J Neurosurg Pediatrics 14:212–218, 2014
©AANS, 2014
Postoperative Mycoplasma hominis infections after
neurosurgical intervention
A review
Wesley J. Whitson, M.D.,1 Perry A. Ball, M.D.,1 S. Scott Lollis, M.D.,1
Jason D. Balkman, M.D., 2 and David F. Bauer, M.D.1
Section of Neurosurgery and 2Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon,
New Hampshire
1
Object. Mycoplasma hominis is a rare cause of infection after neurosurgical procedures. The Mycoplasma genus
contains the smallest bacteria discovered to date. Mycoplasma are atypical bacteria that lack a cell wall, a feature
that complicates both diagnosis and treatment. The Gram stain and some types of culture media fail to identify these
organisms, and typical broad-spectrum antibiotic regimens are ineffective because they act on cell wall metabolism.
Mycoplasma hominis commonly colonizes the genitourinary tract in a nonvirulent manner, but it has caused postoperative, postpartum, and posttraumatic infections in various organ systems.
The authors present the case of a 17-year-old male with a postoperative intramedullary spinal cord abscess due
to M. hominis and report the results of a literature review of M. hominis infections after neurosurgical procedures.
Attention is given to time to diagnosis, risk factors for infection, ineffective antibiotic regimens, and final effective
antibiotic regimens to provide pertinent information for the practicing neurosurgeon to diagnose and treat this rare
occurrence.
Methods. A PubMed search was performed to identify reports of M. hominis infections after neurosurgical procedures.
Results. Eleven cases of postneurosurgical M. hominis infection were found. No other cases of intramedullary
spinal cord abscess were found. Initial antibiotic coverage was inadequate in all cases, and diagnosis was delayed in
all cases. Multiple surgical interventions were often needed. Once appropriate antibiotics were started, patients typically experienced rapid resolution of their neurological symptoms. In 27% of cases, a suspicious genitourinary source
other than urinary catheterization was identified.
Conclusions. Postoperative M. hominis infections are rarely seen after neurosurgical procedures. They are typically responsive to appropriate antibiotic therapy. Mycoplasma infection may cause prolonged hospitalization and
multiple returns to the operating room due to delay in diagnosis. Early clinical suspicion with appropriate antibiotic
coverage could help prevent these significant complications.
(http://thejns.org/doi/abs/10.3171/2014.4.PEDS13547)
M
Key Words • Mycoplasma hominis • intramedullary • abscess • spine • brain • infection
ycoplasma hominis is a rare complication of neurosurgical procedures. The organism lacks a cell
wall and instead has a 3-layer sterol membrane,
so it does not appear on Gram stain.13 To culture M. hominis, specialized media containing animal serum are needed.14 Polymerase chain reaction (PCR) may be the most
sensitive method for diagnosis, but it is not routinely performed.13 For these reasons, diagnosis is often delayed.
Because it is an atypical bacterium, M. hominis does not
respond to common empirical antibiotics, which act on
cell wall metabolism.13 This leads to initially inadequate
antibiotic coverage of postoperative infections.
Mycoplasma hominis is known to asymptomatically
Abbreviations used in this paper: EVD = external ventricular
drain; IUD = intrauterine device; MVC = motor vehicle collision;
PCR = polymerase chain reaction; SCI = spinal cord injury; UTI =
urinary tract infection; WBC = white blood cell.
212
colonize the genitourinary system, where it acts as a parasite living on the nutrients available. It is typically unable
to infiltrate beyond the submucosa of the genitourinary
tract. When acting in a virulent manner, it has been most
commonly implicated in cases of cervicitis, urinary tract
infections (UTIs), pelvic inflammatory disease, postpartum infections, and postabortal fever.13 However, small
numbers of infections have been reported in multiple sites
outside the genitourinary system.12,15,17,20 Case reports
have shown that M. hominis can cause spontaneous meningitis or postoperative neurosurgical infections.
There are several other related microorganisms that
lack a cell wall and therefore cause the same diagnostic
and therapeutic difficulties as M. hominis. Mycoplasma
pneumoniae colonizes the respiratory tract and is well
known for its role in “walking pneumonia.” Mycoplasma
genitalium colonizes the genitourinary tract and has been
associated with pelvic inflammatory disease. UreaplasJ Neurosurg: Pediatrics / Volume 14 / August 2014
Postneurosurgical M. hominis infections
ma parvum and U. urealyticum also colonize the genitourinary tract and are known to cause urethritis. Like
M. hominis, these organisms have more rarely been implicated in neonatal and postoperative wound infections,
and remain in the differential diagnosis for persistent infections when no organism has been identified by culture.
