Physicians: J. Gordon McComb, M.D., Division Head; Mark D. Krieger, M.D.
Contact Information:
Division of Neurosurgery
Childrens Hospital Los Angeles
4650 Sunset Blvd. #102
Los Angeles, CA 90027-6062
Phone (323) 669-2169
Physicians who wish to contact a faculty member, consult about a patient or refer a patient can also call 1-800-ASK-PACE (1-800-275-7223). Please note, this service is for physicians ONLY.
Diseases and Conditions Treated
Anomalies of the Vertebral Column
Arachnoid Cysts
Brachial Plexus Injuries
Brain Tumors
Cerebrospinal Fluid Physiology
Chiari Malformation and Spinal Cord Syringes
Congenital Dermal Sinus (with dermoids)
Craniofacial Reconstruction
Craniosynostosis
CSF Diverting Shunts
Diaphragmatic Pacing
Encephaloceles
Head Trauma
Hydrocephalus
Lipomatous Malformations (dysraphism, lipomyelomeningocele)
Meningoceles
Myelomeningoceles (spina bifida)
Neural Tube Defects
Neuroendoscopy
Neurosurgical Manifestations of the Neurocutaneous Syndromes (neurofibromatosis, tuberous sclerosis, Sterge-Weber, etc.)
Other (myelocystocele, neuroenteric cysts, etc.)
Vascular Malformations (AVM's aneurysms, Moya-Moya disease)
Selective Dorsal Rhizotomy for Spasticity
Spinal Cord Syringes (hydromyelia, syringomyelia, association with Chiari I & II malformations)
Spinal Cord Trauma
Spinal Cord Tumors
Split Cord Malformations (diastematomyelia)
Surgical Management of Medically Intractable Epilepsy
Tethered Cord Syndrome
Description of Programs and Services
Anomalies of the Vertebral Column
Either with neurosurgery alone or in conduction with orthopedics, many children with unusual and difficult dysplasias or segmentation abnormalities of the vertebral column are seen and treated each year 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.
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Arachnoid Cysts
Modern imaging techniques have revolutionized the ability to diagnose and treat CNS problems. This includes arachnoid cysts that can result in mass effect causing raised intracranial pressure or impairment of CSF pathways to produce hydrocephalus. The department have developed extensive experience treating arachnoid cysts, not only of the brain but of the spinal cord as well. Extensive experience has led to multiple publications on this condition. When possible, the faculty tries to treat the cyst with fenestration before resorting to CSF diversion by shunting techniques.
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Brachial Plexus Injuries
Brachial plexus injuries following difficult childbirth or after sustaining a traumatic injury are evaluated and treated at CHLA. All of the components to include neurology with EMG testing, orthopedics, plastic surgery, and rehabilitation in addition to neurosurgery are available to treat infants and children with brachial plexus injuries. Injuries of the other peripheral nerves can also be treated as well.
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Brain and Spinal Cord Tumors
Optimal treatment of brain tumors require a sophisticated, coordinated multidisciplinary 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. Coordinated expertise in all of the above areas is available at CHLA to provide optimum treatment of children with tumors. Every year approximately 100 operations are done on the brain or spine for tumors. 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 the management of the immediate post-operative care of these patients. CHLA is an active and leading participant in the Childrens Cancer Group wherein new modes of therapy are continually being evaluated so as to improve the outcome for the patients with these devastating diseases. The outcome statistics exceed or match any other program within the United States and beyond.
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Chiari Malformation and Spinal Cord Syringes
With the advent of MR 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 that of the Chiari malformation and hydrosyringomyelia. The patients often present in the pediatric age group with scoliosis. Routine screening by orthopedic surgeons has yielded a number of children with the Chiari malformation and syrinx formation. We have had excellent results with decompression and only rarely have to place a syrinx to pleural shunt to treat the condition. The progression of the scoliosis usually stops and often even reverses, preventing the need for any additional therapy.
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Craniosynostosis and Craniofacial Reconstuction
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 section). Division members also see children who have so-called positional plagiocephaly or functional unilambdoid synostosis who do not require surgical intervention. These patients are evaluated and referred for the use of the headband to correct the deformation as required.
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Diaphragmatic Pacing
UCMG neurosurgeons in conjunction with the pulmonologist and pediatric surgeons insert and repair those children with central hypoventilation syndrome (Ondine's curse) who would benefit from this mode of therapy. Of recent, a endoscopic thoracotomy technique has been developed to place the electrodes without having to resort to a thoracotomy. This allows for a much more rapid patient recovery and discharge from the hospital at a shorter time interval.
