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Michael C. Dewan, Jaims Lim, Chevis N. Shannon, and John C. Wellons III

OBJECTIVE

Up to one-third of patients with a posterior fossa brain tumor (PFBT) will experience persistent hydrocephalus mandating permanent CSF diversion. The optimal hydrocephalus treatment modality is unknown; the authors sought to compare the durability between endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) therapy in the pediatric population.

METHODS

The authors conducted a systematic review of articles indexed in PubMed between 1986 and 2016 describing ETV and/or VPS treatment success/failure and time-to-failure rate in patients < 19 years of age with hydrocephalus related to a PFBT. Additionally, the authors conducted a retrospective review of their institutional series of PFBT patients requiring CSF diversion. Patient data from the systematic review and from the institutional series were aggregated and a time-to-failure analysis was performed comparing ETV and VPS using the Kaplan-Meier method.

RESULTS

A total of 408 patients were included from 12 studies and the authors' institutional series: 284 who underwent ETV and 124 who underwent VPS placement. The analysis included uncontrolled studies with variable method and timing of CSF diversion and were subject to surgeon bias. No significant differences between cohorts were observed with regard to age, sex, tumor grade or histology, metastatic status, or extent of resection. The cumulative failure rate of ETV was 21%, whereas that of VPS surgery was 29% (p = 0.105). The median time to failure was earlier for ETV than for VPS surgery (0.82 [IQR 0.2–1.8] vs 4.7 months [IQR 0.3–5.7], p = 0.03). Initially the ETV survival curve dropped sharply and then stabilized around 2 months. The VPS curve fell gradually but eventually crossed below the ETV curve at 5.7 months. Overall, a significant survival advantage was not demonstrated for one procedure over the other (p = 0.21, log-rank). However, postoperative complications were higher following VPS (31%) than ETV (17%) (p = 0.012).

CONCLUSIONS

ETV failure occurred sooner than VPS failure, but long-term treatment durability may be higher for ETV. Complications occurred more commonly with VPS than with ETV. Limited clinical conclusions are drawn using this methodology; the optimal treatment for PFBT-related hydrocephalus warrants investigation through prospective studies.

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Travis R. Ladner, Ashly C. Westrick, John C. Wellons III, and Chevis N. Shannon

OBJECT

The purpose of this study was to design and validate a patient-reported health-related quality of life (HRQOL) instrument for pediatric Chiari Type I malformation (CM-I), the Chiari Health Index for Pediatrics (CHIP).

METHODS

The CHIP has 45 items with 4 components making up 2 domain scores, physical (pain frequency, pain severity, nonpain symptoms) and psychosocial; physical and psychosocial scores are combined to create an overall HRQOL score. Increasing scores (0 to 1) represent increasing HRQOL. Fifty-five patients with CM-I (mean age 12 ± 4 years, 53% male) were enrolled and completed the CHIP and Health Utilities Index Mark 3 (HUI3). Twenty-five healthy controls (mean age 11.9 ± 4 years, 40% male) also completed the CHIP. CHIP scores were compared between these groups via the Mann-Whitney U-test. For CHIP discriminative function, subscore versus presence of CM-I was compared via receiver operating characteristic curve analysis. CHIP scores in the CM-I group were stratified by symptomatology (asymptomatic, headaches, and paresthesias) and compared via Kruskal-Wallis test with Mann-Whitney U-test with Bonferroni correction (p < 0.0167). CHIP was compared with HUI3 (Health Utilities Index Mark 3) via univariate and multivariate linear regression.