We present the case report of a 17-year-old patient
who developed a postoperative intramedullary spinal
cord abscess from M. hominis after 360° fixation and fusion following cervical fracture and dislocation sustained
in a motor vehicle collision (MVC). To the best of our
knowledge, this is the first intramedullary M. hominis
infection reported in the literature, as well as the first review of postoperative infections from M. hominis in both
the spine and brain.
Illustrative Case Report
History. A 17-year-old male presented with multiple
trauma after an MVC that occurred while he was driving under the influence of alcohol. He sustained multiple
spinal injuries, including C6–7 fracture-dislocation with
bilateral jumped facets, 9 mm of anterolisthesis, and 75%
spinal canal narrowing (Fig. 1). He also sustained a left
C-1 lateral mass fracture, left C-3 facet fracture, and left
C-5 facet fracture with associated left vertebral artery
dissection. Other injuries included scalp avulsion, right
orbital floor fracture, left mandible fracture, and right
hand degloving injury.
Examination. He was intubated in the field for airway protection. On examination, he was able to flex his
arms to noxious stimulation bilaterally, but he had no
signs of distal arm or leg function. He was started on the
methylprednisolone protocol for acute spinal cord injury
(SCI). Urinalysis after Foley catheter placement showed
blood but no bacteria.
Operation. He was taken to the operating room for
C-6 corpectomy with C5–7 anterior fixation and fusion.
Postoperative MRI studies showed persistent cord compression, so he was returned to the operating room immediately for posterior decompression and fusion from C-5
to T-2. His posterior neck had extensive abrasions, which
had to be debrided before making the dorsal incision.
Postoperative Course. Postoperatively, he had full
strength in bilateral deltoids and biceps, movement with
gravity eliminated in bilateral triceps, twitch movement
in bilateral hand grip, and complete paralysis in both legs.
He was placed on piperacillin/tazobactam for 1 week for
prophylactic postoperative antibiotic coverage because of
the significant dermal abrasions.
Complications and Outcome. Three weeks later, he
had dehiscence of his posterior cervical wound. Followup MRI studies showed posterior and anterior fluid collections at the operative sites (Fig. 2). He was taken for irrigation and debridement of both wounds. The bone graft
material was removed, but the titanium hardware was left
in place. Significant purulence was found, and intraoperative cultures were sent. A Gram stain was negative for all
wound cultures. He was started on vancomycin and meropenem for broad-spectrum antibiotic coverage.
One week later, he developed new bicep and deltoid
weakness with fever of 38.3°C and leukocytosis of 11,500
cells/dl. Anterior and posterior cervical wounds were
flat, without erythema or drainage. An MRI study was
obtained, which showed an intramedullary spinal cord
rim-enhancing lesion with extensive increased T2 signal
extending up to the medulla, which was of concern for intramedullary spinal cord abscess (Fig. 3). He was taken to
the operating room for emergency evacuation of the rimenhancing lesion. A midline myelotomy was performed
to enter the collection, which was purulent. It was then
debrided from the inside out. Care was taken to remain
within the collection without removing neural tissue. Cultures were sent and the Gram stain remained negative.
Postoperatively, antibiotic coverage was broadened with
the addition of metronidazole.
Fig. 1. Images of the cervical spine at presentation showing fracture-dislocation injury. Left: Sagittal CT scan of the cervical
spine. Right: Sagittal T2-weighted MRI study of the cervical spine.
J Neurosurg: Pediatrics / Volume 14 / August 2014
213
W. J. Whitson et al.
Fig. 2. Cervical spine MRI studies showing the anterior and posterior wound infections before the first washout surgery. A:
Sagittal T1-weighted image. B: Axial T1-weighted image with contrast showing the extent of the anterior collection. C: Axial
T1-weighted image with contrast showing the extent of the posterior collection.
