Giorge Voutsas, Aaron St-Laurent, Crystal Hutchinson, Reshma Amin, James Drake, and Indra Narang
The purpose of this study was to evaluate sleep-disordered breathing outcomes and the need for respiratory support following decompression in a pediatric population with Chiari malformation type I. Although obstructive and central apnea indices improved significantly following decompression, many subjects required long-term positive airway pressure therapy following surgery. Sleep-disordered breathing outcomes following decompression surgery will help inform surgical candidate selection, anticipatory guidance for children and families, and postoperative follow-up in patients with Chiari malformation type I who have sleep-disordered breathing.
Elizabeth N Alford, Travis J Atchley, Tofey J Leon, Nicholas M. B Laskay, Anastasia A Arynchyna, Burkely P Smith, Inmaculada Aban, James M Johnston, Jeffrey P Blount, Curtis J Rozzelle, W. Jerry Oakes, and Brandon G Rocque
The purpose of this study was to evaluate imaging parameters of children with Chiari malformation type I (CM-I) to identify factors that correlate with future surgical treatment. In a cohort of 731 patients evaluated for CM-I, 200 of whom had been treated surgically, the authors found that a lower tonsil position, CM-1.5 features, and the presence of congenital cervical fusion were associated with surgical treatment. This study stresses the importance of clinical and symptom evaluation in the surgical decision-making about CM-I.
Smruti K. Patel, Jorge Zamorano-Fernández, Carlie McCoy, and Jesse Skoch
Wearable and portable electronics are rapidly becoming more numerous and mainstream. Many patients with programmable shunt valves either are subjected to strict restrictions or may be unsuspectingly exposing their valves to strong magnets. Ubiquitous smartphone magnetometer technology was shown to be effective at screening devices for safe use in proximity to programmable valves. This concept can be exploited to enhance patient quality of life and safety.
Shenae Samuels, Rebekah Kimball, Vivian Hagerty, Tamar Levene, Howard B. Levene, and Heather Spader
The authors examined whether hospital ownership type and children's hospital designation impacted primary outcomes for pediatric neurosurgery patients. They found that freestanding children's hospitals may be the optimal setting for pediatric patients undergoing neurosurgery for accidental trauma. The federal government invests in children's hospitals to provide specialized clinical care to pediatric patients and valuable training experience to pediatric subspecialists. This study provides evidence that these investments measurably improve outcomes.
Nikita G. Alexiades, Belinda Shao, Bruno P. Braga, Christopher M. Bonfield, Douglas L. Brockmeyer, Samuel R. Browd, Michael DiLuna, Mari L. Groves, Todd C. Hankinson, Andrew Jea, Jeffrey R. Leonard, Sean M. Lew, David D. Limbrick Jr., Francesco T. Mangano, Jonathan Martin, Joshua Pahys, Alexander Powers, Mark R. Proctor, Luis Rodriguez, Curtis Rozzelle, Phillip B. Storm, and Richard C. E. Anderson
A group of experts conducted a modified Delphi study to identify best practices in pediatric cervical spine traction given the lack of evidence-based guidance in the literature. Consensus was reached on 49 best-practice recommendations spanning the utilization and implementation of traction for pediatric cervical trauma and deformity. These recommendations provide a foundation for clinicians to better incorporate cervical traction into their practices.
Grégoire Boulouis, Sarah Stricker, Sandro Benichi, Jean-François Hak, Florent Gariel, Manoelle Kossorotoff, Nicolas Garcelon, Annie Harroche, Quentin Alias, Lorenzo Garzelli, Fanny Bajolle, Nathalie Boddaert, Philippe Meyer, Thomas Blauwblomme, and Olivier Naggara
Researchers studied the basic clinical outcomes after pediatric intracerebral hemorrhage (pICH) using a large cohort study and metanalysis. They found that 1 in 6 children died after pICH and that the majority of children had residual neurological deficits at their latest follow-up. In the cohort study, the authors found younger age was associated with higher odds of death. This study sheds light on the functional prognosis of intracerebral hemorrhage in children.
Nathan A Shlobin, Eytan Raz, Maksim Shapiro, Luke Moretti, Donald R Cantrell, Sandi K Lam, Michael C Hurley, Sameer A Ansari, Erez Nossek, Howard A Riina, Peter K Nelson, Babak S Jahromi, Ali Shaibani, and Matthew B Potts
Cerebral aneurysms are rare in children. This study sought to characterize the use of the Pipeline embolization device (PED) for treatment of pediatric aneurysms through a combined systematic literature review of patient-level data and multi-institutional retrospective experience. Despite substantial differences between pediatric and adult aneurysms, PED use in children appears to be safe with a short-term efficacy similar to that in adults. This study therefore adds to the growing literature supporting PED use in children.
