OBJECTIVE:Selective dorsal rhizotomy (SDR) is a surgical procedure to reduce spasticity and improve function in children with cerebral palsy (CP). Randomized trials have shown that SDR is superior to physical therapy alone for reduction of spasticity and improvement in gait, but there is wide variation in surgical technique. The purpose of this study was to describe the scope of patient factors and surgical technique of SDR performed for the management of spasticity in children with CP. METHODS:This study is a cross-sectional analysis of data included in the Cerebral Palsy Research Network (CPRN) registry from all subjects who underwent SDR at a CPRN member site. Data from consecutive cases were collected at each site and submitted to the CPRN registry. All cases of SDR submitted to the registry were included. Descriptive statistics were used to summarize data. When possible, results were compared across CPRN centers and patients using descriptive and inferential statistics. RESULTS:A total of 564 patients underwent SDR and had data in the CPRN registry. Most (n = 356, 63%) children were male and White (n = 427, 76%). The Gross Motor Function Classification System (GMFCS) level was I in 63 (14%), II in 108 (23%), III in 134 (29%), IV in 81 (17%), and V in 76 (16%) children. Dystonia was present in 25 (6.2%) children. SDR was performed at the level of the conus medullaris or upper cauda equina in 193 (50%) children. Multilevel laminotomy was performed in 194 (50%) children. Intramuscular monitoring electrodes were placed in 486 (94%) children. The median number of nerve rootlets tested on each side was 27 (IQR 31-34, range 4-139). The median proportion of rootlets cut was 0.63 (IQR 0.52-0.67, range 0.21-1.0). The proportion of rootlets cut was associated with GMFCS level; patients who had a GMFCS level of V had a greater proportion of rootlets cut compared to those with levels of I (mean difference [MD] 0.079, p < 0.01), II (MD 0.129, p < 0.01), and III (MD 0.096, p < 0.01). CONCLUSIONS:There are many variations in SDR technique for the management of spasticity in CP, including differences in approach to surgical site, number of rootlets tested, and proportion cut. Detailed outcome data are needed to compare variations and determine if an optimal technique is associated with ideal treatment results.

Selective dorsal rhizotomy (SDR) is a treatment for lower-extremity spasticity in disorders such as cerebral palsy (CP). "Selective" refers to sectioning nerve rootlets with the most abnormal responses on electromyography (EMG) upon intraoperative stimulation. EMG abnormalities can be classified by waveform appearance or by degree of spread throughout lower extremity muscles. We examine the relationship between different EMG waveforms and grades of spread. Intraoperative SDR EMG records from November 2009 through December 2021 were analyzed for waveform types and degrees of spread. Irregular, incremental, multiphasic, sustained, and clonic waveform patterns were considered more abnormal. Decremental, squared decremental, and squared waveforms were less abnormal. Degrees of spread were graded 0-4+, 4+ signifying the most abnormal spread. Distribution of grades of spread was compared between waveform patterns using pairwise Cochran-Armitage tests with Holm-Bonferroni correction. We hypothesized that more abnormal EMG waveform patterns would correlate with higher grades of spread. Sixty-three patients were included, with an average age of 8 years. Most had cerebral palsy (86%, n = 54). The remainder had brain malformations (8%, n = 5) and other etiologies (6%, n = 4). Higher grades of spread significantly increased the likelihood of multiphasic, sustained, or clonic patterns, compared to decremental, irregular, and squared patterns (p < .05). Squared waveforms decreased with higher grades of spread relative to other patterns (p < .05). Different EMG waveform patterns are associated with varying grades of spread in SDR, suggesting that evaluating both waveform pattern and degree of spread together can be useful in guiding rootlet sectioning.

