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James T. Rutka

With this landmark issue of the Journal of Neurosurgery (JNS), we celebrate the 75th anniversary of continuous publication of articles in neurosurgery. It is likely not a coincidence that the diamond anniversary of the JNS coincides precisely with the 150th anniversary of the birth of Harvey Cushing. It is possible that some events in life are inextricably and cosmically tied together, such as the birth of the founding father of our specialty, the society named after him that ultimately became the American Association of Neurological Surgeons (AANS), and the journal of this organization—the JNS.

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Han Yan, Eric Toyota, Melanie Anderson, Taylor J. Abel, Elizabeth Donner, Suneil K. Kalia, James Drake, James T. Rutka and George M. Ibrahim

OBJECTIVE

Drug-resistant epilepsy (DRE) presents a therapeutic challenge in children, necessitating the consideration of multiple treatment options. Although deep brain stimulation (DBS) has been studied in adults with DRE, little evidence is available to guide clinicians regarding the application of this potentially valuable tool in children. Here, the authors present the first systematic review aimed at understanding the safety and efficacy of DBS for DRE in pediatric populations, emphasizing patient selection, device placement and programming, and seizure outcomes.

METHODS

The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and recommendations. Relevant articles were identified from 3 electronic databases (MEDLINE, Embase, and Cochrane CENTRAL) from their inception to November 17, 2017. Inclusion criteria of individual studies were 1) diagnosis of DRE; 2) treatment with DBS; 3) inclusion of at least 1 pediatric patient (age ≤ 18 years); and 4) patient-specific data. Exclusion criteria for the systematic review included 1) missing data for age, DBS target, or seizure freedom; 2) nonhuman subjects; and 3) editorials, abstracts, review articles, and dissertations.

RESULTS

This review identified 21 studies and 40 unique pediatric patients (ages 4–18 years) who received DBS treatment for epilepsy. There were 18 patients with electrodes placed in the bilateral or unilateral centromedian nucleus of the thalamus (CM) electrodes, 8 patients with bilateral anterior thalamic nucleus (ATN) electrodes, 5 patients with bilateral and unilateral hippocampal electrodes, 3 patients with bilateral subthalamic nucleus (STN) and 1 patient with unilateral STN electrodes, 2 patients with bilateral posteromedial hypothalamus electrodes, 2 patients with unilateral mammillothalamic tract electrodes, and 1 patient with caudal zona incerta electrode placement. Overall, 5 of the 40 (12.5%) patients had an International League Against Epilepsy class I (i.e., seizure-free) outcome, and 34 of the 40 (85%) patients had seizure reduction with DBS stimulation.

CONCLUSIONS

DBS is an alternative or adjuvant treatment for children with DRE. Prospective registries and future clinical trials are needed to identify the optimal DBS target, although favorable outcomes are reported with both CM and ATN in children.

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James T. Rutka

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Joao Paulo Almeida, Carlos Velásquez, Claire Karekezi, Miguel Marigil, Mojgan Hodaie, James T. Rutka and Mark Bernstein

OBJECTIVE

International collaborations between high-income (HICs) and low- and middle-income countries (LMICs) have been developed as an attempt to reduce the inequalities in surgical care around the world. In this paper the authors review different models for international surgical education and describe projects developed by the Division of Neurosurgery at the University of Toronto in this field.

METHODS

The authors conducted a review of models of international surgical education reported in the literature in the last 15 years. Previous publications on global neurosurgery reported by the Division of Neurosurgery at the University of Toronto were reviewed to exemplify the applications and challenges of international surgical collaborations.

RESULTS

The most common models for international surgical education and collaboration include international surgical missions, long-term international partnerships, fellowship training models, and online surgical education. Development of such collaborations involves different challenges, including limited time availability, scarce funding/resources, sociocultural barriers, ethical challenges, and lack of organizational support. Of note, evaluation of outcomes of international surgical projects remains limited, and the development and application of assessment tools, such as the recently proposed Framework for the Assessment of International Surgical Success (FAIRNeSS), is encouraged.

CONCLUSIONS

Actions to reduce inequality in surgical care should be implemented around the world. Different models can be used for bilateral exchange of knowledge and improvement of surgical care delivery in regions where there is poor access to surgical care. Implementation of global neurosurgery initiatives faces multiple limitations that can be ameliorated if systematic changes occur, such as the development of academic positions in global surgery, careful selection of participant centers, governmental and nongovernmental financial support, and routine application of outcome evaluation for international surgical collaborations.

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Taylor J. Abel, Emma Losito, George M. Ibrahim, Eishi Asano and James T. Rutka

Epileptic spasms (ES) are a common manifestation of intractable epilepsy in early life and can lead to devastating neurodevelopmental consequences. Epilepsy surgery for ES is challenging because of inherent difficulties in localizing the epileptogenic zone in affected infants and children. However, recent clinical series of resective neurosurgery for ES suggest that not only is surgery a viable option for appropriately selected patients, but postoperative seizure outcomes can be similar to those achieved in other types of focal epilepsy. Increased awareness of ES as a potentially focal epilepsy, along with advances in neuroimaging and invasive monitoring technologies, have led to the ability to surgically treat many patients with ES who were previously not considered surgical candidates. In this study, the authors review the current state of epilepsy surgery for ES. Specifically, they address how advances in neuroimaging and invasive monitoring have facilitated patient selection, presurgical evaluation, and ultimately, resection planning.

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Ying Meng, Mathew R. Voisin, Suganth Suppiah, Zamir Merali, Ali Moghaddamjou, Naif M. Alotaibi, Arbelle Manicat-Emo, Shelly Weiss, Cristina Go, Blathnaid McCoy, Elizabeth J. Donner and James T. Rutka

OBJECTIVE

Intracranial electroencephalography (iEEG) monitoring is an important method of identifying the seizure focus in patients with medically refractory epilepsy. While previous studies have demonstrated low rates of surgical complications, reported rates of surgical site infection (SSI) are highly variable. To date, no studies have specifically evaluated the patient or operative risk factors contributing to SSI. The goals of this study were to examine the rate of SSI after iEEG monitoring for epilepsy workup in pediatric patients and to determine the variables that might contribute to the development of SSI.

METHODS

A retrospective analysis of hospital charts at the Hospital for Sick Children was performed for all patients who had undergone iEEG monitoring between 2000 and 2016. Univariate and multivariate analyses were performed to look for statistically significant variables in relation to SSI.

RESULTS

Among 199 patients eligible for analysis, 8 (4.0%) developed SSIs within a period ranging from 21 to 51 days postoperatively. Univariate analysis yielded 4 factors related to SSI: number of people present in the operating room on electrode insertion (p = 0.02), length of insertion surgery (p = 0.04), previous operation at the same surgical site (p = 0.04), and number of depth electrodes inserted (p = 0.01). Multivariate analysis revealed that both the number of people present during the implant operation (OR 0.08, 95% CI 0.01–0.70) and the number of depth electrodes inserted (OR 3.52, 95% CI 1.44–8.59) independently contributed to SSI.

CONCLUSIONS

This is the largest case series and the first comprehensive review of both patient and operative risk factors in the development of SSI from iEEG monitoring in a pediatric population. The authors’ institution had a lower rate of infection than those in most other studies, which could be explained by their protocol of administering intravenous antibiotics perioperatively and post–implant removal antibiotics for 14 days. The authors found a correlation between SSI and the number of people present during the implant operation, as well as the number of depth electrodes; both may contribute to breaks in sterility.

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Aviva Abosch and James T. Rutka