Four days later, the cultures from the first wound irrigation and debridement grew M. hominis. This was 10
days after the operation. Antibiotics were changed to vancomycin, moxifloxacin, and doxycycline for 1 week. Without growth of other organisms, antibiotic monotherapy was
implemented with intravenous moxifloxacin. Serial followup MRI showed improvement in the cord signal and good
response to the antibiotics. He regained his biceps and deltoid strength to the same level he had demonstrated on his
best initial examination. He was transferred to an inpatient
spinal cord rehabilitation center. Antibiotic coverage was
transitioned to oral moxifloxacin, which was continued
for 6 months. At 1-year follow-up, he has remained free
of recurrent infection, with stable results on postoperative
examination and imaging (Fig. 4).
Methods
PubMed was queried using the search terms “Mycoplasma hominis, -meningitis, -cranial, -infection, -trauma, -neurosurgery, -immunocompromised, -steroids,
-postoperative, and intramedullary spinal cord abscess.”
Nine papers discussing postneurosurgical M. hominis infections were identified.
Results
Through the literature review, 11 patients were identified who developed brain or spine infections from M.
hominis after neurosurgical procedures; clinical details are
outlined in Table 1. All patients underwent Foley catheterization, and 27% had genitourinary risk factors other than
urinary catheterization. The mean time to diagnosis after
the original procedure was 22 days, with a range of 11–36
days. Five patients (45%) required 2 or more washout surgeries, and 1 patient required 4 procedures before diagnosis was made and appropriate antibiotics were started. No
further washout surgeries were needed after appropriate
antibiotics were started, and in all cases multiple different
antibiotics were used unsuccessfully before diagnosis. After diagnosis, most patients were treated with doxycycline
and/or a fluoroquinolone with good success.
Fig. 3. Cervical spine MRI studies showing the intramedullary abscess. Left: Sagittal T1-weighted image with contrast
showing the rim-enhancing lesion within the spinal cord. Right: Sagittal STIR image showing the extent of spinal cord signal
extending superiorly into the medulla.
214
J Neurosurg: Pediatrics / Volume 14 / August 2014
Postneurosurgical M. hominis infections
C-reactive protein of 120, and a mildly elevated WBC
count of 10,900/dl. Imaging revealed a deep wound infection. Culture revealed M. hominis after 4 days. Although
she did have chronic UTIs due to her myelomeningocele,
M. hominis was never isolated from urine specimens. She
was successfully treated with doxycycline.
Mycoplasma hominis Brain Infections
Fig. 4. Most recent cervical spine MRI study. This sagittal T2weighted image shows improvement in the spinal cord signal and no
signs of recurrent abscess. There is notable spinal cord atrophy due
to the injury.
Mycoplasma hominis Spine Infections
To the best of our knowledge, there are no other reported intramedullary spinal cord infections with M.
hominis in the literature.6,7,21 Intramedullary infections
are themselves a rare entity carrying significant morbidity. In a review of 25 cases, Chan and Gold reported an
8% mortality rate (both of these patients also had brain
abscesses) and a 70% rate of persistent neurological deficit in patients with this condition.3 Multiple organisms
were implicated. In some cases, no organism was identified. Causes included dermal sinus tracts, epidermoid
cysts, hematogenous spread, and postoperative infections.
The majority remained cryptogenic. Of the 25 cases, 21
underwent a myelotomy for drainage of the abscess, 1 had
needle drainage, and 3 were treated based on systemic
culture results.
There are 2 cases of postoperative extramedullary
M. hominis spinal infections reported. The first was a
38-year-old woman who presented 1 month after L4/5
disc replacement with fever to 39°C, C-reactive protein
of 197, and a normal white blood cell (WBC) count of
7000/dl.8 A left psoas-based retroperitoneal abscess was
discovered. Cultures grew M. hominis after 7 days. She
did have a genitourinary risk factor, which was vaginal
discharge with an intrauterine device (IUD). The IUD
was removed, but PCR studies of this device were negative for M. hominis. The authors attributed this negative
result to yeast contamination. Her M. hominis infection
was successfully treated with doxycycline.
The second report was of an 11-year-old paraplegic
girl with a history of myelomeningocele who underwent
T3–L5 instrumented fusion for progressive scoliosis.13
She presented 18 days after surgery with fever to 39°C,
J Neurosurg: Pediatrics / Volume 14 / August 2014
There are a few cases in which patients developed
subdural empyemas after surgical evacuation of traumatic subdural hematomas.10,16,19 In all cases, there was a delayed diagnosis. In some patients multiple irrigation and
debridement procedures were required before adequate
antibiotic treatment was established. Patients were successfully treated with doxycycline, tetracycline, gatifloxacin, moxifloxacin, or erythromycin.