INTRODUCTION:Intrathecal baclofen therapy and baclofen pumps can lead to complications, including recurrent cycles of alternating hypertonia and hypotonia. The causes and optimal treatments for this issue remain unclear. This study reviews presentations, radiologic and surgical findings, treatments, and outcomes in cases of cyclic hypertonia/hypotonia. METHODS:We reviewed patients with baclofen pumps treated at our hospital from 1998 to 2024 who developed cyclic hypertonia/hypotonia. Data collected included patient sex, etiology and type of tone abnormality, age at pump placement, age and weight at symptom onset, infusion rate and type at onset, side port access and catheter dye study results, treatments, surgical findings, and outcomes. RESULTS:We identified 15 cases in 14 patients (10 females, 71%; 4 males, 29%). Among 248 patients with baclofen pumps, 38% were female. Females were significantly more likely to develop cyclic hypertonia/hypotonia (p < 0.01). The mean age at pump implantation was 10.2 years, and the mean time from last pump surgery to symptom onset was 645 days. All patients received enteric baclofen initially; 14 also had pump rate adjustments. Three patients improved without surgery, and one died during a hypotonia episode. Side port access showed patent catheters in 7 of 8 cases, with 6 of these showing good intrathecal dye dispersion. Surgery was performed in 11 cases, including two surgeries in 6 cases. Nine patients had pump replacements; 8 also had catheter revisions. Surgical findings included catheter kinks in 4 cases (36% of surgical cases) and leaks in 5 cases (45%), with 4 leaks at the pump-connector catheter connection. Six of 11 partial revisions (55%) and all 5 complete catheter replacements (100%) resulted in symptom resolution without recurrence. Replacing the pump-connector segment resolved symptoms without recurrence in 4 of 5 patients with leaks at this site. Overall, all patients undergoing surgery experienced symptom improvement without recurrence after one or two revisions. CONCLUSION:Adjusting pump rates and adding enteric baclofen may help some patients with cyclic hypertonia/hypotonia. If a leak at the pump-connector catheter segment is identified, segment replacement should be considered. When partial revisions fail, complete catheter replacement appears more effective, especially as a second surgery. Cyclic hypertonia/hypotonia is a treatable complication of baclofen pumps.

OBJECTIVE Patients with a history of surgery for single-suture craniosynostosis (SSC) as an infant often wish to participate in sports later in childhood. However, there are no established guidelines from neurosurgeons and craniofacial surgeons to guide parents in which sports their child should or should not participate. Therefore, this study aimed to evaluate the attitudes and practice patterns of experienced neurosurgeons and craniofacial surgeons regarding the counseling of caregivers of these patients about sports participation. METHODS A survey was administered to neurosurgeons and craniofacial plastic surgeons of the Synostosis Research Group (SynRG), a group of 9 North American institutions, to identify attitudes toward sports participation in patients with past SSC surgery. Survey responses were collected anonymously in REDCap. Questions regarding specific sports participation recommendations for patients who underwent surgery as an infant for SSC with ideal healing and for those who required a delayed cranioplasty were answered. Questions pertained to patients with nonsyndromic SSC without associated Chiari malformation, syrinx, or other intracranial/intraspinal anomalies. RESULTS Overall, 20 surgeons were invited to participate in the survey, with 18 (90%) (9 neurosurgeons and 9 craniofacial plastic surgeons) fully completing it. Only 1 (5.6%) surgeon counseled against any sports participation for patients with ideal healing. If cranioplasty was required, 39%-50% of surgeons counseled against some participation (most commonly restricting football/rugby, boxing, ice hockey, lacrosse, and wrestling), depending on the extent of the cranioplasty. Overall, more plastic surgeons (56%-67%) counseled against sports participation (including lower-contact sports such as baseball/softball, basketball, gymnastics, and soccer) than neurosurgeons (22%-33%) in patients who required cranioplasty. CONCLUSIONS SynRG surgeons generally did not counsel against sports participation (including contact sports) for children with a history of SSC surgery as an infant who had ideal healing. In patients requiring cranioplasty, 39%-50% of surgeons recommended against high-contact sports participation.

