HYPO is likely a safe therapeutic intervention for children after severe TBI up to 24 hours after injury. Further studies are necessary and warranted to determine its effect on functional outcome and intracranial hypertension.

Endoscopic third ventriculostomy (ETV) has gained widespread acceptance as an effective way to manage hydrocephalus in selected patients. To determine which patient groups have the highest chance of successful ETV, a retrospective case review was performed. From June 1992 to December 1996, 97 patients underwent a total of 98 ETVs at our institution. There were 59 males and 38 females with a mean age of 8.1 years (range 1 day to 29.5 years). Twenty-six of 98 procedures (26%) were abandoned due to either unfavorable anatomy, inability to perform a cisternostomy, or hemorrhage. Follow-up data was available in 92 patients for a mean of 24.2 months. The rate of successful ETV in 71 patients, with either complete shunt avoidance or removal, varied widely by diagnosis and patient age. The highest success rates were achieved in patients with aqueductal stenosis, tectal plate tumor, myelomeningocele and posterior fossa tumor. Complications included one transient herniation syndrome, one basilar artery perforation, 2 cases of ventriculitis, one transient decrease in level of consciousness, and one transient hemiparesis. We feel these results support the continued use of ETV in only carefully selected patients with hydrocephalus.

Posttraumatic hydrocephalus and epilepsy were common complications encountered by children with severe TBI who underwent decompressive craniectomy. In patients who underwent decompressive surgery for raised ICP only, the mortality rate was exceedingly high.

We performed a retrospective, observational study at a level I pediatric trauma center of children with moderate-to-severe traumatic brain injury (TBI) from January 2002 to September 2006 to identify clinical and radiographic risk factors for early post-traumatic seizures (EPTS). Two hundred and ninety-nine children ages 0-15 years were evaluated, with 24 excluded because they died before the initial head computed tomography (CT) was obtained (n=20), or because their medical records were missing (n=4). Records were reviewed for accident characteristics, pre-hospital hypoxia or hypotension, initial non-contrast head CT characteristics, seizure occurrence, antiepileptic drug (AED) administration, and outcome. All care was at the discretion of the treating physicians, including the use of AEDs and continuous electroencephalogram (EEG) monitoring in patients receiving neuromuscular blocking agents. The primary outcome was seizure activity during the first 7 days as determined by clinician observation or EEG analysis. Of the 275 patients included in the study, 34 had identified EPTS (12%). Risk factors identified on bivariable analysis included pre-hospital hypoxia, young age, non-accidental trauma (NAT), severe TBI, impact seizure, and subdural hemorrhage, while receiving an AED was protective. Independent risk factors identified by multivariable analysis were age <2 years (OR 3.0 [95% CI 1.0,8.6]), Glasgow Coma Scale (GCS) score ≤8 (OR 8.7 [95% CI 1.1,67.6]), and NAT as a mechanism of injury (OR 3.4 [95% CI 1.0,11.3]). AED treatment was protective against EPTS (OR 0.2 [95% CI 0.07,0.5]). Twenty-three (68%) patients developed EPTS within the first 12 h post-injury. This early peak in EPTS activity and demonstrated protective effect of AED administration in this cohort suggests that to evaluate the maximal potential benefit among patients at increased risk for EPTS, future research should be randomized and prospective, and should intervene during pre-trauma center care with initiation of continuous EEG monitoring as soon as possible.

Object The most contentious issue in the management of os odontoideum surrounds the decision to attempt atlantoaxial fusion in patients with asymptomatic lesions. The authors examined the clinical presentation and outcome in patients with os odontoideum who underwent surgical stabilization, with an emphasis on 3 patients who initially received conservative treatment and suffered delayed neurological injury. Methods Seventy-eight patients (mean age 20.5 years; median 15 years) were identified in a 17-year retrospective review. The median follow-up period was 14 months (range 1–115 months). Neck pain was the most common symptom (64%), and 56% of patients presented after traumatic injury. Eighteen patients had neurological signs or symptoms at presentation, and an additional 15 had a history of intermittent or prior neurological symptoms. Fifteen patients had undergone ≥ 1 attempt at atlantoaxial fusion elsewhere. Results Seventy-seven patients underwent posterior fusion and rigid screw fixation combined with a graft/wire construct: 75 had C1–2 fusion and 2 had occipitocervical fusion. One patient had an odontoid screw placed. Fusion was achieved in all patients at a median of 4.8 months (range 2–17 months). Approximately 90% of patients had resolution or improvement of their neck pain or neurological symptoms. Conclusions The authors believe that patients with os odontoideum are at risk for future spinal cord compromise. Forty-four percent of our patients had myelopathic symptoms at referral, and 3 had significant neurological deterioration when a known os odontoideum was left untreated. This risk of late neurological deterioration should be considered when counseling patients. Stabilization using internal screw fixation techniques resulted in 100% fusion, whereas 15% of patients had previously undergone unsuccessful wire and external bracing attempts.

Object. In this, the second of two articles regarding C1–2 transarticular screw fixation, the authors discuss their surgical experience in treating patients 16 years of age and younger, detailing the rate of fusion, complication avoidance, and lessons learned in the pediatric population. Methods. The authors retrospectively reviewed 67 consecutive patients (23 girls and 44 boys) younger than 16 years of age in whom at least one C1–2 transarticular screw fixation procedure was performed. A total of 127 transarticular screws were placed in these 67 patients whose mean age at time of surgery was 9 years (range 1.7–16 years). The indications for surgery were trauma in 24 patients, os odontoideum in 22 patients, and congenital anomaly in 17 patients. Forty-four patients underwent atlantoaxial fusion and 23 patients underwent occipitocervical fusion. Two of the 67 patients underwent halo therapy postoperatively. All patients were followed for a minimum of 3 months. In all 67 patients successful fusion was achieved.Complications occurred in seven patients (10.4%), including two vertebral artery injuries. Conclusions. The use of C1–2 transarticular screw fixation, combined with appropriate atlantoaxial and craniovertebral bone/graft constructs, resulted in a 100% fusion rate in a large consecutive series of pediatric patients. The risks of C1–2 transarticular screw fixation can be minimized in this population by undertaking careful patient selection and meticulous preoperative planning.

CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

The final products represent the consensus of a group of expert spine surgeons. The checklist includes the most important and high-yield items to consider when responding to IONM changes in patients with a stable spine, whereas the IONM guideline represents the group consensus on items that should be considered best practice among IONM teams with the appropriate resources.