Myelomeningocele complications

Myelomeningocele complications

Associated problems include poor ability to walk, problems with bladder or bowel control, hydrocephalus, a tethered spinal cord, and latex allergy.

Closure of a myelomeningocele is a deceptively simple operation; however, attention to several subtle details can significantly reduce operative complications. Important preoperative concerns include social issues of dealing with a distraught and often overwhelmed family, the timing of surgery, and assessment of associated severe or life-threatening malformations. Operative intervention should be directed toward preserving neurological function and optimizing the subsequent repair of a tethered spine should this become necessary. Careful attention to the vascular supply to the placode, precise separation of neural from cutaneous tissues, a diligent search for associated tethering anomalies such as diastematomyelia and a thickened filum terminale, careful pia to pia reconstruction of the placode, and simple but meticulous wound closure all help in achieving these aims. The timely management of associated hydrocephalus will help to avoid cerebrospinal fluid leakage and wound dehiscence. Close attention to these details will ameliorate many of the immediate and delayed complications of myelomeningocele closure 1).


Patients with Myelomeningocele (MMC) have multiple risk factors for venous thrombosis, but this complication rarely occurs. This lower rate of venous thrombosis in MMC children could be related to some characteristics of the vessels in the lower extremities. A study of Salari et al. aimed at finding explanations for this dilemma.

A case control study was designed in the Children’s Hospital Medical Center Tehran considering paraplegia patients with MMC as the case group and nonparaplegic MMC patients as a control group. Doppler ultrasound was performed to evaluate femoral artery and popliteal artery and venous properties.

Patients aged from 8 months to 12 years were evaluated. The mean diameter of the femoral arteries was 3.73 ± 0.23 and 4.72 ± 0.39 mm among paraplegic and nonparaplegic MMC patients, respectively (p = 0.02). The femoral artery flow was 0.52 ± 0.08 and 0.75 ± 0.06 L/min, respectively in the case and control groups (p = 0.015). The diameters of the femoral veins were 4.85 ± 0.34 and 5.13 ± 0.32 mm in the case and control groups, respectively (p > 0.05). Besides, the blood flows of the case and control groups’ femoral veins were 0.27 ± 0.08 and 0.14 ± 0.01 L/min, respectively (p = 0.6). It turned out that lower extremities’ arteries in the case group had significantly lower blood flow and diameter compared to those of the control group. However, the same venous properties did not show any significant differences.

The decreased arterial flow along with the unchanged venous properties leads to less stasis and better drainage of the blood, which in turn might result in a lower incidence of deep vein thrombosis 2).


Tethered cord syndrome as many as 70 % of Myelomeningocele (MM) patients have a tethered cord radiographically (some quote 10–20%), but only a minority are symptomatic. Unfortunately there is no good test to check for symptomatic retethering (SSEPs may deteriorate, 3) myelography may help)

Hydrocephalus develops in up to 80-90% of children with myelomeningocele (MM) after closure of the defect.

Traditionally, ventriculoperitoneal shunts have been used to manage hydrocephalus in these patients. A role for endoscopic third ventriculostomy (ETV) in MM has provoked much debate, principally due to anatomical variants described, which may complicate the procedure.

Perez da Rosa et al. present 7 cases of children with MM and hydrocephalus undergoing a total of 10 ETV procedures. All patients demonstrated clinical improvement (in acute/subacute cases) or stabilization (in chronic cases). Three patients requiring a second ETV have shown clinical stability and renewed radiological evidence of functioning ventriculostomies in follow-up since reintervention. ETV can be used, albeit cautiously, in selected cases of hydrocephalus associated with MM. However, the frequency with which anatomical variation is encountered and the difficulty of the assessment of success make the procedure more challenging than usual 4).

References

1)

McLone DG, Dias MS. Complications of myelomeningocele closure. Pediatr Neurosurg. 1991-1992;17(5):267-73. PubMed PMID: 1822692.
2)

Salari F, Golpayegani M, Habibi Z, Yaghoubi S, Anbarlouei M, Mehdizadeh M, Nejat F. Evaluation of Lower Extremities’ Vascular Characteristics in Myelomeningocele Patients: A Case-Control Study. Pediatr Neurosurg. 2019 Sep 5:1-5. doi: 10.1159/000502403. [Epub ahead of print] PubMed PMID: 31487737.
3)

Larson SJ, Sances A, Christenson PC. Evoked Somatosensory Potentials in Man. Arch Neurol. 1966; 15:88–93
4)

Perez da Rosa S, Millward CP, Chiappa V, Martinez de Leon M, Ibáñez Botella G, Ros López B. Endoscopic Third Ventriculostomy in Children with Myelomeningocele: A Case Series. Pediatr Neurosurg. 2015;50(3):113-8. doi: 10.1159/000381747. Epub 2015 May 27. PubMed PMID: 26021675.