Introduction: At our institution, revascularization after indirect moyamoya surgery is routinely evaluated using magnetic resonance angiography (MRA) rather than catheter angiography. This study reviews how revascularization can be visualized on axial MRA versus catheter angiography and compares clinical outcomes of surgeries evaluated by routine postoperative MRA versus routine catheter angiography. Methods: We reviewed the records of all patients treated at our institution who underwent unilateral encephaloduroarteriosynangiosis (EDAS)/pial synangiosis 2004-2021 at 1-21 years of age. Inclusion criteria included undergoing preoperative MRA within 18 months of surgery and postoperative MRA 3 to 30 months after surgery. Clinical outcome measures included postoperative stroke and transient ischemic attacks (TIAs), changes in symptoms (improved, unchanged, worsened), and new postoperative symptoms. Measures were compared between surgeries evaluated by routine postoperative MRA versus routine postoperative angiograms. For each surgery, we determined the ratios of the diameters and areas of the donor and contralateral corresponding vessels and the relative signal intensities of these two vessels on preoperative- and 3-to-30-month postoperative MRA. We did the same for the middle meningeal artery (MMA) ipsilateral to the donor artery and the contralateral MMA. We assessed changes from pre- to post-operation in diameter ratios, area ratios, relative signal intensity, ivy sign, and brain perfusion on arterial spin labeled (ASL) imaging. MRI and MRA measures of revascularization and flow were compared to Matsushima grades in patients who had postoperative catheter angiograms. Results: Fifty-one operations were included. There were no significant differences in rates of strokes, TIAs, changes or new symptoms after surgeries evaluated by routine postoperative MRA versus catheter angiogram. Significant associations existed between greater collateralization on postoperative MRA and greater median increases in preoperative-to-postoperative ratios of donor-vessel-over-contralateral-vessel diameter (p=0.0461) and ipsilateral-MMA-over-contralateral-MMA diameter (p=0.0135). The median increase in the ratio of the donor-vessel-over-corresponding-contralateral-vessel diameters was significantly higher for Matsushima grade A versus B (p=0.036). The median increase in the ratio of the sum of donor-and-ipsilateral-MMA diameters over the sum of the contralateral vessel diameters was significantly higher for improved-versus-unchanged perfusion on ASL imaging (p=0.0074). There was a nonsignificant association between greater postoperative collateralization on MRA and Matsushima grade (p=0.1160) Conclusion: Cerebral revascularization after EDAS/pial synangiosis can be evaluated on axial MRA by comparing the diameter and/or signal intensity of the donor vessel and ipsilateral MMA to those of the corresponding contralateral vessels on postoperative-versus-preoperative MRA. The use of routine postoperative MRA rather than catheter angiography does not appear to negatively affect outcomes.

Subdural fluid collection is a common neurosurgical condition in the pediatric population. Patients requiring surgical intervention have historically been managed with subdural drains, subdural-subgaleal shunting, subdural-peritoneal shunting, and mini-craniotomies. An alternative procedure for patients with an open anterior fontanelle is bedside transfontanelle drainage. This study aims to evaluate the efficacy of the transfontanelle angiocatheter drain placement including complications and the need for any further surgery. We performed a single-center retrospective review of all patients who underwent placement of transfontanelle drain to treat subdural fluid collections from January 2013 to June 2023. Data points collected included demographics, comorbidities, mechanism of subdural collection, neurologic status on presentation, subdural size, amount of drainage, complications, and need for further intervention. We identified 28 patients who underwent bedside transfontanelle subdural angiocatheter placement between January 2013 and June 2023. The patient age range was 0–11 months (avg 3.96). Twenty-three patients were male (82

OBJECTIVE As many as 5% of normocephalic children may have a prematurely fused sagittal suture, yet the clinical significance and best course of management of this finding remain unclear. Providers in the Synostosis Research Group were surveyed to create a multicenter consensus on an optimal treatment and monitoring algorithm for this condition. METHODS A four-round modified Delphi method was utilized. The first two rounds consisted of anonymous surveys distributed to 10 neurosurgeons and 9 plastic surgeons with expertise in craniosynostosis across 9 institutions, and presented 3 patients (aged 3 years, 2 years, and 2 months) with incidentally discovered fused sagittal sutures, normal cephalic indices, and no parietal dysmorphology. Surgeons were queried about their preferred term for this entity and how best to manage these patients. Results were synthesized to create a treatment algorithm. The third and fourth feedback rounds consisted of open discussion of the algorithm until no further concerns arose. RESULTS Most surgeons preferred the term "premature fusion of the sagittal suture" (93%). At the conclusion of the final round, all surgeons agreed to not operate on the 3- and 2-year-old patients unless symptoms of intracranial hypertension or papilledema were present. In contrast, 50% preferred to operate on the 2-month-old. However, all agreed to utilize shared decision-making, taking into account any concerns about future head shape and neurodevelopment. Panelists agreed that patients over 18 months of age without signs or symptoms suggesting elevated intracranial pressure (ICP) should not undergo surgical treatment. CONCLUSIONS Through the Delphi method, a consensus regarding management of premature fusion of the sagittal suture was obtained from a panel of North American craniofacial surgeons. Without signs or symptoms of ICP elevation, surgery is not recommended in patients over 18 months of age. However, for children younger than 18 months, surgery should be discussed with caregivers using a shared decision-making process.