There is 1 report of a postoperative brain abscess
from M. hominis following elective cavernoma resection.11 The patient was afebrile with a normal WBC count,
and presented with speech changes and left-sided weakness. She did have a recent episode of vulvar irritation
and ulceration that was unresponsive to fluconazole therapy. She required a craniotomy to evacuate the abscess,
and was placed empirically on vancomycin, cefotaxime,
and metronidazole. She required a second craniotomy for
abscess recurrence. Cultures eventually grew M. hominis,
and she was started on ciprofloxacin and metronidazole,
with subsequent neurological improvement.
Another paper reports a patient with fever and mental
status changes after an elective colloid cyst resection.16
Cerebrospinal fluid Gram stain was negative. The patient
was taken for wound irrigation and debridement with
removal of the bone flap. The patient subsequently experienced further deterioration with the development of
a subdural empyema. The empyema was evacuated and
an external ventricular drain (EVD) was placed. Due to
persistent fevers, 2 additional irrigation and debridement
procedures were performed. Finally, on Day 36, M. hominis grew in a subdural culture. Review of prior cultures
showed presence of the organism, which had been missed
on laboratory analysis. After treatment was changed to
gatifloxacin and clindamycin, the infection resolved.
Finally, there are 3 cases of EVDs that were infected
with M. hominis.5,14,17 In 1 case, the patient also had a craniotomy for clip occlusion of a ruptured middle cerebral
artery aneurysm, so the procedure that resulted in the infection cannot be determined.14 After delay in diagnosis
because of initially negative cultures, appropriate antibiotic therapy effectively treated the infections. In 1 case
the patient had a large intracerebral hemorrhage, and the
family declined antibiotic treatment due to the prognosis
from the hemorrhage. This patient subsequently died.17
The Role of Immunosuppression in M. hominis Infections
Because M. hominis is a common colonizer of the
genitourinary system but a rare cause of CNS infections,
we hypothesized that immunosuppression may play a role
in cases of extragenital infection. Given the small number
of cases, even among immunosuppressed patients, it is difficult to answer the question clearly. There is a correlation
with cell-mediated immune compromise and hypogam215
216
29, M
76, M
Authors & Year
Payan et al., 1981
McMahon et al., 1990
11, F
38, F
17, M
Krijnen et al., 2006
Flouzat-Lachaniette
et al., 2013
present study
instrumented posterior &
anterior cervical spi nal fusions after MVC
T3–L5 instrumented
posterior fusion for
scoliosis
elective L4/5 disc re placement
ruptured MCA aneurysm
clipping & EVD
craniotomy for SDH
evacuation after MVC
elective craniotomy for
cavernoma resection
elective colloid cyst
resection
decompressive crani otomy after MVC
craniotomy for SDH &
cerebral contusion
evacuation after MVC
EVD for spontaneous
ICH
bilat EVDs after MVC
Procedure
32
35
22
17
15
17
12 + “sev eral”
36
20
11
23
Days to Dx
After
Original Op
Antibiotics Used Prior to Dx
Final Antibiotic Regimen
2
piperacillin/tazobactam, van comycin, ceftriaxone, met ronidazole
chronic UTIs status post bladder
augmentation
trauma
none reported
none
none
vulvar ulceration
none reported
none
trauma, dexamethasone (16 mg
daily for 10 days)
Risk Factors Other Than Urinary
Catheter
abnormal vaginal discharge w/ IUD
(device culture negative for M.