RESULTS

CHIP physical and psychosocial subscores were, respectively, 24% and 18% lower in CM-I patients than in controls (p < 0.001); the overall HRQOL score was 23% lower as well (p < 0.001). The area under the curve (AUC) for CHIP physical subscore versus presence of CM-I was 0.809. CHIP physical subscore varied significantly with symptomatology (p = 0.001) and HUI3 pain-related quality of life (R2 = 0.311, p < 0.001). The AUC for CHIP psychosocial subscore versus presence of CM-I was 0.754. CHIP psychosocial subscore varied significantly with HUI3 cognitive- (R2 = 0.324, p < 0.001) and emotion-related (R2 = 0.155, p = 0.003) quality of life. The AUC for CHIP HRQOL versus presence of CM-I was 0.820. Overall CHIP HRQOL score varied significantly with symptomatology (p = 0.001) and HUI3 multiattribute composite HRQOL score (R2 = 0.440, p < 0.001).

CONCLUSIONS

The CHIP is a patient-reported, CM-I-specific HRQOL instrument, with construct validity in assessing pain-, cognitive-, and emotion-related quality of life, as well as symptomatic features unique to CM-I. It holds promise as a discriminative HRQOL index in CM-I outcomes assessment.

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Jonathan Dallas, Chevis N. Shannon, and Christopher M. Bonfield

OBJECTIVE

Spinal fusion is used in the treatment of pediatric neuromuscular scoliosis (NMS) to improve spine alignment and delay disease progression. However, patients with NMS are often medically complex and require a higher level of care than those with other types of scoliosis, leading to higher treatment costs. The purpose of this study was to 1) characterize the cost of pediatric NMS fusion in the US and 2) determine hospital characteristics associated with changes in overall cost.

METHODS

Patients were identified from the National Inpatient Sample (2012 to the first 3 quarters of 2015). Inclusion criteria selected for patients with NMS, spinal fusion of at least 4 vertebral levels, and elective hospitalization. Patients with no cost information were excluded. Sociodemographics, treating hospital characteristics, disease etiology/severity, comorbidities, length of stay, and hospital costs were collected. Univariable analysis and multivariable gamma log-link regression were used to determine hospital characteristics associated with changes in cost.

RESULTS

A total of 1780 weighted patients met inclusion criteria. The median cost was $68,815. Following multivariable regression, both small (+$11,580, p < 0.001) and medium (+$6329, p < 0.001) hospitals had higher costs than large hospitals. Rural hospitals had higher costs than urban teaching hospitals (+$32,438, p < 0.001). Nonprofit hospitals were more expensive than both government (–$4518, p = 0.030) and investor-owned (–$10,240, p = 0.001) hospitals. There was significant variability by US census division; compared with the South Atlantic, all other divisions except for the Middle Atlantic had significantly higher costs, most notably the West North Central (+$15,203, p < 0.001) and the Pacific (+$22,235, p < 0.001). Hospital fusion volume was not associated with total cost.

CONCLUSIONS

A number of hospital factors were associated with changes in fusion cost. Larger hospitals may be able to achieve decreased costs due to economies of scale. Regional differences could reflect uncontrolled-for variability in underlying patient populations or systems-level and policy differences. Overall, this analysis identified multiple systemic patterns that could be targets of further cost-related interventions.

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Christopher M. Bonfield, Rachel Pellegrino, Jillian Berkman, Robert P. Naftel, Chevis N. Shannon, and John C. Wellons III

OBJECTIVE

Both the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Section on Pediatric Neurological Surgery (AANS/CNS Pediatric Section) and the International Society for Pediatric Neurosurgery (ISPN) annual meetings provide a platform for pediatric neurosurgeons to present, discuss, and disseminate current academic research. An ultimate goal of these meetings is to publish presented results in peer-reviewed journals. The purpose of the present study was to investigate the publication rates of oral presentations from the 2009, 2010, and 2011 AANS/CNS Pediatric Section and ISPN annual meetings in peer-reviewed journals.

METHODS

All oral presentations from the 2009, 2010, and 2011 AANS/CNS Pediatric Section and ISPN annual meetings were reviewed. Abstracts were obtained from the AANS/CNS Pediatric Section and ISPN conference proceedings, which are available online. Author and title information were used to search PubMed to identify those abstracts that had progressed to publication in peer-reviewed journals. The title of the journal, year of the publication, and authors’ country of origin were also recorded.

