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Burden of pediatric neurosurgical disease in a rural developing country: perspectives from southwest Nigeria

Toyin A. Oyemolade, Amos O. Adeleye, Ayodele J. Olusola, Busayo A. Ehinola, Ebosetale P. Aikhomu, and Anita A. Iroko

OBJECTIVE

The proportion of the global burden of neurosurgical disease represented by pediatric neurosurgical pathology is unknown, especially in lower-middle income countries (LMICs) where there exists no known data-driven literature on the subject. In this study, the authors aimed to quantify the pediatric neurosurgical disease profile in a rural area of a developing country.

METHODS

This was a prospective observational study of all pediatric neurosurgical patients managed at a single center over a 30-month period.

RESULTS

Overall, 226 pediatric patients were included in the study (150 males and 76 females, male/female ratio 2:1), accounting for 20.4% of the total patient population during the study period. The modal age distribution was the 0- to 4-year-old group (32.3%), and head injury was the most common presentation, occurring alone in 157 patients (69.5%). Hydrocephalus alone was seen in 21 patients (9.3%) and in combination with myelomeningocele in 4 patients (1.8%). Brain tumors were found in 6 patients (2.7%), infective lesions in 6 patients (2.7%), and encephaloceles in 2 patients (0.9%). The treatment outcome was good in 170 patients (75.2%). Fourteen patients (6.2%) were referred to more advanced health facilities for specialized care; 29 patients (12.8%) were discharged against medical advice, mostly because of financial constraints; and 8 patients (3.5%) died. Several surgical cases could not be performed because of sundry logistical constraints.

CONCLUSIONS

Pediatric neurosurgical disease accounted for one-fifth of the neurosurgical workload at a tertiary health facility in southwest Nigeria. Trauma was the most common presentation, and optimal in-hospital treatment, including surgery, was hampered by severe logistical constraints in a significant proportion of the cases.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Correlation between social media utilization by academic neurosurgery departments and higher online patient ratings

Jonathan B. Lamano, Robert A. Riestenberg, Aden P. Haskell-Mendoza, Dennis Lee, Michael T. Sharp, and Orin Bloch

OBJECTIVE

Patients increasingly utilize online physician review websites (PRWs) and social media to inform healthcare-related decisions. This provides neurosurgeons with opportunities for increased patient engagement. And despite the growing use of social media among neurosurgeons, the relationship between social media utilization and online reviews remains unknown. The goal of this study was to characterize the relationship between social media utilization and PRW ratings across academic neurosurgery departments.

METHODS

Social media accounts (Twitter, Facebook, YouTube, Instagram) of academic neurosurgery departments were identified. Online reviews for individual faculty were obtained from Healthgrades, Vitals, WebMD, and Google. Reviews were aggregated to identify the total number of reviews per department, to generate a composite departmental rating, and to calculate a summed departmental score. US News & World Report (USNWR) and Doximity rankings were recorded for each department. Social media utilization by individual neurosurgeons and associated ratings were investigated within the departments with the highest social media utilization.

RESULTS

Seventy-eight percent of academic neurosurgery departments utilized social media. The most prevalent platform was YouTube (49.1%), followed by Twitter (46.5%), Facebook (38.6%), and Instagram (16.7%). Higher patient ratings on PRWs were associated with the utilization of YouTube (p = 0.048) or Twitter (p = 0.02). The number of social media platforms utilized demonstrated a significant, positive correlation with patient ratings (p = 0.006) and summed patient ratings (p = 0.048). Although USNWR (p = 0.02) and Doximity (p = 0.0008) rankings correlated with patient ratings, only the number of social media platforms utilized remained a significant predictor of patient ratings on multivariate analysis (p = 0.0001). Thirty-one percent of academic neurosurgeons from departments with high social media utilization were active on social media. The most prevalent social media platform among individual neurosurgeons was Twitter (27.4%), followed by Instagram (8.4%), Facebook (4.9%), and YouTube (2.2%). Higher summed patient scores were associated with individual neurosurgeon utilization of YouTube (p = 0.04), Facebook (p < 0.0001), and Instagram (p = 0.01). Increased social media utilization among neurosurgeons was correlated with a greater number of patient reviews (p = 0.006) and higher summed patient scores (p = 0.003). On multivariate analysis, only Facebook use remained a significant predictor of the number of patient reviews received (p = 0.002) and summed patient satisfaction scores (p < 0.001).

