LAUSR

Dear Editor: We read with interest the recent technical note presenting a low-cost device to treat depressed neonatal “ping-pong” fractures [1]. We believe that replicating these results is essential in order to support colleagues working in developing countries and especially to promote the care of children where a lack of material resources is an issue. Here, we present two cases of non-surgical treatment of “ping-pong” fractures using the Manual Aspiration Reduction System (MARS) [1]. The first patient was a 6-day-old boy born at 40 weeks by cesarean delivery due to failure of vaginal delivery. The second patient was a 7-month-old boy injured by a fall from the bed. Both patients had normal neurological examinations apart from depressed skull bones. These physical alterations associated with computerized tomography (CT) scans showed “ping-pong” fractures with no other associated abnormalities (Fig. 1). The patients had no neurological signs or symptoms. The neurosurgery teams decided to treat these patients’ fractures with the MARS. All the potential risks and benefits of the procedure were explained to the patients’ families, who then signed informed consent forms. Both procedures were performed at operating rooms with general anesthesia for the first patient and sedation for the second patient. The original authors performed this new technique at the patient’s bedside without anesthesia. We believe it is safer to perform this minimally invasive procedure in an operating theater with the patient under sedation or under general anesthesia to enable respiratory and cardiac support, use of emergency resuscitation devices, and patient monitoring. We used the technique as described in the technical note [1]. After aspiration, post-operative CTs were performed (Fig. 2). There was no worsening of neural status and no detected intracranial bleeding in either patient. Both patients had uneventful postoperative courses. The entire procedure took 40 min for the first patient and 30 min for the second patient. The first patient required a total of 180 cm3 of negative pressure, while the second required 240 cm3. The two procedures were performed by different neurosurgeons. The patients were discharged in 24 h after the procedure. Several considerations arise from these results. First, is it possible that our patients’ outcomes were improved by the use of general anesthesia or sedation? On the one hand, bedside treatment eliminates operating room time and the implications of anesthesia, and at the same time decreases costs. On the other hand, it seems reasonable to point out that using any form of anesthesia can reduce unwanted movements in newborn and infant patients and performing the procedure without anesthesia could impair immediate response to possible complications not yet described in the literature. Second, in our sample, the second patient was 7 months old and had a satisfactory reduction. This suggests another question. Could the MARS procedure be performed on older babies? We believe probably so. As discussed in the original paper, an appropriate age range can be determined when more patients have been treated. Furthermore, our findings support the reproducibility of this technique, since the procedure has now been performed with good results by different neurosurgeons. The modest sample size available in the literature should not prevent the findings from being considered, and use of the MARS procedure should be encouraged among neurosurgeons even in the absence of prospective studies. * Eduardo Varjão Vieira [email protected]