Introduction: Penttinen premature aging syndrome is caused by mutations in the PDGFRB gene. We describe the case of a 10-year-old girl with a de novo c.1994T>C variant in PDGFRB who developed multiple cranial, intracranial, and spinal manifestations, including macrocephaly, enlarged convexity subarachnoid spaces crossed by numerous vascularized arachnoid trabecule, hydrocephalus, spinal epidural lipomatosis, a low conus medullaris, calvarial thinning with large anterior fontanelle, and a skull fracture with bilateral epidural hematomas. Vascularized arachnoid granulations, spinal epidural lipomatosis, and low conus medullaris have not been previously described in Penttinen syndrome. Case Presentation: A female with Penttinen syndrome diagnosed at 9 years of age initially presented as an infant with cutaneous hemangiomas and macrocephaly; imaging showed enlarged convexity subarachnoid spaces. Her convexity subarachnoid spaces continued to expand, leading to subdural shunt placement. At surgery, her enlarged subarachnoid spaces were found to contain numerous abnormally thick, vascularized arachnoid trabecule. Eventually, her subdural shunt failed and her ventricles enlarged, leading to ventricular shunt placement. A large, sunken anterior fontanelle which did not diminish in size led to cranioplasty with a custom implant. She later developed chronic back pain and imaging revealed spinal epidural lipomatosis, a low conus medullaris, and mild scoliosis. At 10 years of age, a fall from a chair resulted in a depressed skull fracture and bilateral parietal epidural hematomas. Emergency left parietal craniotomy was performed for evacuation of the left hematoma, and the patient recovered without complications. Intraoperatively, it was noted that her skull was extremely thin. Conclusion: This case report highlights the clinical presentation and multifaceted neurosurgical management of a patient with Penttinen syndrome. The patient exhibited characteristic features including hypertrophic skin lesions, macrocephaly, and skeletal abnormalities. Our patient’s vascularized arachnoid trabecule, spinal epidural lipomatosis, and low conus medullaris have not previously been reported in Penttinen syndrome. Her thin skull potentially contributed to the extent of her depressed skull fracture after her backwards fall and predisposed her toward developing epidural hematomas. Patients with Penttinen syndrome can have multiple cranial, intracranial, and spinal manifestations which may need the attention of a neurosurgeon.

OBJECTIVE The primary objective of this study was to determine the frequency and nature of complications that occur during intrathecal baclofen (ITB) therapy, including nonsurgical complications as well as complications associated with both implantation surgeries and subsequent revisions. METHODS The authors retrospectively reviewed the medical records of all patients who had baclofen pumps implanted at a tertiary children’s hospital from 2006 through June 2019. The study employed appropriate descriptive statistics and statistical models to analyze patient demographics, improvements in tone, and clinical complications. The authors evaluated the associations of complications as well as changes in modified Ashworth Scale (MAS) scores with various preexisting conditions (e.g., presence of gastrostomy tubes [G-tubes] and ventriculoperitoneal [VP] shunts) and surgical variations (e.g., use of newer [Ascenda] catheters and subfascial versus subcutaneous catheter tunneling). RESULTS One hundred forty-two pumps were implanted. Complications occurred in 111 patients (78.2%). The most frequent complications were catheter complications and pseudomeningoceles, each of which occurred in 63 (44%) patients. On multivariable analysis, pseudomeningoceles and percutaneous CSF leaks were significantly less likely when intrathecal catheters were placed via laminotomy versus spinal needle (OR 4.6, p = 0.044), and when catheters were passed from the posterior incision to the abdominal pump pocket deep to the thoracolumbar fascia rather than superficial to it (OR 2.7, p = 0.008). Preexisting G-tubes and VP shunts at the time of pump implantation were not associated with a significantly increased likelihood of pump malfunction or infection. Ascenda catheters were significantly less likely to have disconnections (p < 0.001) and obstructions (p = 0.016), and overall were less likely to have any catheter-related complications (p = 0.01). Patients with preexisting VP shunts at the time of implantation had a significantly greater mean decrease in MAS scores in both their lower extremities (1.8, p = 0.003) and upper extremities (1.3, p = 0.002) than did patients without shunts. CONCLUSIONS Various complications are associated with ITB therapy, most commonly catheter complications and pseudomeningoceles. There have been fewer catheter complications associated with the newest catheter model, while pseudomeningoceles have become less frequent since the surgical technique was modified to prevent them. VP shunts and G-tubes are not associated with significantly higher complication rates and shunts seem to be associated with greater efficacy of ITB therapy, as represented by a greater mean improvement in MAS scores.