CONCLUSIONS

An increased social media presence is associated with higher ratings on PRWs. As neurosurgeons continue to expand their online presence, they should be aware of the possible impact of social media on online patient reviews.

In Journal of Neurosurgery Publish Before Print

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Determinants of seizure outcome after resective surgery following stereoelectroencephalography

Juan C. Bulacio, James Bena, Piradee Suwanpakdee, Dileep Nair, Ajay Gupta, Andreas Alexopoulos, William Bingaman, and Imad Najm

OBJECTIVE

The aim of this study was to investigate seizure outcomes after resective epilepsy surgery following stereoelectroencephalography (SEEG), including group characteristics, comparing surgical and nonsurgical groups and assess predictors of time to seizure recurrence.

METHODS

Clinical and EEG data of 536 consecutive patients who underwent SEEG at Cleveland Clinic Epilepsy Center between 2009 and 2017 were reviewed. The primary outcome was defined as complete seizure freedom since the resective surgery, discounting any auras or seizures that occurred within the 1st postoperative week. In addition, the rate of seizure freedom based on Engel classification was determined in patients with follow-up of ≥ 1 year. Presumably significant outcome variables were first identified using univariate analysis, and Cox proportional hazards modeling was used to identify outcome predictors.

RESULTS

Of 527 patients satisfying study criteria, 341 underwent resective surgery. Complete and continuous seizure freedom after surgery was achieved in 55.5% of patients at 1 year postoperatively, 44% of patients at 3 years, and 39% of patients at 5 years. As a secondary outcome point, 58% of patients achieved Engel class I seizure outcome for at least 1 year at last follow-up. Among surgical outcome predictors, in multivariate model analysis, the seizure recurrence rate by type of resection (p = 0.039) remained statistically significant, with the lowest risk of recurrence occurring after frontal and temporal lobe resections compared with multilobar and posterior quadrant surgeries. Patients with a history of previous resection (p = 0.006) and bilateral implantations (p = 0.023) were more likely to have seizure recurrence. The absence of an MRI abnormality prior to resective surgery did not significantly affect seizure outcome in this cohort.

CONCLUSIONS

This large, single-center series shows that resective surgery leads to continuous seizure freedom in a group of patients with complex and severe pharmacoresistant epilepsy after SEEG evaluation. In addition, up to 58% of patients achieved seizure freedom at last follow-up. The authors’ results suggest that SEEG is equally effective in patients with frontal and temporal lobe epilepsy with or without MRI identified lesions.

In Journal of Neurosurgery Publish Before Print

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Dosimetric parameters associated with the long-term oncological outcomes of Gamma Knife surgery for sellar and parasellar tumors in pediatric patients

Eun Jung Lee, Ji Yeoun Lee, Jin-Wook Kim, Ji Hoon Phi, Yong Hwy Kim, Seung-Ki Kim, Hyun-Tai Chung, Kyu-Chang Wang, and Dong Gyu Kim

OBJECTIVE

The authors aimed to investigate the dosimetric parameter and the minimally required dose associated with long-term control of sellar and parasellar tumors after Gamma Knife surgery (GKS) in children.

METHODS

A retrospective analysis was performed on pediatric patients younger than 19 years of age who were diagnosed with sellar and parasellar tumors and received GKS at the authors’ institution from 1998 to 2019. Cox proportional hazards regression analyses were used to investigate the dosimetric parameters associated with treatment outcome. The Kaplan-Meier method was used to analyze tumor control rates after GKS.