RESULTS

Overall, 60.6% of the presented oral abstracts from the AANS/CNS Pediatric Section meetings progressed to publication in peer-reviewed journals, as compared with 40.6% of the ISPN presented abstracts (p = 0.0001). The journals in which the AANS/CNS Pediatric Section abstract-based publications most commonly appeared were Journal of Neurosurgery: Pediatrics (52%), Child’s Nervous System (11%), and Journal of Neurosurgery (8%). The ISPN abstracts most often appeared in the journals Child’s Nervous System (29%), Journal of Neurosurgery: Pediatrics (14%), and Neurosurgery (9%). Overall, more than 90% of the abstract-based articles were published within 4 years after presentation of the abstracts on which they were based.

CONCLUSIONS

Oral abstract presentations at two annual pediatric neurosurgery meetings have publication rates in peer-reviewed journal comparable to those for oral abstracts at other national and international neurosurgery meetings. The vast majority of abstract-based papers are published within 4 years of the meeting at which the abstract was presented; however, the AANS/CNS Pediatric Section abstracts are published at a significantly higher rate than ISPN abstracts, which could indicate the different meeting sizes, research goals, and resources of US authors compared with those of authors from other countries.

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Rebecca A. Reynolds, Arnold Bhebhe, Roxanna M. Garcia, Shilin Zhao, Sandi Lam, Kachinga Sichizya, and Chevis N. Shannon

OBJECTIVE

Hydrocephalus is a global disease that disproportionally impacts low- and middle-income countries. Limited data are available from sub-Saharan Africa. This study aims to be the first to describe pediatric hydrocephalus epidemiology and outcomes in Lusaka, Zambia.

METHODS

This retrospective cohort study included patients < 18 years of age who underwent surgical treatment for hydrocephalus at Beit-CURE Hospital and the University Teaching Hospital in Lusaka, Zambia, from August 2017 to May 2019. Surgeries included ventriculoperitoneal shunt insertions, revisions, and endoscopic third ventriculostomies (ETVs) with or without choroid plexus cauterization (CPC). A descriptive analysis of patient demographics, clinical presentation, and etiologies was summarized, followed by a multivariable analysis of mortality and 90-day complications.

RESULTS

A total of 378 patients met the inclusion criteria. The median age at first surgery was 5.5 (IQR 3.1, 12.7) months, and 51% of patients were female (n = 193). The most common presenting symptom was irritability (65%, n = 247), followed by oculomotor abnormalities (54%, n = 204). Postinfectious hydrocephalus was the predominant etiology (65%, n = 226/347), and 9% had a myelomeningocele (n = 32/347). It was the first hydrocephalus surgery for 87% (n = 309) and, of that group, 15% underwent ETV/CPC (n = 45). Severe hydrocephalus was common, with 42% of head circumferences more than 6 cm above the 97th percentile (n = 111). The median follow-up duration was 33 (IQR 4, 117) days. The complication rate was 20% (n = 76), with infection being most common (n = 29). Overall, 7% of the patients died (n = 26). Postoperative complication was significantly associated with mortality (χ2 = 81.2, p < 0.001) with infections and CSF leaks showing the strongest association (χ2 = 14.6 and 15.2, respectively, p < 0.001). On adjusted multivariable analysis, shunt revisions were more likely to have a complication than ETV/CPC or primary shunt insertions (OR 2.45 [95% CI 1.26–4.76], p = 0.008), and the presence of any postoperative complication was the only significant predictor of mortality (OR 42.9 [95% CI 12.3–149.1], p < 0.001).

CONCLUSIONS

Pediatric postinfectious hydrocephalus is the most common etiology of hydrocephalus in Lusaka, Zambia, which is similar to other countries in sub-Saharan Africa. Most children present late with neglected hydrocephalus. Shunt revision procedures are more prone to complication than ETV/CPC or primary shunt insertion, and postoperative complications represent a significant predictor of mortality in this population.

