Neurosurgery/Abuse

Question 1

neurosurgery consult indications

Answer 1

• Too much brain (Brain Tumor, abscess, swollen brain)
• Too much blood (Bleeding such as subdural hematoma, epidural hematoma)
• Too much CSF (hydrocephalus)

Question 2

hydrocephalus

Answer 2

• Disorder in which there is an excessive amount of cerebrospinal fluid (CSF).
• Disorder may arise from one of three conditions or combination of the following
  
  • CSF overproduction
  • CSF circulation/flow
  • CSF absorption
• Why do we worry about Hydrocephalus?
  
  • Unfused Sutures- head enlargement, ventricles enlarge and poor brain development (common scenario of infancy)
  • Fused Sutures- increased intracranial pressure, rapid destruction of brain tissue, herniation
• Causes of Hydrocephalus in infants/children
• Defective Reabsorption
  
  • Hypoplasia of arachnoid villa
  • Post-infectious destruction of arachnoid villi
• Overproduction of CSF
  
  • Choroid Plexus papilloma
• Obstruction of CSF pathways
  
  • Brain Mass/Brain Tumor
  • Aqueductal Stenosis
  • Post-infectious/Post-inflammatory
  • Arnold Chiari Malformation
  • Dandy Walker Malformation

Question 3

Risk factors and signs of hydrocephalus

Answer 3

• Risk Factors for Infantile Hydrocephalus
  
  • Birth Weight < 1500 gms
  • Prematurity
  • Maternal Diabetes
  • Male sex
  • Race/ethnicity (Asians at decreased risk)
• Hydrocephalus Signs
  
  • Vital Signs- bradycardia, hypertension, altered respiratory rate - CUSHINGS TRIAD
  • Head Circumference/Head Shape
    
    • Macrocephaly (off the growth curve, or significantly increasing)
    • Frontal bossing
    • Prominent scalp veins
  • Cranial nerve- paresis of 3^rd or 6^th cranial nerve
    
    • 3rd nerve carries info for eyes and pupils - what you see is big pupils that arent responsive to light reflex (sometimes assymetrically)
  • Fundoscopic Exam- papilledema
  • Spine- Neural Tube Defect
  • Motor Function- spasticity
  • Growth and pubertal development- maybe altered

Question 4

diagnosis and management of hydrocephalus

Answer 4

• Diagnosis
  
  • Imaging
    
    • CT scan
    • MRI
    • Ultrasound can be of some utility in patients who have an open fontanelle
• Management
  
  • Surgical Placement of Shunt
    
    • Ventriculo-Peritoneal Shunt
      
      • Catheter placed into one of the lateral ventricles
      • Catheter is connected to right atrium or peritoneal cavity
  • Medical Therapy
    
    • Acute: hyperventillation, mannitol, 3% saline, positioning
    • Serial Lumbar Punctures (temporizing for non-acute hydrocephalus)
  • Considerations in Management
    
    • Infection of the VP Shunt
      
      • difficult to manage
      • emergent neurosurgery consult
    • Mechanical Failure of the shunt
      
      • emergent neurosurgery consult
    • Overdrainage

Question 5

child abuse

Answer 5

• Physical Abuse
• Sexual Abuse
• Shaken Baby Syndrome
• Neglect
• Child Abuse and the Social System/Foster Care

Question 6

physical abuse

Answer 6

• any non-accidental injury inflicted by a caretaker
• estimated 1-2% are physically abused in childhood
• physical abuse accounts for ~2000 deaths/year
• mothers are most frequently reported, but fathers or mother’s boyfriend are more likely to inflict serious injury
• approximately 1/3 of patients with inflicted head trauma are misdiagnosed on their first presentation to medical care
  
  • risk factors for misdiagnosis include mild injury, age under 6 months
• screening for physical abuse includes ruling out unusual diseases that have previously been mistaken for abuse
  
  • coagulopathies
  • diseases that increase risk of fracture
    
    • glutaric aciduria type I (subdural hemorrhages)
    • Osteogenesis Imperfecta
    • Rickets - even in cases where child abuse is highly likely, defense will say low vitamin D level caused the fracture

Question 7

red flags for physical abuse

Answer 7

• red flag: history inconsistent with injury
  
  • a parent unable to explain an injury (its extent, location, timing, etc.) prevents ruling out a non-accidental cause
• bruise red flags
  
  • patterned bruises
  • bruises isolated to the trunk, neck, or not over bony prominences
  • bruises in non-ambulatory infants
• burn red flags
  
  • immersion injury, particularly around buttocks and heels during toilet training
• fracture red flags
  
  • unexplained fractures
  • fractures in non-ambulatory children
  • fractures of multiple bones
  • fractures of different ages
• abdominal injury red flags
  
  • bruises over soft areas
  • injury to hollow or solid organs without explanation

Question 8

non-accidental burns

Answer 8

• unusual burn patterns raise concern for non-accidental trauma
  
  • water immersion produces full thickness burns

Question 9

workup of suspected abuse

Answer 9

• history
  
  • consistent with the injury?
  • consistent with development abilities?
  • past history of injury or unexplained illness?
• social evaluation
  
  • dysfunctional family
  • substance abuse
  • medically fragile child (premature, impaired, etc.)
• complete physical examination
  
  • may include photographs and measurements of suspicious areas
  • care for chain of evidence in forensic photography is essential
• laboratory
  
  • platelets, coagulation studies, liver function tests
• radiologic studies have much greater value in small children
  
  • skeletal survey
  • +/- bone scan
  • head imaging
• ophthalmologic examination
• evaluate for abdominal or other injuries
• social service and police referral/report