RESULTS

Overall, 37 patients with 40 sellar and parasellar tumors, including 22 craniopharyngiomas and 12 pituitary adenomas, had a mean follow-up of 85.8 months. The gross target volume was 0.05 cm3 to 15.28 cm3, and the mean marginal dose was 15.8 Gy (range 9.6–30.0 Gy). Ten patients experienced treatment failure at a mean of 28.0 ± 26.7 months. The actuarial 5- and 10-year tumor control rates were 79.0% and 69.8%, respectively. D98% was an independent predictive factor of tumor control (HR 0.846 [95% CI 0.749–0.956], p = 0.007), with a cutoff value of 11.5 Gy for the entire cohort and 10 Gy for the craniopharyngioma group. Visual deterioration occurred in 2 patients with the maximum point dose of 10.1 Gy and 10.6 Gy to the optic apparatus.

CONCLUSIONS

In pediatric patients, D98% was a reliable index of the minimum required dose for long-term control of sellar and parasellar tumors after GKS. The optimal D98% value for each tumor diagnosis needs to be elucidated in the future.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Editorial. Observations on a report of a new neurosurgical service in Nigeria

Jeffrey P. Blount

In Journal of Neurosurgery: Pediatrics Publish Before Print

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FEBio finite element model of a pediatric cervical spine

Sean M. Finley, J. Harley Astin, Evan Joyce, Andrew T. Dailey, Douglas L. Brockmeyer, and Benjamin J. Ellis

OBJECTIVE

The underlying biomechanical differences between the pediatric and adult cervical spine are incompletely understood. Computational spine modeling can address that knowledge gap. Using a computational method known as finite element modeling, the authors describe the creation and evaluation of a complete pediatric cervical spine model.

METHODS

Using a thin-slice CT scan of the cervical spine from a 5-year-old boy, a 3D model was created for finite element analysis. The material properties and boundary and loading conditions were created and model analysis performed using open-source software. Because the precise material properties of the pediatric cervical spine are not known, a published parametric approach of scaling adult properties by 50%, 25%, and 10% was used. Each scaled finite element model (FEM) underwent two types of simulations for pediatric cadaver testing (axial tension and cardinal ranges of motion [ROMs]) to assess axial stiffness, ROM, and facet joint force (FJF). The authors evaluated the axial stiffness and flexion-extension ROM predicted by the model using previously published experimental measurements obtained from pediatric cadaveric tissues.

RESULTS

In the axial tension simulation, the model with 50% adult ligamentous and annulus material properties predicted an axial stiffness of 49 N/mm, which corresponded with previously published data from similarly aged cadavers (46.1 ± 9.6 N/mm). In the flexion-extension simulation, the same 50% model predicted an ROM that was within the range of the similarly aged cohort of cadavers. The subaxial FJFs predicted by the model in extension, lateral bending, and axial rotation were in the range of 1–4 N and, as expected, tended to increase as the ligament and disc material properties decreased.

CONCLUSIONS

A pediatric cervical spine FEM was created that accurately predicts axial tension and flexion-extension ROM when ligamentous and annulus material properties are reduced to 50% of published adult properties. This model shows promise for use in surgical simulation procedures and as a normal comparison for disease-specific FEMs.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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In the eyes of Herophilus: a Greco-Roman design of human neuroanatomy

Barbara A. Hanna

In Journal of Neurosurgery Publish Before Print

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Incidence and risk factors of iatrogenic coronal malalignment after adult spinal deformity surgery: a single-center experience

Scott L. Zuckerman, Christopher S. Lai, Yong Shen, Nathan J. Lee, Mena G. Kerolus, Alex S. Ha, Ian A. Buchanan, Eric Leung, Meghan Cerpa, Ronald A. Lehman, and Lawrence G. Lenke

OBJECTIVE

The authors’ objectives were: 1) to evaluate the incidence and risk factors of iatrogenic coronal malalignment (CM), and 2) to assess the outcomes of patients with all three types of postoperative CM (iatrogenic vs unchanged/worsened vs improved but persistent).