INTRODUCTION: Moyamoya arteriopathy can be idiopathic (moyamoya disease, MMD) or associated with other diseases, i.e., Down syndrome (moyamoya syndrome, MMS). The prevalence of Down syndrome in patients admitted for moyamoya has been estimated using the National Inpatient Sample to be 3.8%. However, the prevalence of moyamoya in Down Syndrome is not well-quantified. METHODS: This retrospective study used the Sie Center for Down Syndrome and Stroke Program databases at Children’s Hospital Colorado to identify moyamoya patients aged 30 days to 18 years at diagnosis. Demographics, clinical presentation, treatment, and outcome were compared among patients with DS, those with idiopathic MMD, and the entire group. RESULTS: Sixty-five patients (30 idiopathic, 14 MMS with DS, 21 MMS without DS). Prevalence of MMS in the DS population was 0.4%. Gender and age at presentation did not differ significantly between populations. 47% of idiopathic moyamoya patients initially presented with transient ischemic attacks (TIAs) versus 14% of DS patients (P < 0.05). This is compared to 34% of the total population that presented with TIAs. DS patients were more likely to present with stroke (57%) compared to idiopathic (37%) and total patient populations (40%) although these results were not significant. 23% of idiopathic patients presented with basal ganglia strokes compared to 7% in the DS population (P < 0.05). CONCLUSIONS: In this study, the prevalence of moyamoya in DS was 0.4%. Patients with DS were less likely to present with TIAs and more likely to present with stroke, with different stroke locations, than were other moyamoya populations.

Introduction: Encephaloduroarteriosynangiosis (EDAS) for moyamoya is predominantly performed using a branch of the superficial temporal artery (STA) as the donor artery. At times, other branches of the external carotid artery are better suited for EDAS than is the STA. There is little information in the literature concerning using the posterior auricular artery (PAA) for EDAS in the pediatric age-group. In this case series, we review our experience using the PAA for EDAS in children and adolescents. Case Presentations: We describe the presentations, imaging, and outcomes of 3 patients in whom the PAA was used for EDAS, as well our surgical technique. There were no complications. All 3 patients were confirmed to have radiologic revascularization from their surgeries. All patients also had improvement of their preoperative symptoms, and no patient has had a stroke postoperatively. Conclusion: The PAA is a viable option for use as a donor artery in EDAS for the treatment of moyamoya in children and adolescents.

BACKGROUND: Septorhinoplasty (SRP) is the most common otolaryngologic (ENT) procedure performed, often alongside Endoscopic Sinus-Surgery (ESS). Due to the infectious potential of the natural nasal flora, it is thought that procedures that expose the underlying tissue to bacteria necessitate antibiotic use to prevent infection. The objective of this review is to evaluate the available evidence for the use of antibiotics in these settings and explore the trends of antibiotic administration among physicians. METHODS: A systematic review using PubMed, OVID, and Web of Science databases through Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) yielded 475 papers. Based on the inclusion criteria, information focusing on the use of anti-biotics during SRP and ESS procedure was extracted from 9 studies. RESULTS: Of the nine studies selected, three (33%) concluded that prophylactic antibiotics were not necessary. Subsequently, these studies were reviewed and it was found that 7 contained data relevant to preoperative use of anti-biotics during SRP or ESS procedure

Purpose: Fetal repair of myelomeningocele (MMC) and myeloschisis leads to improved neurologic out-comes compared to postnatal repair, but the effects of modifications in closure techniques have not been extensively studied. Previous work has suggested that a watertight repair is requisite for improvement in hindbrain herniation (HBH) and to decrease postnatal hydrocephalus (HCP). Our institution adopted the myofascial closure technique for open fetal MMC repair in July 2019, which we hypothesized would result in decreased need for patch closure, improved HBH, and decreased rate of surgically-treated HCP.Methods: A single-center retrospective study of patients who underwent fetal MMC or myeloschisis re-pair between March 2013 and February 2022 was performed. Outcomes were evaluated ( n = 70 prior to July 2019, n = 34 after July 2019). Statistical significance was determined by Fisher's exact and Chi square tests ( p < 0.05 significant).Results: Patients who underwent myofascial closure were less likely to require a patch for skin closure (14.7% vs 58.6%, p < 0.0 0 01). Myofascial closure was also associated with an increased rate of HBH im-provement on two-week postoperative fetal MRI (93.9% vs 65.7%, p = 0.002). Surgically-treated HCP at one year was lower in the myofascial closure group ( n = 21), however this did not reach statistical sig-nificance (23.8% vs 41.9%, p = 0.19).Conclusions: We conclude that the myofascial closure technique for repair of fetal MMC and myeloschisis is associated with significantly decreased need for patch closure and improvement in hindbrain herni-ation compared to our previous skin closure technique. These results support a surgical approach that employs a multilayer watertight closure.(c) 2022 Elsevier Inc. All rights reserved.

