Treatment of pediatric extra-axial sinogenic infection: case series and literature review

PURPOSE: Analyze the clinical presentation, microbiology, outcomes, and medical and surgical treatment strategies of intracranial extension of sinogenic infection in pediatric patients. METHODS: A retrospective, single-center study of patients \u3c 18 years of age, presenting with intracranial extension of bacterial sinogenic infections requiring surgical intervention over a 5-year period, was conducted. Electronic medical records were reviewed for age, sex, primary symptoms, duration of symptoms, presence of sinusitis at initial presentation, microorganisms isolated, mode of surgery, timing of surgery, length of stay, and neurologic sequelae. RESULTS: Seventeen patients were identified; mean age was 10 years with 82.3% male predominance. Average duration of illness prior to presentation was 9.8 days, with 64.7% of patients displaying disease progression while on oral antibiotics prior to presentation. Sinusitis and intracranial extension were present in all patients upon admission. Simultaneous endoscopic endonasal drainage and craniotomy were performed on 70.5% of the patients, with the remaining 29.5% undergoing endonasal drainage only. Of the patients who underwent simultaneous endoscopic endonasal drainage and craniotomy, 17.6% required repeat craniotomy and 5.8% required repeat sinus surgery. The most commonly isolated organisms were S. intermedius (52.9%), S. anginosus (23.5%), and S. pyogenes (17.6%). All patients were treated postoperatively antibiotic on average 4-6 weeks. Frequently occurring long-lasting complications included seizures (29.4%) and focal motor deficits (17.6%); learning disability, anxiety disorders, impaired cognition, and sensory deficits occurred less frequently. CONCLUSION: In the case of intracranial extension of bacterial sinogenic infection, early identification and surgical treatment are crucial to avoid neurological sequelae

Magnetic kyphoplasty: A novel drug delivery system for the spinal column.

Vertebral compression fractures (VCFs) caused by metastatic malignancies or osteoporosis are devastating injuries with debilitating outcomes for patients. Minimally invasive kyphoplasty is a common procedure used for symptomatic amelioration. However, it fails in treating the underlying etiologies of VCFs. Use of systemic therapy is limited due to low perfusion to the spinal column and systemic toxicity. Localized delivery of drugs to the vertebral column can provide a promising alternative approach. A porcine kyphoplasty model was developed to study the magnetically guided drug delivery of systemically injected magnetic nanoparticles (MNPs). Jamshidi cannulated pedicle needles were placed into the thoracic vertebra and, following inflatable bone tamp expansion, magnetic bone cement was injected to the vertebral body. Histological analysis was performed after intravenous injection of MNPs. Qualitative analysis of harvested tissues revealed successful placement of magnetic cement into the vertebral body. Further quantitative analysis of histological sections of several vertebral bodies demonstrated enhanced accumulation of MNPs to regions that had magnetic cement injected during kyphoplasty compared to those that did not. By modifying the kyphoplasty bone cement to include magnets, thereby providing a guidance stimulus and a localizer, we were successfully able to guide intravenously injected magnetic nanoparticles to the thoracic vertebra. These results demonstrate an in-vivo proof of concept of a novel drug delivery strategy that has the potential to treat the underlying causes of VCFs, in addition to providing symptomatic support

Magnetic nanoparticle localization and quantification in thoracic vertebra.

<p>(<b>A</b>) Prussian blue staining of histological sections from thoracic vertebra injected with magnetic cement display heavy concentrations of magnetic nanoparticle (MNP) clusters near the blood vessels (BV), with diffuse MNPs throughout the tissue, indicating the MNPs can exit the blood vessel lumen and enter the bone marrow space. (<b>B</b>) No MNPs were noted in lumbar vertebrae or thoracic vertebra that did not have a magnet. (<b>C</b>) Quantification of Prussian blue staining in 10 fields of view of each experimental group. * Compared with thoracic vertebra containing magnets, p<0.05.</p

Schematic representation of experimental outline used to establish a porcine cement kyphoplasty model.

<p>In this experimental setup, a balloon is inserted into a porcine vertebra. Following inflation of the balloon, PMMA cement with or without magnets is injected into the vertebra. 24-hours after surgery, magnetic nanoparticles (MNPs) are injected systemically via the ear vein. (Image illustrated by Victoria Zakrzewski.).</p