METHODS

A single-institution, retrospective cohort study was performed on adult spinal deformity (ASD) patients who underwent > 6-level fusion from 2015 to 2019. Iatrogenic CM was defined as immediate postoperative C7 coronal vertical axis (CVA) ≥ 3 cm in patients with preoperative CVA < 3 cm. Additional subcategories of postoperative CM were unchanged/worsened CM, which was defined as immediate postoperative CVA within 0.5 cm of or worse than preoperative CVA, and improved but persistent CM, which was defined as immediate postoperative CVA that was at least 0.5 cm better than preoperative CVA but still ≥ 3 cm; both groups included only patients with preoperative CM. Immediate postoperative radiographs were obtained when the patient was discharged from the hospital after surgery. Demographic, radiographic, and operative variables were collected. Outcomes included major complications, readmissions, reoperations, and patient-reported outcomes (PROs). The t-test, Kruskal-Wallis test, and univariate logistic regression were performed for statistical analysis.

RESULTS

In this study, 243 patients were included, and the mean ± SD age was 49.3 ± 18.3 years and the mean number of instrumented levels was 13.5 ± 3.9. The mean preoperative CVA was 2.9 ± 2.7 cm. Of 153/243 patients without preoperative CM (CVA < 3 cm), 13/153 (8.5%) had postoperative iatrogenic CM. In total, 43/243 patients (17.7%) had postoperative CM: iatrogenic CM (13/43 [30.2%]), unchanged/worsened CM (19/43 [44.2%]), and improved but persistent CM (11/43 [25.6%]). Significant risk factors associated with iatrogenic CM were anxiety/depression (OR 3.54, p = 0.04), greater preoperative sagittal vertical axis (SVA) (OR 1.13, p = 0.007), greater preoperative pelvic obliquity (OR 1.41, p = 0.019), lumbosacral fractional (LSF) curve concavity to the same side of the CVA (OR 11.67, p = 0.020), maximum Cobb concavity opposite the CVA (OR 3.85, p = 0.048), and three-column osteotomy (OR 4.34, p = 0.028). In total, 12/13 (92%) iatrogenic CM patients had an LSF curve concavity to the same side as the CVA. Among iatrogenic CM patients, mean pelvic obliquity was 3.1°, 4 (31%) patients had pelvic obliquity > 3°, mean preoperative absolute SVA was 8.0 cm, and 7 (54%) patients had preoperative sagittal malalignment. Patients with iatrogenic CM were more likely to sustain a major complication during the 2-year postoperative period than patients without iatrogenic CM (12% vs 33%, p = 0.046), yet readmission, reoperation, and PROs were similar.

CONCLUSIONS

Postoperative iatrogenic CM occurred in 9% of ASD patients with preoperative normal coronal alignment (CVA < 3 cm). ASD patients who were most at risk for iatrogenic CM included those with preoperative sagittal malalignment, increased pelvic obliquity, LSF curve concavity to the same side as the CVA, and maximum Cobb angle concavity opposite the CVA, as well as those who underwent a three-column osteotomy. Despite sustaining more major complications, iatrogenic CM patients did not have increased risk of readmission, reoperation, or worse PROs.

In Journal of Neurosurgery: Spine Publish Before Print

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Influence of dexamethasone on visible 5-ALA fluorescence and quantitative protoporphyrin IX accumulation measured by fluorescence lifetime imaging in glioblastomas: is pretreatment obligatory before fluorescence-guided surgery?

Lisa I. Wadiura, David Reichert, Veronika Sperl, Alexandra Lang, Barbara Kiesel, Mikael Erkkilae, Adelheid Wöhrer, Julia Furtner, Thomas Roetzer, Rainer Leitgeb, Mario Mischkulnig, and Georg Widhalm

OBJECTIVE

Fluorescence-guided surgery using 5-aminolevulinic acid (5-ALA) is nowadays widely applied for improved resection of glioblastomas (GBMs). Initially, pretreatment with dexamethasone was considered to be essential for optimal fluorescence effect. However, recent studies reported comparably high rates of visible fluorescence in GBMs despite absence of dexamethasone pretreatment. Recently, the authors proposed fluorescence lifetime imaging (FLIM) for the quantitative analysis of 5-ALA–induced protoporphyrin IX (PpIX) accumulation. The aim of this study was thus to investigate the influence of dexamethasone on visible fluorescence and quantitative PpIX accumulation.