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Head and Spinal Cord Trauma
CHLA is a Level I trauma center and as a result receives, either directly or in transfer, many infants and children with extensive and often life threating injuries. The emergency room is 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. The neurosurgical division is well versed in taking care of severely injured children and has pioneered in assessing new therapies in improving outcome.
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Hydrocephalus
Hydrocephalus is one of the most common problems faced in pediatric neurosurgery and has multiple etiologies. Patients are very carefully evaluated for CSF diversion that is only undertaken if absolutely necessary as the best way to avoid shunt problems is not to insert a shunt. As a discipline, we do more good for more infants and children by optimal care of their hydrocephalus than anything else. The division either inserts or revises approximately 300 shunts a year. There is extensive expertise in all aspects of hydrocephalus. This experience has been shared with the medical community with many publications in this area. The division gets referrals from neonatal units all over the Los Angeles area for treatment of pre-term infants who develop hydrocephalus associated with intraventricular hemorrhage.
One of the major research interests of the Division is the pathophysiology of hydrocephalus particularly as it relates to CSF drainage pathways.
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Neural Tube Defects
The most common form of neural tube defect is one which is open, i.e.; the myelomeningocele or so-called spina bifida. This is the lesion where the spinal cord is exposed and often CSF is leaking at the site. The lesions are usually repaired very shortly after birth. Almost all of these children require a CSF diverting shunt. They have multiple problems to include not only extensive CNS involvement but varying degrees of motor/sensory deficit in the lower extremities and a neurogenic bladder and bowel. Care of a child with a myelomeningocele requires a close teamwork among a diverse group of specialists to include not only neurosurgeons but orthopedists, urologists, pediatricians, nurses, physical therapists, occupational therapists, and social workers. CHLA has one of the largest clinics 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 many pregnant women who have been diagnosed as having a child with an open NTD. Counseling is given regarding the situation.
In addition to open NTD there is also a large group of infants who are born with a closed NTD often referred to as a spinal dysraphism. Under this category are those with lipomatous malformation (lipomyelomeningocele), congenital dermal sinuses (with dermal inclusion cysts), split cord malformation (diastematomyelia), and other more uncommon types of closed NTD's such as myelocystoceles, neuroenteric cysts, etc.. Most of these conditions can also 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. These patients are treated in conjunction with orthopedics and urology depending upon the extent of the 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. Extensive experience is available to treat all of the various permutations that can occur with an encephalocele.
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Neurocutaneous Syndromes
The department have developed 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 ancillary services are available to treat other conditions associated with these disorders such as genetics, orthopedics, neurology, etc.
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Neuroendoscopy
We 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.
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Spasticity Surgery
UCMG neurosurgeons participate with other team members to include those from orthopedics, neurology, and physical therapy to do a comprehensive evaluation of children with a spasticity who might benefit from selective dorsal rhizotomy. A state of the art gait analysis laboratory is available for those selected patients to help determine the appropriateness of doing a selective dorsal rhizotomy and the results of such a procedure on subsequent follow-up.
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Surgical Management of Medically Intractible Epilepsy
Neurosurgery participates in the comprehensive epilepsy program whereby a patient with medically intractable epilepsy is evaluated for possible surgical intervention. The assessment may include MRI, PET, and/or SPECT, EEG, and videotelemetry. In those very selective cases in whom surgical intervention is indicated, subdural electrodes are placed for seizure monitoring to determine the appropriate seizure foci for elimination. Additional seizures procedures include corpus callosotomy and partial or complete functional hemispherectomy.
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Vascular Malformations
Although uncommon, arteriovenous malformations (AVM's) and aneurysms can cause life threatening and/or devastating neurologic impairment following hemorrhage. The availability of excellent imaging techniques for MRI, MRA, angiography, and interpretation of the images has greatly enhanced our ability to treat these lesions either by a direct surgical approach or endovascularly. Having the availability of neuroradiologists and anesthesiologists to proper sedate patients greatly aids in patient comfort as well as achieving superior imaging studies by which to treat these lesions. Also used is intraoperative angiography to assure that the AVM has either been completely excised or that the aneurysm has been properly clipped. The staff also has significant experience in re-vascularization techniques for children with Moya-Moya disease.
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