor morbidities were observed in this series. Conclusion: A precise planned keyhole craniotomy and the simultaneous use of the microscope and the endoscope render the procedure of the decompression less traumatic.