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Objective: This report addresses the clinical experience of the Division of Pediatric Neurosurgery with dedicated nurse practitioners and a physician assistant (PA) in outpatient and inpatient health care delivery, including surgical activities, as well as participation with the neurosurgery call schedule, quality improvement, teaching, and clinical research activities. Methods: We report on the activities of allied health personnel in the Division of Pediatric Neurosurgery for the purpose of identifying the current and future role for health care delivery, related to the care of the child with a neurosurgical condition. This addresses the participation of 2 advanced registered nurse practitioners (ARNPs) and a PA in the outpatient and inpatient setting, call schedule, interventions in and out of the operating room, quality improvement sessions, continuing medical education, clinical research, clinical databases, presentations in meetings, teaching, and scientific publications. Results: This report covers the period from September 2003 (when the division was initiated) to February 2011. The division currently consists of 3 pediatric neurosurgeons, 2 ARNPs and 1 PA. The ARNPs/PA have participated in the pediatric neurosurgery clinic held 5 half-days per week, the monthly multidisciplinary clinics (Spinal Defects Clinic, Pediatric Neurosciences Clinic, and the Fetal Diagnosis and Therapy Center working group), and inpatient care, as well as assisting in operative interventions. They participated in the on-call schedule and attended the monthly quality improvement sessions of the division in addition to presenting papers and topics in the monthly continuing medical education session. The PA maintained a computerized database of operative interventions, coding, morbidities, and outcomes. All were involved in teaching activities. They prepared preoperative and postoperative orders and practice guidelines, and they were also involved in the preparation of the database of institutional clinical research projects. They have presented posters in a total of 9 national and 2 international meetings, and have co-authored 8 manuscripts published in peer review journals. Conclusion: The ARNP/PA members have been active participants in all functions of the Division of Pediatric Neurosurgery. They have facilitated the work of the faculty in day-to-day activities and enhanced the scope of divisional activities, providing a team approach for the care of the patients, families, and caretakers.

Object Bioresorbable implant systems have been used in neurosurgery for the rigid fixation of cranial and facial bones. A relatively recent advancement has been the fixation of these implants using an ultrasonic device. The experience with such a device in neurosurgical practice has been limited. The authors report on their experience with ultrasound-aided fixation of bioresorbable implants in pediatric neurosurgical practice. Methods The study consisted of 2 parts. The retrospective portion consisted of a chart review of pertinent clinical information, complications, and outcomes after the use of a commercially available ultrasound-aided bioresorbable implant system (SonicWeld Rx, KLS Martin L.P.). Follow-up was obtained in all patients via clinical examination or telephone interview. The prospective portion of the study consisted of video analysis of the implantation technique in a routine craniotomy. Implantation times were measured, and delays during treatment were noted. Results Over a period of 2 years, 28 consecutive patients underwent placement of these implants for bone fixation during craniotomies or craniofacial reconstructions. The only complication was seen in a child with Crouzon syndrome, who had a wound infection caused by Serratia sepsis from a central venous line infection. There were no repeated operations for implant-related swelling, and no cases of premature plate resorption, bone instability, or settling. In vivo, the average time required to implant a resorbable pin with this system was 22 seconds. Conclusions The use of a bioresorbable implant system with ultrasound-aided pin fixation in pediatric neurosurgery cases achieved adequate stability with few complications. This system was easy to use and provided rapid fixation of implants.

