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Twenty-four children and young adults who underwent surgery for intrinsic tumors of the medulla were studied, correlating preoperative symptoms to postoperative brain stem dysfunction. 75% harbored benign tumors with a mean survival of 3.6 years, while the remaining 25% with anaplastic tumors had a mean survival of 3.2 years. Six patients required postoperative ventilatory support for an extended period of time, and 9 required feeding gastrostomies. Those patients who experienced frequent symptoms of upper respiratory tract infection, preoperative pneumonia, or an alteration in their voice were at risk of postoperative ventilatory dependency. Those without such symptoms did not experience such a fate. Difficulty in swallowing food or liquids seems to predict the need for postoperative feeding gastrostomies, and a lack of such a history was correlated with no such need 100% of the time. There seem to be preoperative signs and symptoms which predict postoperative brain stem dysfunction for an extended period of time in those undergoing brain stem surgery for tumors intrinsic to the medulla.

The introduction of a second portal during endoscopic procedures is presented. This second portal allows passage of larger instruments while the surgical field is viewed with an endoscope placed through the first portal. This dual portal technique provides an angled view of the operative site, thus avoiding optical obstruction by tissue being pulled toward the endoscope. We report the use of this technique in 6 endoscopic cases.

Fourth-ventricular shunting is commonly used to treat symptomatic posterior fossa cysts of the Dandy-Walker malformation and trapped fourth ventricle. Although the benefits of this procedure have been widely reported, there is a paucity of data on the pitfalls of posterior fossa shunting in the neurosurgical literature. During the 4-year period from July 1989 to June 1993, we placed fourth-ventricular shunts in 12 patients. Remarkably, 5 patients suffered complications related to posterior fossa catheter placement (42% rate). Three of these patients developed new cranial nerve dysfunction caused by direct injury to the floor of the fourth ventricle, 1 patient suffered an intracystic hemorrhage and acute shunt malfunction, and 1 patient had the catheter tip in the brainstem on postoperative studies without new neurological deficit. We conclude that placement of fourth-ventricular shunts can be fraught with complications which we believe is related to technique. We propose that altering the trajectory of the ventricular catheter from our usual midline technique to a more lateral position will lessen the chances for injury to the floor of the fourth ventricle. In this manner we hope to decrease our incidence of complications for this procedure.

Patients with medulloblastoma frequently present with hydrocephalus. While not all patients with medulloblastoma will continue to suffer from hydrocephalus after tumor resection, there is a significant proportion who will require a permanent shunt. We have retrospectively reviewed a group of children with medulloblastoma not shunted preoperatively, and have identified several characteristics which are associated with a requirement for permanent shunt. We studied 42 patients and found that 17 patients (40%) required permanent shunts within 4 weeks of craniotomy. The shunted patients were younger (5.4 +/- 2.9 vs. 10.0 +/- 5.7 years; p0.01), had larger ventricles (p0.05), and had more extensive tumors (Chang's stage T3 and T4; p0.01). These variables were all independently significant. In addition, we found that the patients requiring postcraniotomy shunts had a much higher rate of morbidity including a postoperative pseudobulbar syndrome. Of interest, we found that none of our patients without the above characteristics required a shunt. In particular, we found that no patient older than 10 years required a shunt. Thus, we conclude that younger patients with moderate to severe preoperative hydrocephalus and extensive tumors may benefit from perioperative CSF diversion. Other patients not meeting the above criteria can probably be safely managed with perioperative corticosteroids alone.

We present a case illustrating the usefulness of motor evoked potentials (MEPs) in differentiating psychogenic from organic postoperative paralysis. Discussed is a 12-year-old girl who underwent surge

Since 1986 250 patients have undergone selective posterior rhizotomy for spastic cerebral palsy at New York University Medical Center. Severe, perioperative complications were experienced by 15% of these patients and consisted of bronchospasm, aspiration pneumonia, urinary retention, ileus, sensory loss. Additionally, most of our patients had severe pain immediately after the surgery and nearly half had dysesthesias for up to 3 weeks. Long-term complications such as decreasing range of muscle movement and hip dislocation are now becoming apparent. This patient population must be viewed as having special risks attendant with surgery and particularly with selective posterior rhizotomy.

Intrinsic focal tumor of the medulla oblongata is an uncommon entity. Of the 51 cases presenting for treatment of a brainstem glioma between 1984 and 1990, only 7 were confined to the medulla. Radical excision was performed on each patient. Four of the first 5 patients who were extubated in the recovery room had CO2 retention, with associated respiratory arrest and hypoxia. Three suffered permanent cranial nerve deficits as a result. It is the purpose of this report to describe the serious complications of medullary surgery and to make recommendations as to how they may be avoided.