Head fixation device complications in pediatric neurosurgery

Head fixation device complications in pediatric neurosurgery

Head Fixation in pediatric neurosurgery is associated with complications.

They are widely used among pediatric neurosurgeons in patients younger than 5 years old. Guidelines for their safe use are not well defined despite common use and experience of significant complications associated with such devices 1).


Variability in the thickness of the developing cranium necessitates age-specific considerations to reduce the risk of adverse events. To suggest possible guidelines for the use of cranial fixation pins in children, Berry et al. surveyed neurosurgeons treating pediatric patients regarding their experience with such devices.

An Institutional Review Board-approved, 30-item multiple choice survey was provided by electronic mail to 605 neurosurgeons treating pediatric patients. The survey included specific questions regarding their experience with cranial fixation pins with respect to age ranges of patients, selection of pin size, type of pin pressure applied, and complications encountered.

One hundred sixty-four (27%) responses were received. One hundred fifty-eight of the 164 (96%) neurosurgeons reported using cranial fixation pins in their pediatric practice. Forty-four of the 164 (27%) apply fixation pins in patients aged 1 to 2 years. Eighty-two (50%) apply pins in patients aged 2 to 3 years, and 89 (54%) apply pins in patients aged 3 to 4 years. For patients aged 2 to 5 years old, the majority of responders use between 10 and 40 pounds of pressure, whereas for those older than 5 years of age, most use between 30 and 40 pounds of pressure. After age 10, patients are treated as adults. Eighty-nine of the 164 (54%) responders reported complications directly related to the use of cranial fixation pins, including cranial fracture, epidural or subdural hematoma, scalp laceration, or cerebrospinal fluid leak. One hundred fifty-four of the 164 (94%) neurosurgeons responded that they are not aware of any standard guidelines for cranial fixation pin use in pediatric patients. Seven (4%) who stated that they were aware of guidelines did not describe where they obtained those guidelines.

Cranial fixation pins are widely used among pediatric neurosurgeons in patients younger than 5 years old. Guidelines for their safe use are not well defined despite common use and experience of significant complications associated with such devices. 2).


Udayakumaran et al. applied a headband made of Plaster of Paris (POP) around the head and then applying the fixation pins of the fixation frame directly on to the POP.

They used this technique of head fixation successfully for infants with no complications 3).


Agrawal et al. described an extremely simple technique of head fixation for image-guided neurosurgery in young children in whom standard pin fixation cannot be used.

This involves positioning the head on a horseshoe headrest and using a ‘U-drape’ to fix the head to the headrest.

Over the last 5 years, this technique of head fixation (in conjunction with Stealthstation) has been used for various neurosurgical procedures in more than ten infants successfully 4).


Rubber plugs (usually used for antibiotic bottles) pierced by the skull pins are used to avoid intracranial penetration of the pins. The upper surface of the rubber plugs attached to the scalp contributes to support of the head. Four infants were successfully treated in a prone position with this technique 5).


Gupta adapted a standard Mayfield horseshoe headrest and cranial fixation system to allow simultaneous use of the headrest and three-point pin fixation. The system is compatible with most neuronavigational systems.

The combined horseshoe and pin system was used successfully in more than 30 patients ranging in age from 6 months to 14 years. No complications were encountered.

Rigid immobilization is achievable in the pediatric population, facilitating intracranial and frameless stereotaxy procedures 6).

Case series

Five of 766 children (0.65%) undergoing craniotomies with pin fixation of the head had depressed skull fractures and/or epidural hematomas from the pin fixation. Age ranged from 2.6 to 7.5 years; all fractures were temporal and occurred during posterior fossa craniotomies 7).


Lee et al. examined complications over the past 6 years, and encountered 5 children with depressed skull fractures secondary to the application of a skull clamp fixation device. There were 3 boys and 2 girls with ages ranging from 3 to 8 years (mean 5.8 years). Two patients had brainstem gliomas, 2 patients had hypothalamic gliomas and 1 patient had a medulloblastoma. Four of the children required separate cranial procedures for the exploration and elevation of the depressed fractures. There were no sequelae associated with the depressed fractures. We conclude that skull clamp fixation devices are safe, but should be used with caution in the pediatric patient. In addition, we present several modifications of existing skull clamps which may decrease the risk of depressed skull fractures 8).