Object The authors report a clinical protocol for the application of ventriculogallbladder (VGB) shunts in children who may be unable to maintain or receive ventriculoperitoneal (VP) shunts. Methods Eighteen patients underwent placement of VGB shunts as an alternative to VP shunt therapy for the following reasons: malfunction of the VP shunt due to suspected failure of the peritoneum to absorb cerebrospinal fluid (17 cases) and multiple intraabdominal general surgical procedures (1 case). The patients ranged in age from 4 months to 17 years (mean 6.5 ± 6.1 years [standard deviation {SD}]). All patients underwent preoperative imaging of the gall-bladder either by ultrasonography or computed tomography scanning. A team consisting of a pediatric neurological surgeon and a pediatric general surgeon performed all operative procedures. The procedures were conducted by open laparotomy to precisely place the appropriate length of distal catheter and to anchor it to the gallbladder wall. Results There were 2 early shunt malfunctions, both obstructions due to “sludge” (1 in the biliary duct and 1 in the common bile duct). A late-onset (5-year) malfunction occurred secondary to gallbladder stones. In all 3 cases of malfunction, the devices were successfully converted to VP shunts. In 1 patient a conversion to a VP shunt was chosen following a general surgical intervention. There were 2 shunt infections (Staphylococcus epidermidis and Haemophilus influenzae). These were successfully treated. Two patients underwent conversion to a VGB shunt on 2 occasions. Thirteen patients had functional VGB shunts at the time of their last follow-up assessment. The follow-up for these 13 patients ranged from 1 to 8 years (mean 2.1 ± 2.0 years [SD]). Conclusions Ventriculogallbladder shunts may be considered for the treatment of hydrocephalus in children when the peritoneal cavity cannot be used as a distal terminus.

Background: To treat with minimally invasive surgery, recurrent spinal arachnoid cysts, progressive syringomyelia, cranial and spinal cerebrospinal fluid fistulas. Patients andMethods: This is a clinical report that describes the management of recurrent spinal arachnoid cysts (2 patients), progressive syringomyelia (11 patients), postoperative spinal cerebrospinal fluid fistulas (15 patients) and postoperative cranial cerebrospinal fluid fistulas (2 patients) that were treated with spinal peritoneal shunts. The spinal arachnoid cyst and syringomyelia patients promptly resolved the signs and symptoms. The cranial and spinal cerebrospinal fluid fistula patients had a resolution of the fistulas. The shunts placed for spinal arachnoid cysts and syringomyelia required permanent implantation. The shunts placed for cerebrospinal fluid fistulas were temporary. All were removed, except for 2 patients whose parents did not want further operative interventions. Conclusion: Spinal peritoneal shunts have a variety of clinical applications and should be considered by neurological surgeons for disease processes other than communicating hydrocephalus and pseudotumor cerebri.

The authors describe 3 children who presented with progressively enlarging skin-covered solid masses over the shunt catheter in the neck/clavicular region. The authors reviewed the clinical, laboratory, pathological, radiographic, and follow-up data for all 3 patients and reviewed the literature on the subject. The patients had no clinical evidence of an infectious process. Surgical exploration revealed that masses were surrounding and encasing the shunt tubing to which they were strongly attached. Pathological studies of the tissues demonstrated varying degrees of exuberant chronically inflamed granulation tissues, interstitial fibrosis, and dystrophic calcification. One patient had associated thinning of the skin overlying the mass and subsequently developed ulceration. No infectious organisms were observed. The cerebrospinal fluid aspirates from the shunts did not yield any organisms. There has been no recurrence of the masses. The presence of a growing mass over the shunt tube in the neck or the chest region without clinical evidence of infection does not indicate that the mass should be treated with antibiotics and complete shunt removal. Rather, the mass can be cured by extirpation and with “bypass” new shunt tubing locally.

