In this series, the use of the patients' own craniectomised flap had a low infection rate, and was mainly seen in patients who had bilateral flaps re-implanted soon after removal. There were no complications arising from the use of split calvarial and allograft material. Use of autologous implant material should be preferred whenever possible due to obvious resource and biological advantages, and can even be re-implanted if infected.
Background/Objective: As prior studies analysed predictive factors for various post-laminectomy spinal deformities in mixed spinal regions, age groups or pathologies, their validity and conclusions were unclear. The objective of this study was to determine predictive factors for worsened cervical or thoracic spinal sagittal alignment following laminectomy or laminotomy for primary intramedullary spinal cord tumours in children. Methods: In this retrospective study, patients treated between 1980 and 1998 were reviewed. Changes in spinal alignment at the last follow-up compared to the pre-operative state were studied. Factors analysed were age, pre-operative spinal alignment, procedure types (laminectomy or laminoplasty), number of laminae operated, surgery of C2 or T1 laminae, histological grade, presence of post-operative neurological deficit and post-operative radiotherapy. Results: There were 27 patients. The mean age was 5.6 years (range 1.3–14.0 years), and the mean duration of follow-up was 3.7 years (range 0.075–9.9 years). In the cervical-cervicothoracic surgical group (n = 12), alignment worsened post-operatively in 3 patients. The number of laminae operated upon had a statistically significant impact on the development of post-operative kyphosis (p = 0.07). In the thoracic-thoracolumbar surgical group (n = 15), alignment worsened in 9 patients. Procedure types were statistically significantly different, with laminectomy associated with an increased risk of post-operative kyphosis (p = 0.01). All 5 patients who had spinal fusion for worsened post-operative alignment were in the thoracic-thoracolumbar group; no patients in the cervical-cervicothoracic group required spinal fusion (p = 0.047). Other predictive factors did not reach statistical significance (p > 0.05). Conclusions: Worsened spinal sagittal alignment following laminectomy or laminoplasty and the need for spinal fusion is more common in the thoracic-thoracolumbar region than in the cervical-cervicothoracic region. In the cervical-cervicothoracic region, operation on a greater number of laminae tends to increase the risk of worsened alignment. In the thoracic-thoracolumbar region, laminectomy is associated with worsened alignment, while laminoplasty reduces this risk; also, pre-operative kyphotic deformity tends to increase the risk of worsened alignment post-operatively.
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Problems may still occur for patients treated for infantile hydrocephalus who graduate to become adults, including unsatisfactory follow-up. We have continued the supervision in an adult institution of 70 children originally treated in the Birmingham Children’s Hospital between 1974 and 1978. In these patients, 33 (16.4%) of a total of 201 shunt revision procedures and 5 of the 8 subtemporal decompressions for slit ventricle syndrome were performed after the age of 16 years. Similarly, 7 shunt infections occurred in this age group. Two patients died from a blocked shunt. Other late complications included blindness (n = 1), endocarditis (n = 1), and renal and heart failure requiring consideration of organ transplantation (n = 1). Also 2 patients developed clinical features of arachnoiditis following earlier lumboperitoneal shunting. An overall good long-term outcome was observed. The majority of children graduated from a normal school (63%) or a school for physically handicapped children (21%). 67% of the patients are socially independent, but live at home with their parents. A further 16% have left their parents’ home and live either on their own (10%) or with their partners (6%). It is clear that although a good social and educational outcome is expected, significant clinical problems do arise during adulthood for patients shunted in infancy, even after a long period of apparent stability. Regular follow-up by surgeons familiar with these problems is essential.
Spinal teratomas are rare intradural spinal tumours, commonly of benign histological profile. The main treatment remains surgical excision which often is incomplete as the tumour is frequently intimately related to surrounding nerve roots and adjacent spinal cord. The value of adjuvant treatment in the form of radiotherapy has not been clearly identified. We report two patients with spinal teratomas in the lower thoracic and conus region, who were treated with surgical excision and did not receive radiotherapy. One of the tumours recurred at 38 months following surgical excision and required a second operation. We review in addition another 20 patients reported in the literature with such tumours. With a mean follow-up of 25 months a local recurrence rate of 10% was observed, the same in both total and subtotal excision groups. No deaths were reported. Analysis of cumulative survival from surgery to treatment failure demonstrated that recurrence occurs late, verifying a slow biological progression of this tumour type. Although no reliable information of the effect of radiotherapy can be obtained, it is difficult to see how radiotherapy could have an impact on such a slow growing tumour. Initial treatment of choice remains surgical excision. If the teratoma shows any malignant histological features or germ cell elements radiotherapy should be employed after surgical excision, even if apparently totally excised. In the presence of benign histology it would seem appropriate to avoid radiotherapy after initial surgery. In case of tumour recurrence or progression to explore the possibility of further surgery first, before considering radiotherapy which even then may have doubtful efficacy.
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