Question 10

non-abusive causes of fractures

Answer 10

• birth trauma: clavicle, humerus, skull, rib, femur-w/neuromuscular disease
• prematurity: higher risk for osteopenia, rickets
• neuromuscular defects, osteoporosis, contractures, decreased or absent pain perception
• hypophosphatasia
• neoplasm
• Osteogenesis imperfecta (OI)
  
  • 1 in 50,000 live births
  • deficiency of type I collagen, results in increased bone fragility
    
    • +/- blue sclera
    • family history
    • osteopenia
    • Wormian Bones
  • biochemical collagen test positive in 80% of OI
• Menkes syndrome
  
  • defect in copper metabolism
  • metaphyseal-epiphyseal fractures, wormian bones, periosteal reaction, sparse & kinky hair, FTT, developmental delay

Question 11

conditions mistaken for fractures

Answer 11

• congenital syphilis and osteomyelitis
  
  • metaphyseal irregularities & periosteal new bone growth
• drug toxicity
  
  • methotrexate - periosteal reaction, metaphyseal fx
  • prostaglandin E - diaphyseal periostitis
  • hypervitaminosis A - diaphyseal periostitis
• scurvy
  
  • painful swollen limbs, metaphyseal irregularity,
    extensive periosteal new bone formation,
    thin cortices, demineralized bones
• rickets
  
  • generalized and symmetric skeletal changes,
    metaphyseal irregularity and widening

Question 13

normal radiographic variants

Answer 13

• 2-8 month old infants
  
  • periosteal new bone along the shafts of long bones
  • spurring and cupping of the metaphyses
• other variants can appear as fractures

Question 14

non-accidental head trauma

Answer 14

• 80% of deaths of children < 2 years of age from non-accidental head trauma
• Abusive head trauma results in estimated 1,500 hospitalizations each year.
• most often in first 6 months

Question 15

shaken baby syndrome

Answer 15

• consider SBS in infants with:
  
  • intracranial injury after minor trauma
    
    • scan infants with symptoms indicative of head injury
    • neurologic deterioration in an infant is always indication for cranial imaging
  • retinal hemorrhages
• does the history explain the injuries?
• common presenting findings
  
  • apnea
  • bulging fontanelle
  • fever
  • history of minor head trauma
  • irritability
  • lethargy
  • poor feeding
  • seizures
  • staring episodes
  • vomiting
• mechanism of injury
  
  • head is relatively large and heavy
    
    • infant 10-15% of body weight
    • adult 2-3% of body weight
  • weak neck muscles
  • brain is underdeveloped in infant
    
    • acceleration-deceleration injury
    • relative lack of myelination
    • shear of neurons and vast variations in intracranial pressure during shaking
    • impact injuries cause even greater focal injury to brain
• injuries from shaken baby syndrome
  
  • subdural and/or subarachnoid hemorrhage
  • diffuse axonal injury
  • intracranial hypertension
  • retinal hemorrhages
    
    • usually documented by ophthalmologist
    • always screen on admission, particularly if CPR is to start
      
      • do not delay CPR to do a funduscopic exam, however
• intervention
  
  • maintain a high suspicion in young infants with mental status changes or other signs of abuse
    
    • key to early diagnosis
    • mandated reporting for cases of suspected child abuse
• prognosis - poor for most infants
• preventive education for parents to safeguard against stressful periods of parenting
  
  • happens with anticipatory guidance
  • the parental “time-out”

Question 16

retinal hemorrhages in head injury

Answer 16

• very unusual after accidental head injury
  
  • high velocity injuries
  • injuries with high rotational component
  • rare with birth trauma
• CPR may rarely cause small hemorrhages
• other conditions may cause retinal hemorrhages, but abuse is most likely if head injury is also present

Question 17

sexual abuse

Answer 17

• 150,000 cases of sexual abuse are substantiated by CPS each year
• 80% of reported victims are girls
• one in 5 adult women reports past sexual abuse
• diagnosis is most often made by child’s disclosure
• red flags include vaginal, penile, and anal injuries as well as sexually transmitted diseases
  
  • some STDs are nearly always caused by abuse if not congenitally acquired
• genital injuries are present in only 5-10% of abused children
• forensic examination has the highest yield within 24 hours of an assault
• forensic examinations are routinely conducted for disclosures within 72 hours of an assault (but may be conducted later)
  
  • child’s clothing and bed linens have the highest yield for evidence
  • universal lab screening for STDs (including baseline antibody levels for hepatitis B, syphilis and HIV) is conducted on all reported sexual abuse cases
  • prophylactic therapy for N. gonorrhoeae, C. trachomatis is routine
  • prophylactic therapy for HIV transmission is offered in some cases

Question 18

verbal and emotional abuse and neglect

Answer 18

• neglect is omissions that prevent a child’s basic needs from being met
  
  • adequate food, clothing, housing, supervision, health care, education and nurturance
• neglect is the most commonly reported form of abuse reported to child welfare agencies
• threshold for verbal and emotional abuse does not have a clear clinical standard

Question 19

informing the family of your concerns

Answer 19

• these injuries were probably not caused by the events that you are describing.
• I’m concerned that someone may be harming your child. Do you have any of these same concerns?
• describe your role
  
  • recognition of suspicious injuries
  • perform physical evaluation
    
    • obtain supporting evidence
    • find alternative diagnosis
  • report suspected abuse
  • remain objective
  • advocate for the child
  • represent the child’s interests

Question 20

report to mandated agencies

Answer 20

• juvenile system - provides child protection
  
  • child protective services
  • juvenile court
• criminal justice system – prosecutes crimes
  
  • police
  • criminal court
  • Child abuse pediatrics is a medical subspecialty and consultation is available.