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Background: Cerebral palsy with medically refractory spasticity and dystonia is a condition that often benefits from intrathecal baclofen pump therapy to treat these symptoms. In this case report, an intracranial baclofen catheter was placed in the prepontine space to improve withdrawal symptoms in a patient unable to undergo new lumbar catheter placement due to infection. Case Description: A 22-year-old female with past medical history of cerebral palsy presented with baclofen pump failure and was unable to undergo placement of a new lumbar baclofen catheter due to an infection in her lower back precluding safe and efficacious catheter placement. It was decided the patient would benefit from intrathecal baclofen administered in the prepontine space as a means to avoid a lumbar catheter and thus bypass this prior infection site. An endoscopic third ventriculostomy (ETV) was performed with the endoscope and the distal end of the baclofen pump catheter was fed through this ETV into the prepontine space. Placement in the prepontine space was confirmed by a follow-up head computed tomography. There was a significant improvement in autonomic symptoms and spasticity. By postoperative day 5, the patient was surgically and medically cleared for discharge. Conclusion: In cases of severe baclofen withdrawal due to dysfunctional pumps, immediate reversal is preferred but may not be feasible due to factors such as infection. This case report has demonstrated that prepontine catheter placement can be effective for the administration of baclofen to reverse withdrawal symptoms in these types of patients.

Prospective randomized, 2-center, clinical trial.To prospectively compare adjacent level degeneration between the Bryan Cervical Disc Prosthesis and anterior cervical discectomy and fusion (ACDF), and assess the reliability of our measurements utilizing a method not previously described.ACDF is a reliable and proven procedure for the treatment of radiculopathy and/or myelopathy. Despite a successful track record several limitations including adjacent segment degeneration/disease, loss of viscoelastic disc properties, perioperative immobilization, graft site morbidity, pseudarthrosis, and plating complications have been identified. An original driving force and theoretical basis for total disc arthroplasty was prevention of adjacent level degeneration.Seventy-nine patients were enrolled and followed prospectively at 2 centers in a multicenter, Food and Drug Administration Investigational Device Exemption trial for the Bryan Cervical Disc arthroplasty. Neutral lateral radiographs were obtained preoperatively and postoperatively, and at 1-, 2-, 4-, and out to 7-year follow-up after surgery. The cephalad, adjacent level above the blinded procedure level was analyzed for all patients and time points by measuring the anteroposterior distance and the vertical disc height. A ratio was created using disc height/anteroposterior distance.Seventy patients (Bryan Cervical Disc N=34 and ACDF N=36) met inclusion criteria. Both fusion and arthroplasty groups showed a significant (P=0.001) decrease in disc height over time, indicative of adjacent level degeneration. Overall change in disc height between groups was not significantly different. Using our measurement technique, the overall interreviewer reliability was good [intrareviewer correlation coefficients (95% confidence interval)=0.77 (0.55-0.85)] and intrareviewer reliability was excellent [0.93 (0.91-0.94) and 0.85 (0.81-0.87)].Adjacent level degeneration occurs in a similar manner in both the ACDF and total disc arthroplasty group. Our measurement technique is reliable and to the best of our knowledge not previously reported in the literature.

OBJECTIVEEndoscopic third ventriculostomy (ETV) is a surgical alternative to placing a CSF shunt in certain patients with hydrocephalus. The ETV Success Score (ETVSS) is a reliable, simple method to estimate the success of the procedure by 6 months of postoperative follow-up. The highest score is 90, estimating a 90% chance of the ETV effectively treating hydrocephalus without requiring a shunt. Treatment with ETV fails in certain patients, despite their being the theoretically best candidates for the procedure. In this study the authors attempted to identify factors that further predicted success in patients with the highest ETVSSs.METHODSA retrospective review was performed of all patients treated with ETV at 3 institutions. Demographic, radiological, and clinical data were recorded. All patients by definition were older than 1 year, had obstructive hydrocephalus, and did not have a prior shunt. Failure of ETV was defined as the need for a shunt by 1 year. The ETV was considered a success if the patient did not require another surgery (either shunt placement or a repeat endoscopic procedure) by 1 year. A statistical analysis was performed to identify factors associated with success or failure.RESULTSFifty-nine patients met the entry criteria for the study. Eleven patients (18.6%) required further surgery by 1 year. All of these patients received a shunt. The presenting symptom of lethargy statistically correlated with success (p = 0.0126, odds ratio [OR] = 0.072). The preoperative radiological finding of transependymal flow (p = 0.0375, OR 0.158) correlated with success. A postoperative larger maximum width of the third ventricle correlated with failure (p = 0.0265).CONCLUSIONSThe preoperative findings of lethargy and transependymal flow statistically correlated with success. This suggests that the best candidates for ETV are those with a relatively acute elevation of intracranial pressure. Cases without these findings may represent the failures in this highly selected group.

Medial temporal lobe epilepsy associated with mesial temporal sclerosis (MTS) is perhaps the most well-defined epilepsy syndrome that is responsive to structural interventions such as surgery. Several minimally invasive techniques have arisen that provide additional options for the treatment of MTS while potentially avoiding many of open surgery's associated risks. By evading these risks, they also open up treatment options to patients who otherwise are poor surgical candidates. Radiosurgery is one of the most intensively studied of these alternatives and has found a growing role in the treatment of medial temporal lobe epilepsy.