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Thomas M. O’Lynnger, Chevis N. Shannon, Truc M. Le, Amber Greeno, Dai Chung, Fred S. Lamb, and John C. Wellons III

OBJECT

The goal of critical care in treating traumatic brain injury (TBI) is to reduce secondary brain injury by limiting cerebral ischemia and optimizing cerebral blood flow. The authors compared short-term outcomes as defined by discharge disposition and Glasgow Outcome Scale scores in children with TBI before and after the implementation of a protocol that standardized decision-making and interventions among neurosurgeons and pediatric intensivists.

METHODS

The authors performed a retrospective pre- and postprotocol study of 128 pediatric patients with severe TBI, as defined by Glasgow Coma Scale (GCS) scores < 8, admitted to a tertiary care center pediatric critical care unit between April 1, 2008, and May 31, 2014. The preprotocol group included 99 patients, and the postprotocol group included 29 patients. The primary outcome of interest was discharge disposition before and after protocol implementation, which took place on April 1, 2013. Ordered logistic regression was used to assess outcomes while accounting for injury severity and clinical parameters. Favorable discharge disposition included discharge home. Unfavorable discharge disposition included discharge to an inpatient facility or death.

RESULTS

Demographics were similar between the treatment periods, as was injury severity as assessed by GCS score (mean 5.43 preprotocol, mean 5.28 postprotocol; p = 0.67). The ordered logistic regression model demonstrated an odds ratio of 4.0 of increasingly favorable outcome in the postprotocol cohort (p = 0.007). Prior to protocol implementation, 63 patients (64%) had unfavorable discharge disposition and 36 patients (36%) had favorable discharge disposition. After protocol implementation, 9 patients (31%) had unfavorable disposition, while 20 patients (69%) had favorable disposition (p = 0.002). In the preprotocol group, 31 patients (31%) died while 6 patients (21%) died after protocol implementation (p = 0.04).

CONCLUSIONS

Discharge disposition and mortality rates in pediatric patients with severe TBI improved after implementation of a standardized protocol among caregivers based on best-practice guidelines.

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Nishit Mummareddy, Michael C. Dewan, Anna Huang, Jade Basem, Kelly A. Bennett, Chevis N. Shannon, and John C. Wellons III

OBJECTIVE

The Management of Myelomeningocele Study (MOMS) established several important benefits of myelomeningocele fetal closure, including decreased need for shunting at 30 months. However, the effects of fetal closure on long-term quality of life (QOL) have not been studied. In this study, the authors aimed to analyze the differences in long-term QOL between children treated with intrauterine repair and those treated with postnatal repair.

METHODS

Caregivers of children treated with either intrauterine or postnatal closure at a tertiary acute care hospital between 1997 and 2003 were contacted to participate. The Pediatric Quality of Life Inventory (PedsQL 4.0) and a surgical history questionnaire were administered over the phone. Responses to the QOL survey were reverse scored and linearly transformed to a 0–100 scale, with a higher score indicating better QOL. The Mann-Whitney U-test was used to analyze differences in means.

RESULTS

Seventy-four children had MMC repair between 1997 and 2003. Twenty-three (31%) of the patients’ families responded to the PedsQL 4.0 questionnaire. Of these 23 children, 11 had intrauterine closure and 12 had postnatal closure. The intrauterine group did not differ in age (median [IQR] 17 years [14–17 years] vs 15 years [14–19 years], p = 0.926), sex (27.3% vs 41.7% male, p = 0.469), or lesion level (p = 0.199) from the postnatal group. Fewer patients in the intrauterine group underwent neurosurgical procedures than those in the postnatal group (55.6% vs 100%, p = 0.018). However, of the children receiving neurosurgical procedures, there was no difference in the number of procedures between the intrauterine and postnatal groups (median [IQR] 4 [2–10.5] vs 2.5 [1.75–6.25], p = 0.458). There was no difference in the percentage of children receiving nonneurosurgical procedures between the two groups (100% vs 100%, p > 0.99). Children who underwent intrauterine closure had significantly higher psychosocial health (median [IQR] 70.0 [56.7–83.3] vs 55.0 [42.1–60.0], p = 0.015) as well as total QOL (median [IQR] 56.5 [55.4–81.5] vs 49.5 [32.9–59.0], p = 0.019) than children with postnatal closure. Physical health was not significantly different between the two groups (median [IQR] 62.5 [37.5–78.1] vs 39.1 [18.8–59.4], p = 0.108).