Purpose: Bioresorbable implant systems have been used for the rigid fixation of cranial and facial bones. A relatively recent advancement has been the fixation of these implants using an ultrasonic device. Published reports with such a device in pediatric craniofacial surgery have been limited. We report our experience with ultrasound-aided fixation of bioresorbable implants in the craniofacial surgery of children. Methods: We retrospectively examined the clinical information, complications and outcome following the use of a commercially available ultrasound-aided bioresorbable implant system (SonicWeld Rx™, KLS Martin, Jacksonville, Fla., USA) during craniofacial surgery by University of Florida College of Medicine Jacksonville surgeons. Follow-up was obtained via clinical examination or telephone interview. Results: Over a period of 3 years, 37 pediatric patients (age range: 2 months to 16 years) had placement of these implants for immediate bony fixation during craniofacial procedures. Pathology consisted mainly of craniosynostosis (n = 19), and trauma (n = 16). Twenty-eight had combined craniofacial procedures; 9 patients had facial procedures. Reoperation was performed for: wound infection (n = 1), plate extrusion (n = 1). Delayed subcutaneous plate-related swelling was seen in 5 patients (4 were infants) and had a benign clinical course. Good cosmetic outcomes were seen in all patients. Conclusions: The use of a bioresorbable implant system with ultrasound-aided pin fixation in pediatric craniofacial surgery achieves rapid fixation with minimal morbidity and good cosmetic outcome. This system is easy to use and provides reliable stability in the setting of pediatric trauma and craniosynostosis.

Objective: The Division of Pediatric Neurosurgery of the University of Florida College of Medicine – Jacksonville developed a multidisciplinary clinic for the better management of pediatric patients with spinal defects. The purpose of this report is to assist neurosurgeons in those regions and countries where there are no spinal defects clinics (SDC). Methods: We induced a staged process to develop a comprehensive multidisciplinary clinic for pediatric patients with spinal defects: phase I – during December 2003 to June 2004, the organizational planning, multiinstitutional recruitment of health care personnel and location of clinic space occurred; phase II – the SDC sessions initiated in June 2004 and have consequently been held on a monthly basis; phase III – this consisted of a quality improvement program during which parents/caregivers were surveyed. Results: Between June 2004 and February 2009, 139 patients/families were evaluated. Diagnoses included: myelomeningocele (102), lipomeningocele (18), meningocele (1), myelocystocele (3), spina bifida occulta (9), spinal trauma (2), spasticity of cerebral origin (2), spinal arachnoid cyst (1) and syringomyelia (1). During this period, 110 parents/caregivers were questioned on how the SDC assisted in the care of their child. A total of 62% (of 53 responders) indicated the SDC allowed them to be better informed about their child’s medical conditions and short/long-term health care plans, 52% stated health care needs were better coordinated than prior to their participation in the SDC, and 26% responded that the initiation of the clinic had reduced their medical care travel. Conclusions: Pediatric neurosurgeons may take the lead in organizing a multidisciplinary clinic for the betterment of these children. Multidisciplinary care settings facilitate health care delivery and lead to better patient care as perceived by parents/caregivers.

Bioresorbable implant systems have been used in neurosurgery for the rigid fixation of cranial and facial bones. A relatively recent advancement has been the fixation of these implants using an ultrasonic device. The experience with such a device in neurosurgical practice has been limited. The authors report on their experience with ultrasound-aided fixation of bioresorbable implants in pediatric neurosurgical practice.The study consisted of 2 parts. The retrospective portion consisted of a chart review of pertinent clinical information, complications, and outcomes after the use of a commercially available ultrasound-aided bioresorbable implant system (SonicWeld Rx, KLS Martin L.P.). Follow-up was obtained in all patients via clinical examination or telephone interview. The prospective portion of the study consisted of video analysis of the implantation technique in a routine craniotomy. Implantation times were measured, and delays during treatment were noted.Over a period of 2 years, 28 consecutive patients underwent placement of these implants for bone fixation during craniotomies or craniofacial reconstructions. The only complication was seen in a child with Crouzon syndrome, who had a wound infection caused by Serratia sepsis from a central venous line infection. There were no repeated operations for implant-related swelling, and no cases of premature plate resorption, bone instability, or settling. In vivo, the average time required to implant a resorbable pin with this system was 22 seconds.The use of a bioresorbable implant system with ultrasound-aided pin fixation in pediatric neurosurgery cases achieved adequate stability with few complications. This system was easy to use and provided rapid fixation of implants.