Introduction:After treating a child with familial sagittal craniosynostosis, clinocephaly, and bilateral parietomastoid/posterior squamosal suture fusion, the authors wondered if major-suture synostosis and clinocephaly were associated with abnormal fusion of minor lateral calvarial sutures. Methods:The authors reviewed all preoperative volume-rendered head computed tomography reconstructions performed for craniosynostosis at their institution from 2010 through 2014 and determined whether the sphenoparietal, squamosal, and parietomastoid sutures were open, partially fused, or fused. The authors determined whether any sutures were abnormally fused based upon a previous study from their center, in which abnormal fusion was defined as either 1 of 3 abnormal fusion patterns or abnormally-early fusion. The authors then determined the rate of abnormal fusion of these sutures and whether abnormal fusion was associated with (1) major-suture craniosynostosis, (2) type of craniosynostosis (sutures involved; single-suture versus multisuture; syndromic versus nonsyndromic), and (3) clinocephaly. Results:In 97 included children, minor lateral sutures were abnormally fused in 8, or 8.2%, which was significantly higher than in children without craniosynostosis from our earlier study. Abnormal minor lateral suture fusion was not associated with the type of single-suture synostosis or with multisuture synostosis but was associated with syndromic synostosis. Four of 8 children with abnormal minor lateral suture fusion had multisuture synostosis and 6 had syndromic synostosis. Lateral sutures were abnormally fused in 1 of 4 subjects with clinocephaly, which was not significant. Conclusion:Abnormal minor lateral calvarial suture fusion is significantly associated with major-suture craniosynostosis, especially syndromic synostosis.

Introduction: Determining the need, optimal timing, amount, and type of fluid for volume expansion in hypovolemic infants is challenging, due to their small intravascular volumes and robust compensatory reserve. To assess markers of fluid responsiveness in hypovolemic infants, we studied those undergoing cranial vault reconstructive surgery-a procedure associated with significant blood loss. We aimed to determine the ability of the Compensatory Reserve Index (CRI) monitor, which provides a continuous, individual-specific, beat-to-beat estimate of central volume status, to distinguish fluid responders from non-responders.Methods: A prospective observational pilot study of infants undergoing cranial vault reconstructive surgery for craniosynostosis was performed from May 2019-January 2020. A CardioQ-Esophageal Doppler Monitor, which measures changes in peak aortic velocity, was utilized to distinguish fluid responders- defined as those who demonstrated an increase in peak aortic velocity > 15% following a crystalloid bolus (10 mL/kg). Several static and dynamic variables were analyzed, including the CRI monitor. Each variable's performance was compared using area under the receiver operator curves (AUC), adjusting for age and bolus volume.Results: Twenty subjects were included and a total of 23 boluses (19 crystalloid and 4 blood) were administered. Of all boluses, 7 (all crystalloid) were provided to fluid responders and 16 to non-responders. There were no statistically significant differences in bolus volumes or bolus durations between responders and non-responders. While adjusting for age and bolus volume, CRI performed similarly to other bedside tools to predict fluid responsiveness with an AUC of 0.7024 (95% CI = 0.459, 0.946).Conclusion: Distinguishing infants who are fluid responders from those who are not can be challenging. CRI is a continuous, non-invasive measure that was developed using adult waveform data, yet even in very young patients is able to identify those who may benefit from additional volume expansion. Study type: Therapeutic/Care management. Level of evidence: Level II.