Case reports

An 11-year-old girl diagnosed with non-communicating hydrocephalus, caused by a posterior fossa tumor. During the surgery, complications were found in the form of acute epidural hematoma due to head fixation pins. So, the operation was stopped. An emergent CT scan was carried out and showed a bilateral skull fracture and a massive right-sided epidural hematoma. An emergency craniotomy for clot removal was performed and five days later, a second surgery was carried out uneventfully for the residual tumor. The patient fully recovered after the second surgery.

Complications due to the use of a pinhead fixation are easier to occur in pediatric patients because the bones are thinner and need a more careful strategy when pinning. With prompt identification of any complications and earlier treatment, a good outcome will be achieved.

Parenrengi et al. compared this case report with published literature in order to suggest a way to prevent this complication.

Skull fractures and associated epidural hematomas in pediatric patients need to be considered as possible complications of the pin-type head fixation application. The head fixation devices in pediatric need to be used with great caution and knowing the risk factors, safe technique for application and management of complications will prevent a worse outcome 9).


A 4-year-old girl who sustained a depressed skull fracture by penetration of a pin of the head holder. The fracture was noted at the end of the surgery performed for treatment of a cerebellar astrocytoma and was managed conservatively.

Several factors seem to be involved in the production of this complication as are faulty application of the pins, excessive pin pressure, skull thinning, young patient’s age, and pathological conditions that evolve with long-standing raised intracranial pressure 10).


A 5-month-old girl with a growing lesion in the right thalamus and basal ganglia underwent stereotactic biopsy, which disclosed an anaplastic astrocytoma. To avoid insertion of the four stereotactic frame fixation pins through the infant’s skin and into bone, the pins were advanced into the hollowed end of rubber tops obtained from Vacutainer blood sampling tubes. The pressure applied to the skin was diffused through the rubber onto a wide skin surface, obviating skin puncture or bone deformation. This technique provided firm head fixation, and target accuracy was confirmed on postoperative imaging. This technique is safe and should permit the use of conventional stereotactic techniques in young infants 11).

References

1) , 2)

Berry C, Sandberg DI, Hoh DJ, Krieger MD, McComb JG. Use of cranial fixation pins in pediatric neurosurgery. Neurosurgery. 2008 Apr;62(4):913-8; discussion 918-9. doi: 10.1227/01.neu.0000318177.95288.cb. PubMed PMID: 18496197.
3)

Udayakumaran S, Onyia CU. Customizable rigid head fixation for infants: technical note. Childs Nerv Syst. 2016 Jan;32(1):159-61. doi: 10.1007/s00381-015-2896-y. Epub 2015 Sep 4. PubMed PMID: 26337702.
4)

Agrawal D, Steinbok P. Simple technique of head fixation for image-guided neurosurgery in infants. Childs Nerv Syst. 2006 Nov;22(11):1473-4. Epub 2006 Sep 19. PubMed PMID: 17047964.
5)

Aoki N, Sakai T. Modified application of three-point skull clamp for infants. Neurosurgery. 1989 Oct;25(4):660-2. PubMed PMID: 2677825.
6)

Gupta N. A modification of the Mayfield horseshoe headrest allowing pin fixation and cranial immobilization in infants and young children. Neurosurgery. 2006 Feb;58(1 Suppl):ONS-E181; discussion ONS-E181. PubMed PMID: 16462615.
7)

Vitali AM, Steinbok P. Depressed skull fracture and epidural hematoma from head fixation with pins for craniotomy in children. Childs Nerv Syst. 2008 Aug;24(8):917-23; discussion 925. doi: 10.1007/s00381-008-0621-9. Epub 2008 Apr 4. PubMed PMID: 18389258.
8)

Lee M, Rezai AR, Chou J. Depressed skull fractures in children secondary to skull clamp fixation devices. Pediatr Neurosurg. 1994;21(3):174-7; discussion 178. PubMed PMID: 7803306.
9)

Parenrengi MA, Adhiatmadja F, Arifianto MR, Apriawan T, Fauzi AA, Servadei F. Bilateral skull fracture with massive epidural hematoma secondary to pin-type head fixation in a pediatric patient: Case report and review of the literature. Int J Surg Case Rep. 2019 Aug 13;62:43-49. doi: 10.1016/j.ijscr.2019.07.079. [Epub ahead of print] PubMed PMID: 31445499.
10)

Martínez-Lage JF, Almagro MJ, Serrano C, Mena L. Depressed skull fracture by a three-pin head holder: a case illustration. Childs Nerv Syst. 2011 Jan;27(1):163-5. doi: 10.1007/s00381-010-1213-z. Epub 2010 Jun 24. PubMed PMID: 20574740.
11)

Kondziolka D, Adelson PD. Technique of stereotactic biopsy in a 5-month-old child. Childs Nerv Syst. 1996 Oct;12(10):615-8. PubMed PMID: 8934022.

