Division of Neurosurgery (see also Neuroscience Group)

UCMG physicians within the Division of Neurosurgery provide comprehensive services to patients with conditions requiring neurosurgical care. In addition to the UCMG Division of Neurosurgery office adjacent to CHLA in the Queen of Angels/Hollywood Presbyterian Doctors Tower, patients are also seen at an office adjacent to Huntington Memorial Hospital in Pasadena and at the Shriner's Hospital. Description of Programs and Services Brain and Spinal Cord Tumors Optimal treatment of brain tumors requires a sophisticated, coordinated multidisciplinary treatment approach - one that calls upon the expertise not only of neurosurgeons, but neurologists, neuroradiologists, neuropathologists, neuro-oncologists, neuro-ophthalmologists, radiation therapists, psychologists, rehabilitation therapists and clinical nurse specialists. UCMG physicians provide coordinated expertise in all of these areas allowing for optimum treatment of children with tumors. Every year, Division surgeons perform approximately 100 operations for tumors on the brain or spine. All of the latest technical equipment is available to provide the most advanced approach to surgical resection of tumors of the central nervous system. An excellent ICU staff is available to help with management of the immediate post-operative care of these patients. UCMG physicians at CHLA are active and leading participants in the Childrens Oncology Group wherein new modes of therapy are continually being evaluated so as to improve the outcome for our patients with these devastating diseases. Our outcome statistics exceed or match any other program within the United States and beyond. Arachnoid Cysts Modern imaging techniques have revolutionized our ability to diagnose and treat central nervous system (CNS) problems. This includes arachnoid cysts that can result in mass effect causing raised intracranial pressure or impairment of cerebral spinal fluid (CSF) pathways to produce hydrocephalus. UCMG neurosurgeons have extensive experience treating arachnoid cysts, not only of the brain but of the spinal cord as well. When possible, we try to treat the cyst with fenestration before resorting to CSF diversion by shunting techniques. Neurocutaneous Syndromes UCMG neurosurgeons have extensive experience treating children with neurosurgically related problems associated with neurofibromatosis, tuberous sclerosis, Sterge-Weber disease, von Hippel-Lindau and the less common forms of the phakomatosis. All of the other pediatric specialties services are available to treat other conditions associated with these disorders such as genetics, orthopaedics, neurology, etc. Vascular Malformations Although uncommon, arteriovenous malformations (AVMs) and aneurysms can cause life threatening and/or devastating neurologic impairment following hemorrhage. The availability of excellent imaging techniques for magnetic resonance imaging (MRI), MRA, angiography and interpretation of the images has greatly enhanced our ability to treat these lesions either by direct surgical approach or endovascularly. In addition, the availability of neuroradiologists and anesthesiologists to properly sedate patients greatly aids in patient comfort as well as achieving superior imaging studies by which to treat these lesions. UCMG neurosurgeons use intraoperative angiography to assure that the AVM has either been completely excised or that the aneurysm has been properly clipped. We also have significant experience in re-vasculatization techniques for children with Moya-Moya disease. Surgical Management of Medically Intractible Epilepsy UCMG physicians in the Division of Neurosurgery participate in the comprehensive epilepsy program within which a patient with medically intractable epilepsy is evaluated for possible surgical intervention. Assessment may include MRI, PET, and/or SPECT, EEG and videotelemetry. In those very selective patients in whom surgical intervention is indicated, subdural electrodes are placed for seizure monitoring to determine the appropriate seizure foci for elimination. Additional seizure procedures include corpus callosotomy and partial or complete functional hemispherectomy. Craniosynostosis and Craniofacial Reconstruction Craniosynostosis can vary from involvement of a single suture, such as the sagittal, to multiple sutural involvement as one can find in Apert and Crouzon Syndromes. If only the calvarium is involved and surgery is required, the neurosurgical team will correct the problem. If the face is involved, then a combined procedure with the full craniofacial team is indicated. An extensive Craniofacial Program is available to address all of the aspects involved with these particular anomalies (see Craniofacial and Cleft Program). UCMG neurosurgeons also see children and adolescents who have positional plagiocephaly or functional unilambdoid synostosis, who do not require surgical intervention. We evaluate these patients and refer them for use of the headband to correct the deformation as required. Hydrocephalus Hydrocephalus is one of the most common problems faced in pediatric neurosurgery and has multiple etiologies. Patients are very carefully evaluated for cerebral spinal fluid (CSF) diversion. This is only undertaken if absolutely necessary because the best way to avoid shunt problems is to not insert a shunt. As a discipline, UCMG neurosurgeons do more good for more infants and children by optimally caring for their hydrocephalus than anything else. Division physicians either insert or revise approximately 300 shunts a year. We have extensive experience in all aspects of hydrocephalus. This experience has been shared with the medical community and has been written about in many publications in this area. Neonatal units from all over the Los Angeles metropolitan area refer neonates for treatment of pre-term infants who develop hydrocephalus associated with intraventricular hemorrhage. One of the main research interests of Division physicians is the pathophysiology of hydrocephalus particularly as it relates to cerebral spinal fluid (CSF) drainage pathways. Chiari Malformation and Spinal Cord Syringes With the advent of magnetic resonance imaging it has been possible to diagnose