hominis), intraop peritoneal breach
doxycycline, moxifloxacin trauma, methylprednisolone
oxacillin, cephalothin, nafcillin, tetracycline then eryth chloramphenicol
romycin due to ad verse drug reaction
0
none
none (per family request
due to severity of ICH)
0
erythromycin
doxycycline, ciprofloxa cin, chloramphenicol
2
vancomycin, cefotaxime,
ciprofloxacin, metroni metronidazole
dazole
4 washouts plus EVD
ceftazidime, vancomycin
gatifloxacin, then clinda mycin
prior washouts for persis- vancomycin, meropenem
gatifloxacin, then moxi tent infection: 1 cranial,
floxacin
2 orthopedic
2 (craniotomy & EVD re- flucloxacillin, vancomycin (IV moxifloxacin
placement)
& IT)
2
vancomycin, piperacillin/tazdoxycycline
obactam, ceftriaxone, met ronidazole
1
cefazolin, cefradine, gentami- doxycycline
cin collagen fleeces, genta micin, flucloxacillin
1
cefuroxime, cefotaxime, fosdoxycycline
fomycine
1
No. of Ops for Infection
* Dx = diagnosis; ICH = intracerebral hemorrhage; IT = intrathecal; IV = intravenous; MCA = middle cerebral artery; Pt = patient; SDH = subdural hematoma.
40, M
48, F
Henao-Martínez et
al., 2012
Lee et al., 2012
48, M
McCarthy & Looke,
2008
17, F
40, F
House et al., 2003
Cohen & Kubak, 1997 18, F
Pt Age
(yrs),
Sex
TABLE 1: Clinical characteristics of postneurosurgical M. hominis infections*
W. J. Whitson et al.
J Neurosurg: Pediatrics / Volume 14 / August 2014
Postneurosurgical M. hominis infections
maglobulinemia. Meyer and Clough report that in 67 patients with M. hominis infection, 32 had one of these risk
factors.18 Patients with transplants, many of whom are on
long-term corticosteroid regimens, are in this group. In our
case, the patient was given the methylprednisolone protocol for acute SCI, and it is possible that this made him more
susceptible to the M. hominis infection.
Discussion
Genitourinary Tract and Oropharyngeal Colonization as
Cause of M. hominis Abscesses
Because M. hominis is known to colonize the genitourinary tracts of healthy patients, many papers claim
that postoperative or trauma-related M. hominis infections
are caused by injury to these structures by Foley catheter
placement. This causes a transient bacteremia that can seed
hematomas or surgical cavities. In our case, the urinalysis
showed blood but no bacteria. Mycoplasma hominis would
not have been detected as a bacterium by this test, but the
presence of blood indicates a possible route for hematogenous spread if the genitourinary tract had been colonized.
Several case reports in the literature are used to support this theory. There are many cases of patients with
multiple traumas who subsequently developed M. hominis abscesses outside the genitourinary system. These
patients all underwent Foley catheterization. 5,10,15,17,22,24
There are multiple cases of M. hominis brain abscesses in
mothers following normal vaginal deliveries and cesarean sections.14 There is a case of M. hominis brain abscess
developing after a uterus curettage.1 There are multiple
reports of cases of neonatal meningitis that are attributed
to scalp monitoring or to instrumented deliveries exposing infants to their mother’s vaginal flora.4,9
Unfortunately, there is a lack of culture data from
the genitourinary tracts of patients with M. hominis abscesses. Even in cases of frank infection, cultures do not
always grow M. hominis, and the likelihood of obtaining reliable culture data in an area colonized with fewer
organisms could be even lower. Although Foley catheterization could be a risk factor for colonized patients, a significant number of surgical patients with Foley catheters
must be colonized but never develop these infections. It is
possible that some colonized patients harbor strains of M.
hominis that are more virulent than others, making infection more likely in this subset. This hypothesis, however,
is not supported by any current laboratory data. Finally,
to show that an infection came from a patient’s own flora
and not from an iatrogenic source, positive cultures or
PCR data would have to be obtained prior to any intervention. This is unlikely ever to be studied due to the low
rate of extragenitourinary M. hominis infection.
The hypothesis that these infections are caused by
hematogenous spread of native organisms is supported by
significant circumstantial evidence but no definitive culture or PCR data. It also remains possible that M. hominis
is simply an uncommon cause of iatrogenic infection during invasive procedures.
Diagnosis and Management
Diagnosis of M. hominis infections in the postopera-
J Neurosurg: Pediatrics / Volume 14 / August 2014
tive period is difficult. Mycoplasma hominis is a slowgrowing organism that cannot be detected easily by routine techniques. Time from initial procedure to diagnosis
ranges from 11 days to 5 weeks in the literature. Because
all patients in our series improved with appropriate antibiotic treatment, we believe that early broadening of
antibiotics with PCR testing for Mycoplasma and Ureaplasma species is prudent when treating a patient with
persistent signs of infection or abscess recurrence but
negative cultures. This should include either doxycycline
or a fluoroquinolone. Of the fluoroquinolones tested for
CSF penetration in 1 article, moxifloxacin and gatifloxacin showed significantly higher CSF penetration than trovafloxacin, levofloxacin, or ciprofloxacin.16 Gatifloxacin
has been associated with significant hypoglycemia and is
unavailable in many markets, so moxifloxacin is probably
the best choice of these agents.