Transsphenoidal approach complications

Transsphenoidal approach complications

No significant differences in surgical outcomes, mortality during the perioperative period or complications were observed between patients younger than 14 years old and similar patients in the general population 1).


Microsurgical and endoscopic techniques are commonly utilized surgical approaches to pituitary pathologies. There are limited data comparing these 2 procedures.

To evaluate postoperative complications, associated costs, and national and regional trends of microscopic and endoscopic techniques in the United States employing a nationwide database.

The Truven MarketScan database 2010 to 2014 was queried and Current Procedural Terminology codes identified patients that underwent microscopic and/or endoscopic transsphenoidal pituitary surgery. International Classification of Diseases codes identified postoperative complications. Adjusted logistic regression and matched propensity analysis evaluated independent odds for complications.

Among 5886 cases studied, 54.49% were microscopic and 45.51% endoscopic. The commonest surgical indications were benign pituitary tumors. Annual trends showed increasing utilization of endoscopic techniques vs microscopic procedures. Postoperative complications occurred in 40.04% of cases, including diabetes insipidus (DI; 16.90%), syndrome of inappropriate antidiuretic hormone (SIADH; 2.02%), iatrogenic hypopituitarism (1.36%), fluid/electrolyte abnormalities (hypoosmolality/hyponatraemia [5.03%] and hyperosmolality/hypernatraemia [2.48%]), and cerebrospinal fluid (CSF) leaks (CSF rhinorrhoea [4.42%] and other CSF leak [6.52%]). In our propensity-based model, patients that underwent endoscopic surgery were more likely to develop DI (odds ratio [OR] = 1.48; 95% confidence interval [CI] = 1.28-1.72), SIADH (OR = 1.53; 95% CI = 1.04-2.24), hypoosmolality/hyponatraemia (OR = 1.17; 95% CI = 1.01-1.34), CSF rhinorrhoea (OR = 2.48; 95% CI = 1.88-3.28), other CSF leak (OR = 1.59; 95% CI = 1.28-1.98), altered mental status (OR = 1.46; 95% CI = 1.01-2.60), and postoperative fever (OR = 4.31; 95% CI = 1.14-16.23). There were no differences in hemorrhagic complications, ophthalmological complications, or bacterial meningitis. Postoperative complications resulted in longer hospitalization and increased healthcare costs.

Endoscopic approaches are increasingly being utilized to manage sellar pathologies relative to microsurgery. Postoperative complications occur in both techniques with higher incidences observed following endoscopic procedures 2).

Internal carotid artery injury

Internal carotid artery injury is a potentially lethal complication in transsphenoidal approach for pituitary lesions. The intercarotid distance (ICD) is thus a major parameter, determining the width of the surgical corridor.


Cerebrospinal fluid leak after endoscopic skull base surgery

Endoscopic transnasal surgery for tumors located at the base of the skull has a high incidence of postoperative cerebrospinal fluid leaks.

see Cerebrospinal fluid leak after endoscopic skull base surgery


Transnasal transsphenoidal (TNTS) resection of pituitary tumors involves wide fluctuation in hemodynamic parameter and causes hypertension and tachycardia due to intense noxious stimuli during various stages of surgery. None of routinely used anesthetic agents effectively blunts the undesirable hemodynamic responses, and therefore usually there is a need to use increased doses of anesthetic agents. Dexmedetomidine may ensure optimal intraoperative hemodynamic stability during critical moments of surgical manipulation. In addition, DEX reduced the anesthetic requirement with rapid recovery at the end of surgery.

DEX as an anesthetic adjuvant improved hemodynamic stability and decreased anesthetic requirements in patients undergoing Transsphenoidal resection of pituitary tumor. In addition, DEX provided better surgical field exposure conditions and early recovery from anesthesia 3).