Hemispherotomy is a major procedure that involves a large craniotomy and significant morbidity. Here, the authors present the preliminary findings of 6 patients who underwent a new technique, robotic thermocoagulative hemispherotomy (ROTCH). This is a minimally invasive “bloodless” procedure. All patients had an International League Against Epilepsy class 1 outcome (except 1 patient with a class 2 outcome). Based on these results, ROTCH seems to be a promising and efficacious technique.
Heather J McCrea, Jacques Lara-Reyna, Imali Perera, Rafael Uribe, Silky Chotai, Nicole Savage, Eliza H Hersh, Therese Haussner, and Mark M Souweidane
The authors identified differentiating features between children and adults undergoing endoscopic removal of a colloid cyst. Consistent with their congenital nature, cysts in children (n = 9) were more frequently smaller, seldom resulted in hydrocephalus, were more commonly incidental, and did not result in acute deterioration or sudden death compared with cysts in adults (n = 119). These age disparities likely call into question the utility of currently available natural history information for children with colloid cysts.
Tsunenori Takatani, Yasushi Motoyama, Young-Soo Park, Taekyun Kim, Hironobu Hayashi, Ichiro Nakagawa, Masahiko Kawaguchi, and Hiroyuki Nakase
The authors investigated the efficacy of posttetanic motor evoked potentials (MEPs) in pediatric neurosurgery patients. Tetanic stimulation of the pudendal nerve prior to transcranial electrical stimulation was found to augment the amplitude of MEPs during pediatric neurosurgery, and the effect on posttetanic MEPs after tetanic stimulation of the pure sensory branch of the pudendal nerve was stronger than that of the standard median and tibial nerves, which contain a mixture of sensory and motor fibers. Elicitation of pudendal nerve MEPs might be useful in pediatric patients in whom it is difficult to elicit conventional MEPs.
M. Omar Iqbal, Amer F. Samdani, Joshua M. Pahys, Peter O. Newton, Suken A. Shah, Tracey P. Bastrom, Paul D. Sponseller, Firoz Miyanji, and Steven W. Hwang
The authors sought to investigate what happens to unfused upper thoracic (UT) curves in adolescent idiopathic scoliosis patients after fusion of their primary curves. In 450 patients, the UT curve spontaneously improved 86% of the time and no patients had worsening. Larger preoperative main thoracic curve magnitude and greater main thoracic curve correction were associated with UT curve improvement. Patients with improved spontaneous UT curves had a mean improvement of 50%.
The authors sought to determine if there was a difference in scoliosis outcomes between patients with Chiari malformation type I (CM-I) and scoliosis who received posterior fossa decompression (PFD) with or without duraplasty. After controlling for relevant preoperative variables, the authors found that those patients receiving duraplasty were less likely to have progression of their scoliosis compared with those who received extradural PFD, although rates of spinal fusion between the two groups were similar. This finding has implications for clinical management of patients with CM-I and scoliosis.
Utilizing a national cancer registry, the authors sought to characterize the risk of secondary neoplasm development after external-beam radiation therapy (EBRT) treatment of low-grade gliomas (LGGs) in pediatric patients. After controlling for available covariates and adjusting for competing risks, EBRT was associated with an increased risk of secondary neoplasm development for pediatric survivors of LGGs. The study results have suggested that the long-term implications of EBRT should be considered when making treatment decisions for these patients.
With a nationwide survey, the authors investigated current stereoelectroencephalography (SEEG) practices among US pediatric epilepsy surgeons. SEEG was found to be widely used in pediatric patients and considered safe and satisfactory in defining critical epileptogenic networks. Wide variations in some aspects of SEEG use, including electrode number, laterality, and insular assessment, were also revealed, with statistically significant associations of SEEG program duration and patient age with number of electrodes used. These findings provide insight into how US pediatric epilepsy surgeons manage drug-resistant epilepsy and underscore the advantages of interinstitutional collaboration.
The objective of this study was to characterize changes in head impact exposure (HIE) across football seasons and to evaluate the relationship between changes in HIE and changes in imaging metrics identified in youth football players. This study demonstrated a significant positive association between changes in HIE metrics and changes in imaging metrics between consecutive seasons. Reducing HIE, especially in practice sessions, may decrease the number of abnormal imaging findings from one season to the next in youth football.
