1. Indications for neurosurgical admission for blunt head injury in kids: 
- GCS <15
- Significant mechanism of injury (fall > 3 body lengths, MVA, etc)
- LOC, amnesia, any focal neurological deficits
- Multisystem injury requiring surgical management for any reason
2. Management of above injury: 
- NPO
- Preop labs (T+S, coags, CBC. BMP)
- Repeat CBC/BMP in the AM
- Isotonic fluids
- Consider mannitol 0.25 to 1 gm/kg IV, start low and titrate up.
3. If you need intracranial monitoring: EVD if you can, bolt if the ventricles are small/you can't get the EVD to work.
4. Temporal lobe: 

5. Temporal lobectomy: 

- measure from tip of temporal lobe 3.5 cm back (L side) or 4 cm back (R side) to determine how much to cut

- Preserve the superior temporal gyrus, as it has part of wernicke's area on it, as well as the primary auditory cortex 

6. Cauda equina symptom: 

- Urinary retention is often the first sign, incontinence follow later (overflow incontinence) 

- Loss of lower extremity reflexes is a very sensitive sign 

7. Dens fractures: 

8. Management of Type I Dens fractures: 

- Extremely rare, little evidence. 

- May indicate underlying atlanto-axial instability. 

- 6-8 weeks in a collar, unless there is instability at occiput-C1, or disruption of alar ligaments, in which case you go to surgery 

9. Management of type II dens fractures: 

- Controversial, still no good way of predicting who will heal with immobilization alone and who will need surgery 

- Nonunion with immobilization alone estimates range from 5 to 75% in the literature-- according to greenberg, 30% is probably a good estimate, 10% for those with displacement <6mm

- Some authors think displacement <4mm indicates likelihood of fusion, >6mm associated with high risk of non-union (70% regardless of age or direction of displacement) 

- Kids (esp <7) almost always heal with immobilization, while older people (age cutoff in literature ranges 40 to 65) are less likely to heal. 

- Soft guidelines for surgery: Displacement >5mm, instability even with halo, age >51 (increases rate of non-union with halo alone 21 times), disruption of transverse ligament (associated with delayed instability), 

- Odontoid screw: acute fractures with intact/attached transverse ligament and no risk factors for non-healing (osteopenia, old person, old non-healed fracture)

- Posterior fusion: for everyone else, fuse either C1-C2 or O-C1-C2. 

- No indication for surgery: 10-12 weeks of immobilization; some data that halo vest (fusion rate 72%) is the best. 

- NB: Old (>6 weeks) fractures: unlikely to heal an odontoid screw. So old people with old fractures- soft collar rather than surgery (hard collars are an aspiration risk in old people) 

- Type III: traction, 8-12 weeks in a halo 

10. Management of type III dens fractures: 

- 90% heal with 8-14 weeks of immobilization. Halos fuse better than collars.