Sinonasal complications

A high incidence of nasal complications after conventional transsphenoidal surgery observed through examination and not reported spontaneously point to the need of otorhinolaryngological investigation complemented by nasal endoscopy in patients submitted to procedures through this route4)

Olfactory dysfunction

The patients must be informed that their olfaction may be impaired 5).

Obstruction

The percentage of nasal obstruction and nasal crusting was 38% in Monnier’s series evaluating the transvestibular transeptal approach 6).

Chronic nasal irritation was seen in only 2% of cases in Feigenbaun et al.’s series 7).


A study assessed the long-term impact of endoscopic skull base surgery on olfaction, sinonasal symptoms, mucociliary clearance time (MCT), and quality of life (QoL). Patients with pituitary adenomas underwent TTEA (n = 38), while patients with other benign parasellar tumours who underwent an EEA with vascularised nasoseptal flap reconstruction (n = 17) were enrolled in this prospective study between 2009 and 2012. Sinonasal symptoms (Visual Analogue Scale), subjective olfactometry (Barcelona Smell Test-24, BAST-24), MCT (saccharin test), and QoL (short form SF-36, rhinosinusitis outcome measure/RSOM) were evaluated before, and 12 months after, surgery. At baseline, sinonasal symptoms, MCT, BAST-24, and QoL were similar between groups. Twelve months after surgery, both TTEA and EEA groups experienced smell impairment compared to baseline. Moreover, EEA (but not TTEA) patients reported increased posterior nasal discharge and longer MCTs compared to baseline. No significant changes in olfactometry or QoL were detected in either group 12 months after surgery. Over the long-term, expanded skull base surgery, using EEA, produced more sinonasal symptoms (including loss of smell) and longer MCTs than pituitary surgery (TTEA). EEA showed no long-term impact on smell test or QoL 8).

Hyponatremia after transsphenoidal surgery

References

1)

Zhao Y, Lian W, Xing B, Wang R. The characteristics of and surgical treatment for pituitary adenomas in patients under 14 years old. Clin Neurol Neurosurg. 2019 Jul 12;184:105423. doi: 10.1016/j.clineuro.2019.105423. [Epub ahead of print] Review. PubMed PMID: 31376772.
2)

Asemota AO, Ishii M, Brem H, Gallia GL. Comparison of Complications, Trends, and Costs in Endoscopic vs Microscopic Pituitary Surgery: Analysis From a US Health Claims Database. Neurosurgery. 2017 Sep 1;81(3):458-472. doi: 10.1093/neuros/nyx350. PubMed PMID: 28859453.
3)

Gopalakrishna KN, Dash PK, Chatterjee N, Easwer HV, Ganesamoorthi A. Dexmedetomidine as an Anesthetic Adjuvant in Patients Undergoing Transsphenoidal Resection of Pituitary Tumor. J Neurosurg Anesthesiol. 2014 Dec 9. [Epub ahead of print] PubMed PMID: 25493927.
4)

Petry C, Leães CG, Pereira-Lima JF, Gerhardt KD, Sant GD, Oliveira Mda C. Oronasal complications in patients after transsphenoidal hypophyseal surgery. Braz J Otorhinolaryngol. 2009 May-Jun;75(3):345-9. English, Portuguese. PubMed PMID: 19649482.
5)

Kim BY, Kang SG, Kim SW, Hong YK, Jeun SS, Kim SW, Kim HB, Kim M, Maeng JH, Lee DC, Cho JH, Park YJ. Olfactory changes after endoscopic endonasal transsphenoidal approach for skull base tumors. Laryngoscope. 2014 Mar 13. doi: 10.1002/lary.24674. [Epub ahead of print] PubMed PMID: 24623575.
6)

Monnier DS. Séquelles endonasales après hypophysectomie. Ann Otolaryngol Chir Cervicofac. 1998;115:49-53.
7)

Feigenbaum SL, Downey DE, Wilson CB, Jaffe RB. Transsphenoidal pituitary resection for preoperative diagnosis of prolactin-secreing pituitary adenoma in women: long term follow-up. J Clin Endocrinol Metab. 1996;81(5):1711-19
8)

Rioja E, Bernal-Sprekelsen M, Enriquez K, Enseñat J, Valero R, de Notaris M, Mullol J, Alobid I. Long-term outcomes of endoscopic endonasal approach for skull base surgery: a prospective study. Eur Arch Otorhinolaryngol. 2016 Jul;273(7):1809-17. doi: 10.1007/s00405-015-3853-9. Epub 2015 Dec 19. PubMed PMID: 26688432.
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