non-invasively and in an early stage, many problems that previously were only detected after considerable disability had developed. One is Chiari malformation and hydrosyringomyelia. Patients often present in the pediatric age group with scoliosis. Routine screening by orthopaedic surgeons has yielded a number of children with Chiari malformation and syrinx formation. UCMG neurosurgeons have had excellent results with decompression and only rarely have to place a syrinx to pleural shunt to treat the condition. Progression of scoliosis usually stops and often even reverses, preventing the need for any additional therapy. Neural Tube Defects The most common form of neural tube defect (NTD) is one which is open, i.e., the myelomeningocele or spina bifida. This is the lesion where the spinal cord is exposed and often cerebral spinal fluid (CSF) is leaking at the site. Lesions are usually repaired very shortly after birth. Almost all of these children require a CSF diverting shunt. They have multiple problems including not only extensive central nervous system (CNS) involvement but varying degrees of motor/sensory deficit in the lower extremities and a neurogenic bladder and bowel. Care of a child with myelomeningocele requires close teamwork among a diverse group of pediatric specialists and ancillary providers including not only neurosurgeons but orthopaedists, urologists, pediatricians, nurses, physicial therapists, occupational therapists and social workers. UCMG has one of the largest programs in the nation devoted to caring for patients with myelomeningoceles. A comprehensive ongoing care program is needed to maximize the potential of these children who have varying degrees of neurologic deficit. We are now also seeing pregnant women who have been diagnosed in utero as having a fetus with an open NTD. We can provide pre-natal counseling. In addition to open NTD, there is also a large group of infants born with a closed NTD often referred to as a spinal dysraphism. Within this category are those infants with lipomatous malformation (lipomyelomeningocele), congenital dermal sinuses (with dermal inclusion cysts), split cord malformation (diastematomyelia) and other more uncommon types of closed NTDs such as myelocystoceles, neuroenteric cysts, etc. Most of these conditions also can be classified under the tethered spinal cord syndrome. The goal of neurosurgery is to decompress or untether the spinal cord to prevent progressive neurologic deficit that can evolve over the course of months to years to decades. We treat these patients in conjunction with the orthopaedic surgeons and urologists depending upon the extent of involvement. Another NTD which can either be open or closed but involves the cranium is that of an encephalocele. Most are located in the occipital region. There are others that are found anteriorly and at the cranial base. Our extensive experience allows us to treat all the various permutations that can occur with an encephalocele. Head and Spinal Cord Trauma CHLA operates the only Level I Trauma Center in Los Angeles solely for children and, as a result, receives either directly or in transfer, many infants and children with extensive and often life threatening injuries. The UCMG emergency division physicians are fully equipped to take care of the most severely traumatized patient. After initial assessment and diagnostic studies, the patient is either transferred to our fully equipped ICU or to the operating room as indicated. UCMG neurosurgeons are well versed in taking care of severely injured children and have pioneered assessment of new therapies in improving outcome. Anomalies of the Vertebral Column Either the Division of Neurosurgery alone or in conjunction with the Division of Orthopaedic Surgery, many children with unusual and difficult dysplasias or segmentation abnormalities of the vertebral column are seen and treated each year by UCMG physicians at CHLA. Individual expertise as well as all of the support services needed to bring about successful treatment of some of these very complex problems are available. Brachial Plexus Injuries UCMG physicians evaluate and treat brachial plexus injuries following difficult childbirth or after sustaining a traumatic injury. In addition to neurosurgeons, other UCMG pediatric specialists including neurologists (with EMG testing capability), orthopaedic surgeons, plastic surgeons and rehabilitative specialists, treat infants, children and adolescents with brachial plexus injuries. We treat injuries of the other peripheral nerves as well. Spasticity Surgery UCMG neurosurgeons participate with other team members including those from orthopaedics, neurology and physical therapy to perform a comprehensive evaluation of children with a spasticity who might benefit from selective dorsal rhizotomy. For selected patients, we utilize a state-of-the-art Gait Analysis Laboratory to help determine appropriateness of performing a selective dorsal rhizotomy and the results of such a procedure on subsequent follow-up. Neuroendoscopy UCMG neurosurgeons have all of the appropriate instrumentation and experience for minimally invasive treatment of patients who would benefit from this surgical approach. Careful selection is done for those patients that would most benefit from this type of surgery compared to that which is more extensive. Diaphragmatic Pacing UCMG neurosurgeons in conjunction with pulmonologists and pediatric surgeons, insert and repair those children with central hypoventilation syndrome (Ondine's curse) who would benefit from this mode of therapy. Recently, an endoscopic thoracotomy technique was developed to place the electrodes without having to resort to a thoracotomy. This allows for a much more rapid patient recovery and earlier discharge from the hospital. PHYSICIANS J. Gordon McComb, M.D., Division Head Mark D. Krieger, M.D. HOW TO CONTACT US The Division of Neurosurgery welcomes your inquiries. To contact us you can: Email us at: msamson@chla.usc.edu Call the Division directly at: (323) 663-8128 Or Fax: (323) 361-3101 Write to us at: Division of Neurosurgery Childrens Hospital Los Angeles 4650 Sunset Blvd., #102 Los Angeles, CA 90027-6062

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