METHODS

The authors prospectively analyzed the presence of visible fluorescence during surgery in a cohort of patients with GBMs. In this study, patients received dexamethasone preoperatively only if clinically indicated. One representative tumor sample was collected from each GBM, and PpIX accumulation was analyzed ex vivo by FLIM. The visible fluorescence status and mean FLIM values were correlated with preoperative intake of dexamethasone.

RESULTS

In total, two subgroups with (n = 27) and without (n = 20) pretreatment with dexamethasone were analyzed. All patients showed visible fluorescence independent from preoperative dexamethasone intake. Furthermore, the authors did not find a statistically significant difference in the mean FLIM values between patients with and without dexamethasone pretreatment (p = 0.097).

CONCLUSIONS

In this first study to date, the authors found no significant influence of dexamethasone pretreatment on either visible 5-ALA fluorescence during GBM surgery or PpIX accumulation based on FLIM. According to these preliminary data, the authors recommend administering dexamethasone prior to fluorescence-guided surgery of GBMs only when clinically indicated.

In Journal of Neurosurgery Publish Before Print

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Intracranial neuromodulation with deep brain stimulation and responsive neurostimulation in children with drug-resistant epilepsy: a systematic review

Mehdi Khan, Jaber Paktiawal, Rory J. Piper, Aswin Chari, and Martin M. Tisdall

OBJECTIVE

In children with drug-resistant epilepsy (DRE), resective, ablative, and disconnective surgery may not be feasible or may fail. Neuromodulation in the form of deep brain stimulation (DBS) and responsive neurostimulation (RNS) may be viable treatment options, however evidence for their efficacies in children is currently limited. This systematic review aimed to summarize the literature on DBS and RNS for the treatment of DRE in the pediatric population. Specifically, the authors focused on currently available data for reported indications, neuromodulation targets, clinical efficacy, and safety outcomes.

METHODS

PRISMA guidelines were followed throughout this systematic review (PROSPERO no. CRD42020180669). Electronic databases, including PubMed, Embase, Cochrane Library, OpenGrey, and CINAHL Plus, were searched from their inception to February 19, 2021. Inclusion criteria were 1) studies with at least 1 pediatric patient (age < 19 years) who underwent DBS and/or RNS for DRE; and 2) retrospective, prospective, randomized, or nonrandomized controlled studies, case series, and case reports. Exclusion criteria were 1) letters, commentaries, conference abstracts, and reviews; and 2) studies without full text available. Risk of bias of the included studies was assessed using the Cochrane ROBINS-I (Risk of Bias in Non-randomised Studies - of Interventions) tool.

RESULTS

A total of 35 studies were selected that identified 72 and 46 patients who underwent DBS and RNS, respectively (age range 4–18 years). Various epilepsy etiologies and seizure types were described in both cohorts. Overall, 75% of patients had seizure reduction > 50% after DBS (among whom 6 were seizure free) at a median (range) follow-up of 14 (1–100) months. In an exploratory univariate analysis of factors associated with favorable response, the follow-up duration was shorter in those patients with a favorable response (18 vs 33 months, p < 0.05). In the RNS cohort, 73.2% of patients had seizure reduction > 50% after RNS at a median (range) follow-up of 22 (5–39) months. On closer inspection, 83.3% of patients who had > 50% reduction in seizures actually had > 75% reduction, with 4 patients being seizure free.

CONCLUSIONS

Overall, both DBS and RNS showed favorable response rates, indicating that both techniques should be considered for pediatric patients with DRE. However, serious risks of overall bias were found in all included studies. Many research needs in this area would be addressed by conducting high-quality clinical trials and establishing an international registry of patients who have undergone pediatric neuromodulation, thereby ensuring robust prospective collection of predictive variables and outcomes.

In Journal of Neurosurgery: Pediatrics Publish Before Print