The authors investigated late mortality and morbidity during long-term follow-up of a pediatric patient population with moyamoya disease who underwent revascularization surgery at a single center. Of 460 patients receiving surgery over a 28-year period, 15 patients (3.3%) experienced late death or significant neurological morbidity; 8 of those patients experienced intracerebral and/or intraventricular hemorrhage, and 7 patients died of preexisting comorbidities. The authors stress the importance of long-term follow-up of this patient population in hopes of preventing these late events.
The authors analyzed data from a large retrospective study of achondroplasia patients treated during 1957—2017 at four different centers and documented that the median age of patients undergoing cervicomedullary decompression has decreased and the use of neuroimaging and screening modalities has increased over time, suggesting that better surveillance has contributed to earlier identification and intervention in achondroplasia patients with cervicomedullary stenosis. These findings may help guide family counseling about achondroplasia and provide a benchmark of treatments at some of the largest skeletal dysplasia programs in the world.
Pediatric isolated linear skull fracture commonly results from head trauma and rarely requires surgery, yet patients are often admitted. The authors used a national database to investigate admission trends across the United States. Overall, fracture-associated admissions decreased, hospital costs increased, and admissions shifted from smaller rural hospitals to larger urban centers. Neurosurgery has an evolving role in the care of these patients, and this study provides a platform for future discussions about indications for admission.
The authors report the results of the 10-year development and refinement of a multidisciplinary protocol at their institution to manage the treatment of pediatric patients with odontogenic brainstem compression requiring odontoidectomy. A minimally invasive approach was developed, with the combined benefits of the transnasal and transoral routes to perform odontoid resection, along with important otolaryngological considerations that improve surgical exposure and minimize morbidity. Together, these factors help provide favorable outcomes in patients with complex odontogenic brainstem compression.
The objective of this study was to externally validate the condylar—C2 sagittal vertical axis (C-C2SVA) in a large, multicenter cohort. The authors found the C-C2SVA to be a highly sensitive diagnostic test for identifying children who require ventral brainstem decompression or occipitocervical fusion. The C-C2SVA is a novel measurement that can now be used to help screen and identify high-risk Chiari malformation patients.
The authors, based at Great Ormond Street Hospital, set out to evaluate the spectrum of spinal dysraphisms in a complex urological condition (cloacal exstrophy) with poor clinical outcomes in a systematic manner. A large proportion of complex lipomas and terminal myelocystoceles were discovered in this cohort. This is the first comprehensive and large-scale effort on this subject.
This study aimed to find risk factors for predicting shunt failures in pediatric patients. Increased attention during surgery must be given to patients of extremely young age, with close monitoring after surgery. Shunt failure rates were high within the first few months, with decreasing trends over time.
The authors compare different treatment modalities for children with craniopharyngioma. Proton beam therapy, with comparable rates of 5-year progression-free survival for complete resection, may reduce the burden of hypopituitarism and diabetes insipidus. However, radiation adds the risk of potential complications in the long term, such as progressive vasculopathy or second malignancies. This is the first study to specifically examine the role of protons with a comparison to surgery and photon therapy in the treatment of pediatric craniopharyngioma.
The authors report on how their external validation of a predictive model (the modified Canadian Preoperative Prediction Rule for Hydrocephalus [mCPPRH]) did not show a high predictability regarding the children who would require permanent CSF diversion following tumor resection due to persistent hydrocephalus. Clinical judgment remains the mainstay of choosing perioperative treatment. The study provides evidence that the model in its current iteration does not have a high predictive accuracy, and therefore should be used with caution by clinicians.
This study sought to determine whether imaging modality and interobserver variability were factors in ventricular size disparity seen on imaging studies. Retrospective comparison showed that measurements with MRI were 2 mm larger on average than measurements with ultrasound. Centers involved in counseling families about fetal intervention for spina bifida need to be aware of these possible imaging-based disparities.
Late failure can occur after shunt placement or endoscopic third ventriculostomy. However, follow-up practices greatly vary. Therefore, the authors surveyed surgeons at hospitals that are part of the Hydrocephalus Clinical Research Network (HCRN) or its implementation/quality improvement arm, the HCRNq, and found that while there is a general consensus that hydrocephalus patients should have long-term follow-up, radiological surveillance is characterized by considerable variey in terms of modality, frequency, and actions taken when changes are identified in asymptomatic patients. These results highlight opportunities for further clinical research.