CONCLUSIONS

Relative to postnatal closure, children who underwent intrauterine closure of MMC demonstrated better long-term QOL as measured by psychosocial and overall QOL metrics. Given that not all medical and socioeconomic confounders were adjusted for due to the low sample size, validation of these results in a larger population and across multiple centers is needed.

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Travis R. Ladner, Michael C. Dewan, Matthew A. Day, Chevis N. Shannon, Luke Tomycz, Noel Tulipan, and John C. Wellons III

OBJECT

The clinical significance of radiological measurements of the craniocervical junction in pediatric Chiari I malformation (CM-I) is yet to be fully established across the field. The authors examined their institutional experience with the pB–C2 line (drawn perpendicular to a line drawn between the basion and the posterior aspect of the C-2 vertebral body, at the most posterior extent of the odontoid process at the dural interface). The pB–C2 line is a measure of ventral canal encroachment, and its relationship with symptomatology and syringomyelia in pediatric CM-I was assessed.

METHODS

The authors performed a retrospective review of 119 patients at the Monroe Carell Jr. Children's Hospital at Vanderbilt University who underwent posterior fossa decompression with duraplasty, 78 of whom had imaging for review. A neuroradiologist retrospectively evaluated preoperative and postoperative MRI examinations performed in these 78 patients, measuring the pB–C2 line length and documenting syringomyelia. The pB–C2 line length was divided into Grade 0 (< 3 mm) and Grade I (≥ 3 mm). Statistical analysis was performed using the t-test for continuous variables and Fisher's exact test analysis for categorical variables. Multivariate logistic and linear regression analyses were performed to assess the relationship between pB–C2 line grade and clinical variables found significant on univariate analysis, controlling for age and sex.

RESULTS

The mean patient age was 8.5 years, and the mean follow-up duration was 2.4 years. The mean pB–C2 line length was 3.5 mm (SD 2 mm), ranging from 0 to 10 mm. Overall, 65.4% of patients had a Grade I pB–C2 line. Patients with Grade I pB–C2 lines were 51% more likely to have a syrinx than those with Grade 0 pB–C2 lines (RR 1.513 [95% CI 1.024–2.90], p = 0.021) and, when present, had greater syrinx reduction (3.6 mm vs 0.2 mm, p = 0.002). Although there was no preoperative difference in headache incidence, postoperatively patients with Grade I pB–C2 lines were 69% more likely to have headache reduction than those with Grade 0 pB–C2 lines (RR 1.686 [95% CI 1.035–2.747], p = 0.009). After controlling for age and sex, pB–C2 line grade remained an independent correlate of headache improvement and syrinx reduction.

CONCLUSIONS

Ventral canal encroachment may explain the symptomatology of select patients with CM-I. The clinical findings presented suggest that patients with Grade I pB–C lines2, with increased ventral canal obstruction, may experience a higher likelihood of syrinx reduction and headache resolution from decompressive surgery with duraplasty than those with Grade 0 pB–C2 lines.

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Michael C. Dewan, Jaims Lim, Clinton D. Morgan, Stephen R. Gannon, Chevis N. Shannon, John C. Wellons III, and Robert P. Naftel

OBJECTIVE

Endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) offers an alternative to shunt treatment for infantile hydrocephalus. Diagnosing treatment failure is dependent on infantile hydrocephalus metrics, including head circumference, fontanel quality, and ventricle size. However, it is not clear to what degree these metrics should be expected to change after ETV/CPC. Using these clinical metrics, the authors present and analyze the decision making in cases of ETV/CPC failure.