Two techniques for selective dorsal rhizotomy (SDR) involve stimulating and sectioning nerve rootlets either below the conus medullaris or above the entrances to their respective dural root sleeves. In general, both techniques lead to sustained improvements in lower extremity spasticity with low complication rates. To our knowledge, spinal cord tethering has not been previously reported as a complication of SDR using either technique. We review the presentation, treatment, and outcome of two patients who developed symptomatic spinal cord tethering after SDR below the conus. A 4-year-old male and a 6-year-old female each with a history of spastic diparetic cerebral palsy underwent L1–L2 osteoplastic laminectomy and SDR below the conus. Both surgeries went well with no known complications. Both patients initially did well, with marked improvement in their tone and gait. There were no significant immediate postoperative bowel or bladder problems. The male patient presented 10 months after surgery with new-onset urinary incontinence. A urological evaluation was performed but no imaging was performed. He re-presented 8 months later with worsened urinary incontinence, new fecal incontinence, and worsened gait. An MRI showed signs of tethering, including a holocord syrinx. He underwent two untethering surgeries as well syrinx fenestration, and although his gait improved, it remained worse than it had been several months after surgery. The incontinence did not improve. The second patient also developed urinary incontinence a year after SDR. Due to our experience with the first patient, we obtained an MRI immediately and found evidence of tethering. She underwent untethering and her incontinence improved. We report two cases of spinal cord tethering after SDR below the conus, a previously unreported complication. It is important to realize that this complication can occur after SDR.

OBJECTIVEPrior to 2019, the majority of patients at Children's Hospital Colorado were admitted to the pediatric intensive care unit (PICU) following Chiari malformation (CM) decompression surgery. This study sought to identify the safety and efficacy of postoperative general ward management for these patients.METHODSAfter a retrospective baseline assessment of 150 patients, a quality improvement (QI) initiative was implemented, admitting medically noncomplex patients to the general ward postoperatively following CM decompression. Twenty-one medically noncomplex patients were treated during the QI intervention period. All patients were assessed for length of stay, narcotic use, time to ambulation, and postoperative complications.RESULTSPICU admission rates postoperatively decreased from 92.6% to 9.5% after implementation of the QI initiative. The average hospital length of stay decreased from 3.4 to 2.6 days, total doses of narcotic administration decreased from 12.3 to 8.7, and time to ambulation decreased from 1.8 to 0.9 days. There were no major postoperative complications identified that were unsuitable for management on a conventional pediatric medical/surgical nursing unit.CONCLUSIONSMedically noncomplex patients were safely admitted to the general ward postoperatively at Children's Hospital Colorado after decompression of CM. This approach afforded decreased length of stay, decreased narcotic use, and decreased time to ambulation, with no major postoperative complications.

A 9-year-old male presented to the Children's Colorado Emergency Department (ED) after losing consciousness and falling face-first onto a sidewalk while being escorted from a 4th of July parade. He had a mild headache and nausea that worsened as the parade progressed. En route to the hospital, his temperature was 105℉ and he had a tonic-clonic seizure. He had had a head injury one week prior. He had been jumping on a trampoline with siblings when his sister landed on his head. There was no loss of consciousness and he denied headache or nausea afterward. Computed tomography (CT) of his head (not shown) had been reportedly negative. By the time he arrived at the ED this time, he was awake but still had a headache and nausea. On examination, he had nuchal rigidity with gait ataxia and positive Romberg testing. Head CT (Fig. 1A) showed a focal linear hyperdensity in the region of the left Sylvian fissure. There was concern for subarachnoid hemorrhage (SAH) given his two recent head injuries. Later, the same hyperdensity was retrospectively noted on his previous CT. Subsequent magnetic resonance imaging with angiography (MRI/MRA) (Fig. 1B) revealed the hyperdensity to be a large left temporal lobe developmental venous anomaly (DVA). There was no aneurysm. By the next morning, the patient's symptoms and findings had all resolved. It was thought that he had suffered acute hyperthermia. Developmental venous anomalies of the brain are congenital abnormalities that arise from incomplete development of the venous system. They can be found in up to 2.6 % of autopsy studies and are thought to be harmless. They can be associated with sporadic cerebral cavernous malformations. Rare cases of hemorrhage have been reported, but usually in association with cavernous malformations. As DVAs provide venous drainage to the brain, it is important not to damage them during resection of cavernous malformations. The Sylvian fissure is a common place for both posttraumatic and aneurysmal SAH. Sometimes, after trauma, it is unclear whether SAH resulted from the trauma or from aneurysmal rupture. As shown in this report, however, hyperdensity in the region of the Sylvian fissure on CT may not represent SAH. In certain circumstances, if further imaging is being contemplated to search for the source of SAH, providers may consider MRI/MRA with contrast versus CT or catheter angiography, as other lesions will be better seen on MR imaging.