The objective of this study was to describe a potential management strategy for an uncommon sequela of Chiari malformation type I (CM-I) decompression. The authors found that deferment of surgery in favor of close follow-up is a safe treatment plan for some patients who have worsening syrinx without worsening neurological status after CM-I decompression. These findings help provide a basis for decision-making in an ambiguous clinical scenario.
Hypothalamic obesity is common among patients with craniopharyngioma. This study examined whether precise stereotactic radiosurgery reduces the risk of hypothalamic obesity in cases of craniopharyngioma with expected long-term survival. Our results revealed that precise radiosurgical dose planning can mediate the subsequent increase in BMI. There is every indication that meticulous Gamma Knife radiosurgery is an effective approach to treating craniopharyngioma while also reducing the risk of hypothalamic obesity.
In this study, the iPlan Flow software infusion simulation algorithm was evaluated for use in convection-enhanced delivery (CED) of drugs to the pediatric brainstem. The authors compared simulated outcomes with the actual radiolabeled infusion distribution and used similarity metrics to quantify the agreement between the actual and the estimated infusate distribution. The combined acceptance criteria were met for 8 of 10 evaluated patients, and based on this finding, the authors recommend the use of iPlan Flow software to optimize personalized CED treatment.
Pediatric neurosurgeons have a structured and well-thought-out philosophy and practice regarding intraoperative decision-making that encompasses a range of approaches including the following: doing no harm, cultivating self-awareness, and seeing the whole patient; and concrete practices such as preparing in advance for uncertainty, working on teams, and learning from experience. These philosophies and practices can be structured and codified in order to teach residents how to develop intraoperative judgment techniques.
Researchers evaluated the role of depression and anxiety, accompanied with or without antidepressant use, on the incidence of and recovery from concussion. Depression or anxiety with antidepressant use was associated with increased incidence of concussion and impaired symptomatic and neurocognitive recovery. The findings suggest that premorbid depression with antidepressant use may be a risk factor for concussion.
The objective of this paper was to determine the clinical benefit in performing outpatient imaging in the setting of pediatric mild traumatic brain injury (TBI). The key finding was that there is no clinical benefit to routine outpatient imaging in pediatric mild TBI, unless there is a clinical change. The imaging does not change the clinical course or the management except for leading to more unnecessary tests and imaging. A reduction in the unnecessary use of routine imaging will benefit patients and curb the waste of resources.
In this article, the authors outline the important contributions of Dr. William R. Cheek to the field of pediatric neurosurgery. As one of the early leaders of the field, he helped to establish its organizational and educational framework and founded the Division of Pediatric Neurosurgery at Texas Childrens Hospital. The authors honor his legacy by appreciating his contributions to the field and continuing to push pediatric neurosurgery forward for the good of patients.
Researchers used radiographic imaging, clinical evaluation, patient-reported outcomes, and formal urodynamics to investigate the safety and short-term efficacy of spinal column shortening as treatment for children and emerging adults with secondary tethered cord syndrome. In this series of 41 patients, spinal column shortening was found to be a safe procedure with promising short-term outcomes. Given these findings, this study emphasizes the importance of and justification for further research into long-term outcomes of spinal column shortening, particularly in children.
This is the largest published study of tethered cord surgery (TCS) among people with myelomeningocele. Objectives were to describe the temporal incidence of TCS and variance between institutions and test the hypothesis that tethering is related to longitudinal spine growth by comparing the relationship between sex-specific spine growth rates and TCS. The authors found no sex-specific differences in TCS timing. This challenges traditional concepts that tethering is solely related to longitudinal spine growth.
The overwhelming majority of literature on instrumentation to the pelvis in children focuses on nonambulatory cohorts. The objective of this study was to address the minimal literature on early complications following fusion to the sacrum with instrumentation to the pelvis in the era of sacral-alar-iliac instrumentation in ambulatory pediatric patients. Instrumentation to the pelvis in this patient population allows for powerful deformity correction with a 36.0% (9/25) complication rate within a mean follow-up period of 24.3 months.
The authors present their experience with responsive neurostimulation in pediatric patients at a single institution and review the indications, strategies, outcomes, and technical considerations for RNS System implantation in this population. They emphasize the compassionate-use indication for this device in pediatric patients. All 5 patients in the study experienced medium-term improvements in seizure control after RNS System implantation, with decreases in seizure frequency greater than 50% from the baseline preoperative seizure frequency. No adverse events were seen.
