International Consensus Statement on the Radiological Evaluation of Dysraphic Malformations of the Spine and Spinal Cord

Dysraphic malformations of the spine and spinal cord (DMSSC) represent a spectrum of common congenital anomalies typically (though not exclusively) affecting the lower spinal segments. These may be responsible for varying degrees of neurologic, orthopedic, and urologic morbidity. With advances in neuroimaging, it is now possible to better diagnose and evaluate these disorders both prenatally and postnatally. Neuroimaging, performed at the right time and with technique optimization, is integral in guiding clinical management. However, the terminology used to describe these lesions has become increasingly confusing, and there is a lack of consensus regarding the essential radiologic features and their clinical weighting. This variability in radiologic practice risks unstructured decision making and increases the likelihood of suboptimal, less informed clinical management. In this manuscript, the first of a series of consensus statements, we outline a standardized international consensus statement for the radiologic evaluation of children with suspected DMSSC derived from a critical review of the literature, and the collective clinical experience of a multinational group of experts. We provide recommendations for plain radiography, sonography, CT, and MR imaging in the evaluation of DMSSC with an emphasis on technique of imaging and imaging protocols

Embryology and bony malformations of the craniovertebral junction

BACKGROUND: The embryology of the bony craniovertebral junction (CVJ) is reviewed with the purpose of explaining the genesis and unusual configurations of the numerous congenital malformations in this region. Functionally, the bony CVJ can be divided into a central pillar consisting of the basiocciput and dental pivot and a two-tiered ring revolving round the central pivot, comprising the foramen magnum rim and occipital condyles above and the atlantal ring below. Embryologically, the central pillar and the surrounding rings descend from different primordia, and accordingly, developmental anomalies at the CVJ can also be segregated into those affecting the central pillar and those affecting the surrounding rings, respectively. DISCUSSION: A logical classification of this seemingly unwieldy group of malformations is thus possible based on their ontogenetic lineage, morbid anatomy, and clinical relevance. Representative examples of the main constituents of this classification scheme are given, and their surgical treatments are selectively discussed

Aggressive or conservative management in extradural hematomas in children – a challenging neurosurgical choice

Epidural hematomas (EDH) in children appear as a consequence of head trauma. Although emergency surgical intervention was the classical neurosurgical treatment for EDH, lately there has been observed a tendency to replace operation by conservative management, whenever the neurological status and imaging appearance allows it. The aim of this article is to present our experience in treating EDH in children 0-3 years old and to establish a management protocol for EDH in infants, by evaluating the clinical and neuroimaging status, of both surgically and conservatively treated patients, from hospital admission to discharge. Retrospective study includes 52 patients diagnosed with an extradural hematoma, admitted in the First Neurosurgery Department of the Clinical Hospital ‘Bagdasar-Arseni’ in Bucharest, from January 2004 to December 2013. The patients were identified by diagnosis from the clinic’s database; clinical and imaging data was extracted from the patient’s individual records and crosschecked with the operating protocols. Cerebral CT scan was the preferred imaging investigation for diagnosis. Our study includes 52 patients (26 boys and 26 girls), with a mean age of 14.5 months (range 6 weeks – 3 years old). 25 patients were surgically treated, while the other 27 received symptomatic medication and were monitored clinically and by imaging exams. The most frequent clinical manifestations were intracranial hypertension (21 patients) and psychomotor agitation (19 patients). The traumatic mechanisms were: accidental falling (38 patients), blunt head trauma (3 patients), road accident (2 patients), unspecified (8 patients) other causes (1 patient). Based on the Glasgow Coma Scale classification of TBI, 39 patients suffered a mild TBI, 7 a moderate TBI and 6 patients suffered a severe TBI. Most of the patients had a good recovery; there was a total of two deaths. The most common location for the EDHs was parietal (20 patients) and temporal-parietal (11 patients). Both surgical treatment and conservative management of EDH have a good clinical outcome. Clinical and neuroimaging evaluation at admission/reevaluation plays an imperative role in deciding the appropriate therapeutic attitude for each patient

Posttraumatic Spinal Cord Injury without Radiographic Abnormality

“Spinal Cord Injury without Radiographic Abnormality” (SCIWORA) is a term that denotes objective clinical signs of posttraumatic spinal cord injury without evidence of fracture or malalignment on plain radiographs and computed tomography (CT) of the spine. SCIWORA is most commonly seen in children with a predilection for the cervical spinal cord due to the increased mobility of the cervical spine, the inherent ligamentous laxity, and the large head-to-body ratio during childhood. However, SCIWORA can also be seen in adults and, in rare cases, the thoracolumbar spinal cord can be affected too. Magnetic resonance imaging (MRI) has become a valuable diagnostic tool in patients with SCIWORA because of its superior ability to identify soft tissue lesions such as cord edema, hematomas and transections, and discoligamentous injuries that may not be visualized in plain radiographs and CT. The mainstay of treatment in patients with SCIWORA is nonoperative management including steroid therapy, immobilization, and avoidance of activities that may increase the risk of exacerbation or recurrent injury. Although the role of operative treatment in SCIWORA can be controversial, surgical alternatives such as decompression and fusion should be considered in selected patients with clinical and MRI evidence of persistent spinal cord compression and instability