METHODS

Infantile hydrocephalus metrics, including bulging fontanel, head circumference z-score, and frontal and occipital horn ratio (FOHR), were compared between ETV/CPC failures and successes. Treatment outcome predictive values of metrics individually and in combination were calculated.

RESULTS

Forty-four patients (57% males, median age 1.2 months) underwent ETV/CPC for hydrocephalus; of these patients, 25 (57%) experienced failure at a median time of 51 days postoperatively. Patients experiencing failure were younger than those experiencing successful treatment (0.8 vs 3.9 months, p = 0.01). During outpatient follow-up, bulging anterior fontanel, progressive macrocephaly, and enlarging ventricles each demonstrated a positive predictive value (PPV) of no less than 71%, but a bulging anterior fontanel remained the most predictive indicator of ETV/CPC failure, with a PPV of 100%, negative predictive value of 73%, and sensitivity of 72%. The highest PPVs and specificities existed when the clinical metrics were present in combination, although sensitivities decreased expectedly. Only 48% of failures were diagnosed on the basis all 3 hydrocephalus metrics, while only 37% of successes were negative for all 3 metrics. In the remaining 57% of patients, a diagnosis of success or failure was made in the presence of discordant data.

CONCLUSIONS

Successful ETV/CPC for infantile hydrocephalus was evaluated in relation to fontanel status, head growth, and change in ventricular size. In most patients, a designation of failure or success was made in the setting of discordant data.

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Jonathan Dallas, Evan Mercer, Rebecca A. Reynolds, John C. Wellons III, Chevis N. Shannon, and Christopher M. Bonfield

OBJECTIVE

Isolated, nondisplaced skull fractures (ISFs) are a common result of pediatric head trauma. They rarely require surgical intervention; however, many patients with these injuries are still admitted to the hospital for observation. This retrospective study investigates predictors of vomiting and ondansetron use following pediatric ISFs and the role that these factors play in the need for admission and emergency department (ED) revisits.

METHODS

The authors identified pediatric patients (< 18 years old) with a linear ISF who had presented to the ED of a single tertiary care center between 2008 and 2018. Patients with intracranial hemorrhage, significant fracture displacement, or other traumatic injuries were excluded. Outcomes included vomiting, ondansetron use, admission, and revisit following ED discharge. Both univariable and multivariable analyses were used to determine significant predictors of each outcome (p < 0.05).

RESULTS

Overall, 518 patients were included in this study. The median patient age was 9.98 months, and a majority of the patients (59%) were male. The most common fracture locations were parietal (n = 293 [57%]) and occipital (n = 144 [28%]). Among the entire patient cohort, 124 patients (24%) had documented vomiting, and 64 of these patients (52%) received ondansetron. In a multivariable analysis, one of the most significant predictors of vomiting was occipital fracture location (OR 4.05, p < 0.001). In turn, and as expected, both vomiting (OR 14.42, p < 0.001) and occipital fracture location (OR 2.66, p = 0.017) were associated with increased rates of ondansetron use. A total of 229 patients (44%) were admitted to the hospital, with vomiting as the most common indication for admission (n = 59 [26%]). Moreover, 4.1% of the patients had ED revisits following initial discharge, and the most common reason was vomiting (11/21 [52%]). However, in the multivariable analysis, ondansetron use at initial presentation (and not vomiting) was the sole predictor of revisit following initial ED discharge (OR 5.05, p = 0.009).

CONCLUSIONS

In this study, older patients and those with occipital fractures were more likely to present with vomiting and to be treated with ondansetron. Additionally, ondansetron use at initial presentation was found to be a significant predictor of revisits following ED discharge. Ondansetron could be masking recurrent vomiting in ED patients, and this should be considered when deciding which patients to observe further or discharge.