An additional surgical concern is whether to remove
spinal hardware when a postoperative infection develops.
In this case, titanium instrumentation was used, which
is generally resistant to microbial colonization. We decided to leave the hardware in place after irrigation and
debridement to maintain spinal stability and minimize
the risk of further neurological injury. The 2 cases involving implants reported in the literature include an artificial
lumbar disc and a multilevel instrumentation for scoliosis. The artificial disc was Mobidisc, a construct composed of a polyethylene layer sandwiched between 2 titanium plates. The scoliosis surgery was performed with
the Stryker Xia system. The article did not specify which
model of Xia was used, although both stainless steel and
titanium submodels are available. In both cases the hardware was left in place, and the infection was managed
adequately with antibiotics. Our experience also suggests
that M. hominis infections can be successfully treated
without removing spinal implants.
Immunosuppression Regimens
Our patient was placed on the methylprednisolone
protocol for SCI, and this may have contributed to his
infection. There are no other case reports of this protocol
causing spinal M. hominis infection, but immunosuppression regimens including those with corticosteroids have
been linked to M. hominis infections.18 With new SCI
guidelines recommending against the methylprednisolone protocol, we do not plan to use it in the future.23
In our review, at least 1 patient who developed an
M. hominis brain abscess was placed on high-dose dexamethasone for cerebral edema. In most articles, there
was no comment on the use of steroids, so it is unclear
whether steroid use is a common factor in intracranial M.
hominis infections.
Conclusions
Mycoplasma hominis is a rare cause of postoperative infections in the neurosurgical population. It is difficult to diagnose, and cultures take at least several days to
yield a positive result. Typical broad-spectrum antibiotics
such as vancomycin, ceftriaxone, clindamycin, and metronidazole are ineffective against M. hominis. Because of
217
W. J. Whitson et al.
the difficulty in diagnosing and treating this organism,
M. hominis infection can lead to significant morbidity,
including neurological decline, multiple returns to the
operating room, and prolonged hospitalization before the
correct diagnosis is made and appropriate therapy is initiated. Fortunately, M. hominis is very responsive to appropriate antibiotic therapy, and neurological deficits incurred with infection are often reversible with aggressive
treatment. Mycoplasma hominis should be suspected in
any case in which a postoperative patient remains persistently febrile with elevated WBC cell count or C-reactive
protein while on broad-spectrum antibiotics without coverage for atypical bacteria like M. hominis. Early culture
on blood agar or PCR may help with definitive diagnosis.
Moxifloxacin may be the antibiotic of choice to treat M.
hominis infection of the brain or spinal cord because of
its increased CSF penetration compared with other fluoroquinolone antibiotics.
Acknowledgment
We acknowledge Clifford J. Belden, M.D., a neuroradiologist
at our institution who played an important part in the diagnosis of
this rare intramedullary spinal cord abscess.
Disclosure
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this
paper.
Author contributions to the study and manuscript preparation
include the following. Conception and design: Whitson, Bauer.
Acquisition of data: all authors. Analysis and interpretation of
data: Whitson. Drafting the article: Whitson. Critically revising the
article: all authors. Reviewed submitted version of manuscript: all
authors. Approved the final version of the manuscript on behalf
of all authors: Whitson. Administrative/technical/material support:
Balkman. Study supervision: Bauer.
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Manuscript submitted October 15, 2013.
Accepted April 17, 2014.
Please include this information when citing this paper: published online May 23, 2014; DOI: 10.3171/2014.4.PEDS13547.
Address correspondence to: Wesley J. Whitson, M.D., Section of
Neurosurgery, Dartmouth-Hitchcock Medical Center, One Medical
Center Dr., Lebanon, NH 03756. email: wesley.j.whitson@hitch
cock.org.
J Neurosurg: Pediatrics / Volume 14 / August 2014