The use of ketamine as a drug of abuse has increased and so too has the risk of accidental overdose. Here, the authors report the case of a 10-month-old infant who inadvertently ingested ketamine. The child demonstrated severe cerebellar swelling that required emergency surgical intervention. The authors describe the clinical course of this child and present the radiographic characteristics of the brain. The imaging characteristics were not consistent with purely anoxic injury, thus suggesting a specific effect of this drug. To the authors’ knowledge, similar imaging characteristics in this context have not been described.

Object A number of mathematical models predict the risk of future cancer from the ionizing radiation exposure of CT scanning. The predictions are alarming. Some models predict 29,000 future cancers and 14,500 deaths in the US will be directly caused by 1 year's worth of CT scanning. However, there are very few clinical data to justify or refute these claims. Young children are theoretically highly susceptible to the damaging effects of radiation. In this study, the authors examined children who underwent CSF shunt placement before 6 years of age. The authors chose to study shunt-treated patients with the assumption that these patients would undergo future imaging, facilitating surveillance. They chose a study period of 1991–2001 to allow more than 10 years of follow-up data. Methods The authors studied 104 consecutive children who underwent CSF shunt placement prior to 6 years of age and who had at least 10 years of follow-up data. Sixty-two of these patients underwent shunt placement prior to 1 year of age. The age at the initial scanning session, the number of future CT scanning sessions, diagnosis, and results of any future studies were recorded. The age-specific radiation dose was calculated for children younger than 1 year. Children younger than 1 year at the time of shunt placement were evaluated separately, based on the assumption that they represented the highest risk cohort. The authors examined all data for any evidence of future leukemia or head/neck tumor (benign or malignant). Results These children underwent a total of 1584 CT scanning sessions over a follow-up period of 1622 person-years. A total of 517 scanning sessions were performed prior to 6 years of age, including 260 in the 1st year of life. Children who underwent shunt placement before 1 year of age underwent an average of 16.3 ± 13.5 CT sessions (range 1–41). Children undergoing placement between 1 and 6 years of age received an average of 14.1 ± 12.5 CT studies (range 5–52). There were no subsequent tumors (benign or malignant) or leukemia detected. Conclusions Previously published models predict a significant number of future cancers directly caused by CT scanning. However, there are very few published clinical data. In the authors' study, zero future radiation-induced malignancies were detected after routine CT scanning in a high-risk group. While the authors do not consider their single-institution study adequate to define the actual risk, their data suggest that the overall risk is low. The authors hope this study encourages future collaborative efforts to define the actual risk to patients.

Object Percutaneous pedicle screw insertion techniques are commonly used to treat a variety of spinal disorders. Typically, Kirschner (K)-wires are used to guide the insertion of taps and screws during placement since the normal anatomical landmarks are not visualized. The use of K-wires adds risks, such as vascular and nerve injuries as well as increased radiation exposure given the use of fluoroscopy. The authors describe a series of patients who had percutaneous pedicle screws placed using a new computer-assisted navigation technique without the need for K-wires. Methods Minimally invasive percutaneous pedicle screw placement in the thoracic and lumbar spine was performed in a consecutive series of 15 patients for a variety of spinal pathologies. Intraoperative 3D CT images were obtained and used with a computer-assisted navigation system to insert an awl-tap into each pedicle. The tap location in the pedicle was marked with the navigation software, and the awl-tap was then removed. The navigation system was used to identify each landmark to insert the pedicle screw. Connecting rods were then inserted percutaneously under fluoroscopic guidance. Postoperative CT scans were obtained in each patient to evaluate screw placement. Results On postprocedure scanning, only 1 screw had a minor lateral and superior breach that was asymptomatic. To date, there have been no hardware failures. Conclusions Percutaneous pedicle screws can be placed effectively and safely without the use of K-wires.

Although lipid peroxidation has long been associated with spinal cord injury (SCI), the specific role of lipid peroxidation-derived byproducts such as acrolein in mediating damage remains to be fully understood. Acrolein, an α-β unsaturated aldehyde, is highly reactive with proteins, DNA, and phospholipids and is considered as a second toxic messenger that disseminates and augments initial free radical events. Previously, we showed that acrolein increased following traumatic SCI and injection of acrolein induced tissue damage. Here, we demonstrate that microinjection of acrolein into the thoracic spinal cord of adult rats resulted in dose-dependent tissue damage and functional deficits. At 24 hours (acute) after the microinjection, tissue damage, motoneuron loss, and spinal cord swelling were observed on sections stained with cresyl violet. Luxol fast blue staining further showed that acrolein injection resulted in dose-dependent demyelination. At 8 weeks (chronic) after the microinjection, cord shrinkage, astrocyte activation, and macrophage infiltration were observed along with tissue damage, neuron loss, and demyelination. These pathological changes resulted in behavioral impairments as measured by both the Basso, Beattie, and Bresnahan (BBB) locomotor rating scale and grid walking analysis. Electron microscopy further demonstrated that acrolein induced axonal degeneration, demyelination, and macrophage infiltration. These results, combined with our previous reports, strongly suggest that acrolein may play a critical causal role in the pathogenesis of SCI and that targeting acrolein could be an attractive strategy for repair after SCI.