The authors describe a series of attempts to treat with minimally invasive surgery cerebrospinal fluid (CSF) fistulas that develop following operations of the spine for congenital anomalies.Sixteen patients in whom CSF fistulas developed following repair of congenital spinal disorders (nine lipomeningoceles, one arachnoid cyst, two myelocystoceles, three tethered cords after myelomeningocele repair, and one scoliosis surgery) underwent placement of a temporary subcutaneous peritoneal shunt. The CSF fistulas resolved in all instances. Two patients required revision of the shunts prior to resolution of the fistula and subsequent shunt removal. Three patients suffered a lumbar wound or shunt infection, which necessitated shunt removal. Subsequent to the removal, the infection resolved and there was no recurrence of the CSF leak. Fourteen patients had their shunts completely removed within 1 year of placement. Two patients did not have their shunts removed because parental consent for the additional surgery was not given.Postoperative subcutaneous CSF fistulas of the spine can be successfully treated using temporary subcutaneous peritoneal shunts. This procedure reduces hospital stay and obviates the need for more extensive or multiple surgical interventions.

Introduction Ventriculogallbladder shunts (VGBSs) have been employed when there is a contraindication for intraperitoneal shunt placement or when CSF is no longer absorbed by the peritoneum. We report our clinical experience with 19 patients (1986–2006) with particular emphasis on perioperative management. Methods In 18 patients VGBS placement was indicated because of failure of abdominal absorption of CSF and in one patient due to multiple intraperitoneal general surgery operative interventions. An absolute preoperative requirement is documenting the presence and status of the gallbladder by ultrasonography or CT. The proximal portion was similar to a ventriculoperitoneal shunt with emphasis in a proximal one-way valve; the distal end was performed by open laparotomy to adequately anchor the distal end to the distal pole of the gallbladder wall and verify the length inside the gallbladder. Additional redundant distal shunt tubing was placed in the abdomen, allowing for subsequent patient growth. Prior to hospital discharge, the gallbladder status was evaluated by ultrasound to document function. Results The following highlights the importance of the preoperative assessment: one patient had congenital agenesis of the gallbladder. One patient had “sludge” formation on preoperative ultrasound that in the immediate postoperative period developed an obstruction of the common duct that required shunt removal. Two patients had shunt infections (S. epidermis, H. influenzae) and 15 patients had successful long-term shunt function. Conclusion We conclude that VGBSs should be considered an important tool in the armamentarium of pediatric neurosurgery.

Introduction The clinical experience with a bioresorbable fixation system that employs ultrasound as a method of fixation in pediatric neurosurgery has not been previously described. We report our experience with the use of ultrasonic fixation of PDLLA implants in our operative practice. The complications, limitations, and advantages of using this commercially available system (SonicWeld Rx, KLS Martin L.P.) will also be described. Results Over a period of 18 months, 23 consecutive patients had placements of these implants for bony fixation during craniotomies or craniofacial reconstructions. Patient age ranged from 2 months to 18 years. Types of pathologies were as follows: craniosynostosis (10); tumor (6); trauma (4); and congenital cysts (3). The only morbidity was seen in a child with Crouzon syndrome, who had a wound infection following Serratia sepsis from a central venous line infection. There were no cases of premature plate reabsorption, bony instability or settling, or skin breakdown. Ease of im...

Results The CSF fistulas were resolved in all. Two patients required revisions of the shunt prior to resolving the fistula and subsequent shunt removal. Three patients acquired a lumbar wound/shunt infection, which necessitated shunt removal. Subsequent to removal, the infection resolved and there was no recurrence of the CSF leak. All patients but two had their shunts completely removed within one year of placement (Range: 2–21 months, Mean: 8.7 ± 5.0 months SD). Two patients did not have their shunts removed due to parental decision for no further surgery. Conclusion We conclude that spinal postoperative subcutaneous CSF fistulas may be successfully treated with temporary subcutaneous peritoneal shunts. This reduces hospital stay and more extensive or multiple surgical interventions. from 50th Annual Meeting of the Society for Research into Hydrocephalus and Spina Bifida Cambridge, UK. 30 August – 2 September 2006