Indications and surgical technique selection for arachnoid cyst fenestration in children are mainly based on individually weighing risks and benefits. The authors identified rigorous virtual planning and the use of neuronavigation enhanced by augmented realty as key features for surgical treatment, and especially for neuroendoscopy. Thereby, the authors safely achieved effective volume reduction and symptom relief with a reasonable complication rate. Infants may represent a special group of patients, having a more complex course of treatment than older children.
Using data from 14 pediatric neurosurgical centers in the Hydrocephalus Clinical Research Network, researchers sought to compare shunt–based and endoscopic third ventriculostomy (ETV)–based treatment strategies for children with Dandy–Walker syndrome–related hydrocephalus (DWSH). Shunt–based and ETV–based primary treatment of DWSH were similarly durable and had similar rates of complications. A pediatric neurosurgeon may reasonably consider ETV–based treatment for DWSH.
Clinical outcomes of patients undergoing shunt externalization were retrospectively reviewed to test the hypothesis that reimplantation with a ventriculoatrial shunt (VAS) rather than return to a ventriculoperitoneal shunt (VPS) is not associated with increased failure rate and may permit shorter externalization duration. There was no significant difference in shunt survival between patients with VASs and those with VPSs, although the externalization period was not shorter with VASs. Early conversion to a VAS may be a viable treatment option following shunt externalization.
The aim of this study was to evaluate a noninvasive biomarker (diffusion tensor imaging [DTI]) and establish its value as a predictor for the need of surgery for hydrocephalus in patients treated with prenatal repair of a myelomeningocele. DTI is an objective biomarker that significantly differentiates between prenatal myelomeningocele patients who need CSF diversion for hydrocephalus and those who do not. Ultimately, these results will help clinicians better evaluate and treat patients with myelomeningocele-associated hydrocephalus, thereby potentially avoiding the long–term neurocognitive ramifications of this lifelong condition.
The objective of this paper was to evaluate the clinical and hemodynamic benefits of an occipital artery–middle cerebral artery bypass for patients with pediatric moyamoya disease who had recurrent symptoms after initial revascularization. Cerebrovascular reactivity values in both middle cerebral artery and posterior cerebral artery territories are significantly improved, with clinical improvement after occipital artery–middle cerebral artery bypass despite progression of posterior cerebral artery stenosis in most patients. The occipital artery–middle cerebral artery bypass is an effective rescue therapy for cases of pediatric moyamoya disease.
The objective of this study was to compare the quality of imaging using EOS low-dose radiography to conventional radiography to evaluate peritoneal shunt tubing. The authors found that overall image quality and hardware delineation of EOS radiography did not significantly differ from conventional radiography for the evaluation of cerebral shunts. EOS appears to be a lower-cost and lower-radiation alternative to radiography for shunt evaluation.
The authors examined trends in the surgical treatment of pediatric hydrocephalus over an 8-year period and found that important changes in the treatment of this condition have occurred over a very short time frame. This work represents the first study using high-quality registry data to examine changes in the surgical care of pediatric hydrocephalus in North America.
In this study the authors compared the survival between pediatric patients with high-grade gliomas who underwent gross-total resection after one or more reoperations versus those with subtotal resection. The authors found that median overall survival was 17 months, and progression-free survival was 10 months for all patients. The authors also found no differences in survival between patients with gross-total resection after reoperation when compared with those who achieved subtotal resection. These findings highlight the importance of the first attempt to remove the tumor, because the second surgery aiming to achieve gross-total resection may not provide the patient with longer survival.
Using finite element modeling techniques, the authors investigated craniocervical biomechanics in a pediatric patient with Down syndrome (DS). Two age-matched models with identical material properties, one of a patient with DS and one of a child without DS, were created and tested. The authors found increases in craniocervical motion with the DS model, supporting the hypothesis that bony geometry plays a large part in the excessive craniocervical motion that occurs in DS patients and calling into question the role of ligamentous laxity.
The authors present a novel method of extraoperative stereoelectroencephalography (SEEG) monitoring complemented by subsequent intraoperative recordings, designed to tailor multistaged resections in rolandic and perirolandic cortex in a highly selected group of patients with pharmacoresistant rolandic and perirolandic focal epilepsy. The results testified to the feasibility and demonstrated the value of the combined benefits of both extra- and intraoperative SEEG recordings when resecting the rolandic and perirolandic areas. With the proposed novel hybrid method one can precisely limit the volume of resection necessary to abort epileptic activity while preserving the functional cortex as much as possible.