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  • Author or Editor: James Drakex
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Occult tethered cord syndrome: not an indication for surgery

James M. Drake

Object

The author describes the paucity of information known about occult tethered cord syndrome and summarizes the argument for using a nonsurgical approach in these cases.

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回顾我们所做的,不知道这个syndrome is provided. Surgical procedures to divide the terminal filum in patients with symptoms of tethered spinal cord without the imaging correlates are said to result in clinical improvement, yet there is little physiological evidence to support the surgical release of the filum in the absence of other anatomical lesions. Validated diagnostic and outcome measures are also lacking, which makes the interpretation of reported results exceedingly difficult. Finally, reports used to support surgical intervention are limited by small size, the absence of control groups, and observer bias.

Conclusions

Without conclusive clinical evidence, the arguments supporting surgery for occult tethered cord syndrome must be viewed cautiously.

In开云手机版app下载安装最新版儿科神经外科杂志:体积开云体育app官方网站下载入口104: Issue 5 (May 2006)

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Surgical management of the tethered spinal cord—walking the fine line

James M. Drake

✓The tethered spinal cord is a fascinating yet controversial condition seen frequently in neurosurgical practice. Treatment decision making is made difficult by the variety of lesions and clinical presentations comprised by this condition and the absence of high-quality clinical outcome data to provide guidance. Clinical presentations may be divided into four general categories or typical scenarios: 1) significant dysraphic abnormality, clear clinical deterioration; 2) significant dysraphic abnormality, clinically normal or stable deficit; 3) incidentally discovered abnormality, other problem; and 4) tethered spinal cord symptomatology, normal imaging. The author provides case examples to illustrate potential treatment approaches and suggests balancing the risks and benefits for each general category.

Clearer diagnostic and treatment strategies for the tethered spinal cord will only result from high-quality clinical and basic research. Until the results of such research are available, surgeons should endeavor to maximize benefit and reduce risk for patients who may have a tethered spinal cord, walking the fine line between over- and undertreatment.

InNeurosurgical Focus Volume 23: Issue 2 (Aug 2007): Tethered Cord

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Reversibility of functionally injured neurotransmitter systems with shunt placement in hydrocephalic rats: implications for intellectual impairment in hydrocephalus

Yuzuru Tashiro and James M. Drake

Intellectual impairment has been related to alteration of neuronal innervation in the following regions: cholinergic basal forebrain nuclei (Ch1–Ch6, learning and memory), dopaminergic ventral tegmental area (emotional control), and noradrenergic locus ceruleus (cognition). Recent studies have implicated neuronal injury in the pathogenesis of hydrocephalus.

Object.The authors used immunohistochemical techniques to investigate functional injury in these regions in animals with progressive hydrocephalus, following shunt placement for cerebrospinal fluid (CSF) drainage.

Methods.Hydrocephalus was induced in 20 Wistar rats by intracisternal injection of 0.05 ml of 25% kaolin solution. Four control animals (Group 1) received the same volume of saline. Ventriculoperitoneal shunts were inserted in eight rats at 2 and 4 weeks after kaolin injection and the animals were killed at 8 weeks (Group 2). The other 12 hydrocephalic animals were killed at 2, 4, and 8 weeks without undergoing shunt placement (Group 3). Immunoreactive (IR) neurons to choline acetyltransferase (ChAT) in Ch1–Ch6, tyrosine hydroxylase (TH) in the ventral tegmental area, and dopamine B-hydroxylase (DBH) in the locus ceruleus, as well as IR projection fibers in the terminal areas, were compared between groups. The number of ChAT- and TH-IR neurons in rats with and without shunt placement was counted for quantitative analysis. The number of ChAT-IR neurons was progressively reduced during the development of hydrocephalus in Ch1, Ch2, Ch3, and Ch4 (p < 0.05). Tyrosine-hydroxylase-immunoreactive neurons were also reduced in number, and demonstrated decreased projection fibers and terminals. Early shunting (at 2 weeks) restored ChAT and TH immunoreactivity to control levels, but late shunting (at 4 weeks) did not (p < 0.05). The DBH—IR neurons in the locus ceruleus were remarkably compressed by the dilated fourth ventricle, and diminished immunoreactivity was observed in the terminal areas. Shunt placement for CSF also restored the immunoreactivity in this system.

Conclusions.These findings indicate that a progressive functional injury occurs in the cholinergic, dopaminergic, and noradrenergic systems as a result of hydrocephalus. This may contribute to intellectual impairment and might be prevented by early treatment with shunt placement.

InJournal of Neurosurgery Volume 88: Issue 4 (Apr 1998)

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Does double gloving prevent cerebrospinal fluid shunt infection?

James M. Drake

In开云手机版app下载安装最新版儿科神经外科杂志:体积开云体育app官方网站下载入口104: Issue 1 (Jan 2006)

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Introduction by Topic Editors, Peter W. Carmel, M.D., and James M. Drake, M.D.

Peter W. Carmel and James Drake

InNeurosurgical Focus Volume 7: Issue 4 (Oct 1999): Hydrocephalus

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Shunt Infections

InJournal of Neurosurgery Volume 85: Issue 5 (Nov 1996)

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Magnetic Resonance Imaging Surveillance

InJournal of Neurosurgery Volume 79: Issue 3 (Sep 1993)

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Needs assessment for simulation training in neuroendoscopy: a Canadian national survey

Clinical article

Faizal A. Haji, Adam Dubrowski, James Drake, and Sandrine de Ribaupierre

Object

In recent years, dramatic changes in surgical education have increased interest in simulation-based training for complex surgical skills. This is particularly true for endoscopic third ventriculostomy (ETV), given the potential for serious intraoperative errors arising from surgical inexperience. However, prior to simulator development, a thorough assessment of training needs is essential to ensure development of educationally relevant platforms. The purpose of this study was to conduct a national needs assessment addressing specific goals of instruction, to guide development of simulation platforms, training curricula, and assessment metrics for ETV.

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Canadian neurosurgeons performing ETV were invited to participate in a structured online questionnaire regarding the procedural steps for ETV, the frequency and significance of intraoperative errors committed while learning the technique, and simulation training modules of greatest potential educational benefit. Descriptive data analysis was completed for both quantitative and qualitative responses.

Results

Thirty-two (55.2%) of 58 surgeons completed the survey. All believed that virtual reality simulation training for ETV would be a valuable addition to clinical training. Selection of ventriculostomy site, navigation within the ventricles, and performance of the ventriculostomy ranked as the most important steps to simulate. Technically inadequate ventriculostomy and inappropriate fenestration site selection were ranked as the most frequent/significant errors. A standard ETV module was thought to be most beneficial for resident training.

Conclusions

To inform the development of a simulation-based training program for ETV, the authors have conducted a national needs assessment. The results provide valuable insight to inform key design elements necessary to construct an educationally relevant device and educational program.

InJournal of Neurosurgery Volume 118 (2013): Issue 2 (Feb 2013)

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Design and evaluation of a new synthetic brain simulator for endoscopic third ventriculostomy

Gerben E. Breimer, Vivek Bodani, Thomas Looi, and James M. Drake

OBJECT

Endoscopic third ventriculostomy (ETV) is an effective but technically demanding procedure with significant risk. Current simulators, including human cadavers, animal models, and virtual reality systems, are expensive, relatively inaccessible, and can lack realistic sensory feedback. The purpose of this study was to construct a realistic, low-cost, reusable brain simulator for ETV and evaluate its fidelity.

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A brain silicone replica mimicking normal mechanical properties of a 4-month-old child with hydrocephalus was constructed, encased in the replicated skull, and immersed in water. Realistic intraventricular landmarks included the choroid plexus, veins, mammillary bodies, infundibular recess, and basilar artery. The thinned-out third ventricle floor, which dissects appropriately, is quickly replaceable. Standard neuroendoscopic equipment including irrigation is used. Bleeding scenarios are also incorporated. A total of 16 neurosurgical trainees (Postgraduate Years 1–6) and 9 pediatric and adult neurosurgeons tested the simulator. All participants filled out questionnaires (5-point Likert-type items) to rate the simulator for face and content validity.

RESULTS

The simulator is portable, robust, and sets up in minutes. More than 95% of participants agreed or strongly agreed that the simulator's anatomical features, tissue properties, and bleeding scenarios were a realistic representation of that seen during an ETV. Participants stated that the simulator helped develop the required hand-eye coordination and camera skills, and the training exercise was valuable.

CONCLUSIONS

一个低成本、可重用、硅树脂ETV模拟器realistically represents the surgical procedure to trainees and neurosurgeons. It can help them develop the technical and cognitive skills for ETV including dealing with complications.

In开云手机版app下载安装最新版儿科神经外科杂志:体积开云体育app官方网站下载入口15 (2015): Issue 1 (Jan 2015)

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Management and outcome of spontaneous subaponeurotic fluid collections in infants: the Hospital for Sick Children experience and review of the literature

Shelly Wang, James Drake, and Abhaya V. Kulkarni

OBJECTIVE

Spontaneous subaponeurotic fluid collection (SSFC) is an uncommon and newly described entity of unknown etiology, observed in infants less than 1 year of age. The authors report on series of infants who presented to the Hospital for Sick Children (HSC) with SSFC, focusing on the natural history of this condition.

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Data from the Hospital for Sick Children were retrospectively reviewed for the period between January 2004 and June 2015. Patient age and sex, birth history, medical history, laboratory findings, and symptoms were reviewed. SSFC location, imaging characteristics, management, and outcome were also analyzed. A MEDLINE and Embase literature search was performed on the condition, yielding previously reported cases of SSFC in the English language.

RESULTS

Nine cases involving patients who presented with SSFC during the study period were identified. The patients were 4 male and 5 female infants (age range 5 weeks to 11 months). All cases of SSFC developed spontaneously over a period of days, and the infants had no history of injuries, trauma, or hair manipulation in the immediate period preceding the development of the subgaleal collections. Six patients underwent remote forceps- or vacuum-assisted instrumented births, although none of the patients developed scalp collections or skin discoloration immediately after birth. All of the cases were managed conservatively on an outpatient (6 cases) or inpatient (3 cases) basis. In 1 case, the size of the fluid collection fluctuated over 4 months, but in all of the cases, the collections resolved spontaneously without structural or infectious complications.

CONCLUSIONS

This is the largest series describing SSFC to date and summarizes 9 cases managed at a large academic neurosurgical center. Although the specific pathophysiology of SSFC remains unknown, in some cases the condition may be associated with a remote history of instrumented delivery. SSFC occurs spontaneously without immediate preceding trauma, and an extensive hematology or child abuse workup is not necessary. A conservative approach with outpatient follow-up is advocated.

In开云手机版app下载安装最新版儿科神经外科杂志:体积开云体育app官方网站下载入口18 (2016): Issue 4 (Oct 2016)

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