Journal of neurosurgery. Pediatrics最新文献

Objective: Nonsyndromic multiple-suture synostosis (MSS) is one of the rarest types of craniosynostosis. While both endoscopic and open surgical approaches have demonstrated efficacy for MSS patients, a comprehensive comparison of perioperative outcomes between the two approaches has yet to be fully explored. The aim of this systematic review and meta-analysis was to assess the available evidence among the two surgical approaches to better inform the management of complex craniosynostosis.

Methods: PubMed, Embase, and Scopus were searched for studies published from the first reports through February 2024 that reported surgical outcomes of either endoscopic or open surgery for nonsyndromic MSS. The main outcome was the reoperation rate, with secondary endpoints including transfusion rates, intraoperative complications, and overall complications, with a subgroup analysis conducted for patients with nonsyndromic bicoronal synostosis.

Results: Sixteen studies involving 310 patients were analyzed. Patients undergoing open surgery were older than those treated with endoscopy (mean age 10.39 vs 3.21 months). The pooled analysis showed a reoperation rate of 11% (95% CI 4%-23%, I2 = 25%) for endoscopic surgery compared with 22% (95% CI 14%-31%, I2 = 0) for open surgery (p = 0.11). Transfusion rates were 26% (95% CI 13%-45%, I2 = 50%) for endoscopic surgery and 50% (95% CI 22%-78%, I2 = 71%) for open surgery (p = 0.18). Intraoperative complications were similar: 17% (95% CI 7%-34%, I2 = 0%) for endoscopic vs 15% (95% CI 4%-42%, I2 = 76%) for open surgery (p = 0.85). Overall complication rates were 15% (95% CI 7%-31%, I2 = 45%) for endoscopic surgery and 20% (95% CI 9%-38%, I2 = 65%) for open surgery (p = 0.59). In the subgroup analysis of bicoronal synostosis, the reoperation rate was 10% (95% CI 4%-21%, I2 = 0%) for endoscopic surgery versus 16% (95% CI 7%-32%, I2 = 0%) for open surgery (p = 0.39).

Conclusions: While both surgical approaches are reasonable options for nonsyndromic MSS, this meta-analysis suggests that endoscopic surgery could be associated with lower morbidity when compared with open surgery. Future studies with longer follow-up periods will be needed to validate these findings and contribute to the understanding of complex craniosynostosis management.

Objective: Abnormal craniocervical motion (ACCM) in the setting of pediatric Chiari type 1 and 1.5 malformation (CM-1/1.5) is generally regarded to be uncommon. The focus of this modified Delphi study was to investigate and build consensus regarding the definition of ACCM in pediatric patients with CM-1/1.5 and the clinical and radiographic methods to identify it.

Methods: An international group of 14 pediatric neurosurgeons with clinical and research expertise in the management of CM was asked to participate. The study focused only on ACCM in the setting of CM-1 and excluded other types of CM. An initial survey of current practices was administered, and based on these responses, a follow-up survey of potential consensus statements was distributed. Consensus was defined as ≥ 80% of participants reaching agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). A final hybrid virtual/in-person meeting was held for discussion and to generate final consensus statements.

Results: Following the final Delphi round, 22 statements reached consensus following discussion and modification of previous statements. Statements that reached consensus included the identification of patient populations that may benefit from screening, recommended imaging for screening along with useful radiographic parameters, and a consideration of trial cervical immobilization in symptomatic patients with supportive imaging. An additional modification to all statements emphasizing the focus on ACCM was agreed upon. All participants stated that they would be willing or somewhat willing to change their practices based on consensus guidelines.

Conclusions: In this study, an international group of pediatric neurosurgeons reached consensus on 22 expert opinion-based statements regarding ACCM in pediatric patients with CM-1. Further study using a standardized approach to screening may facilitate a better understanding of the true incidence and impact of ACCM in CM-1.

Objective: Hydrocephalus in children with posterior fossa tumors (PFTs) is commonly treated with extraventricular drain (EVD) placement, endoscopic third ventriculostomy (ETV), or tumor resection alone. However, the optimal treatment approach remains undetermined. Therefore, the objective of this study was to investigate the relationship between management of preoperative hydrocephalus in children with PFTs and the need for early postoperative CSF diversion and permanent drainage.

Methods: This international multicenter retrospective cohort study included all pediatric patients (aged < 18 years) who underwent primary resection of a posterior fossa tumor at Alder Hey Children's Hospital, United Kingdom, 2008-2018; Rigshospitalet University Hospital, Denmark, 2011-2020; Aarhus University Hospital, Denmark, 2011-2020; and McMaster University Medical Centre, Canada, 2003-2020. The primary outcome was early postoperative CSF diversion (ETV, EVD, or shunt of any kind within 30 days of tumor resection). The secondary outcome was the permanent drainage (ventriculoperitoneal shunt) rate within 30 days after resection. Univariate and multivariate logistic regression analyses were performed.

Results: In total, 310 children with PFTs were included, of whom 234 (75.5%) had preoperative hydrocephalus. Preoperative hydrocephalus was successfully treated in more than 85%. Thirty-eight children (12.3%) required permanent drainage, with a higher incidence in those treated with preoperative EVD. However, no statistically significant association was found between choice of preoperative hydrocephalus management (EVD vs ETV vs tumor resection alone) and persistent hydrocephalus requiring either early postoperative CSF diversion surgery or permanent CSF drainage.

Conclusions: This large international multicenter study did not demonstrate a significant association between choice of management of preoperative hydrocephalus (EVD, ETV, or tumor resection alone) and persisting hydrocephalus requiring surgical intervention after tumor resection.

Objective: The American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) Section on Pediatric Neurological Surgery domestic traveling fellowship was created to cover the travel and living expenses for a North American neurosurgery resident for 1 month at another institution to gain experience in pediatric neurosurgery. The objective of this work was to guide future direction by surveying past recipients about the fellowship and its impact on their training and career.

Methods: Historical data have been maintained by the AANS/CNS Executive Committee and past and current chairs of the Traveling Fellowship Subcommittee. A 10-question REDCap survey was emailed to all previous fellowship recipients.

Results: There have been 58 recipients of the traveling fellowship since 1998. The most common host program was Boston Children's Hospital (n = 21), followed by The Hospital for Sick Children (n = 12). Excluding recent recipients after 2017 who may still be working toward certification, 20 of 38 (53%) recipients have been certified by the American Board of Pediatric Neurological Surgery (ABPNS). Twenty-four of 49 (49%) recipients completed the survey. Twenty (83.3%) respondents were either ABPNS certified or planning to seek certification, 17 (70.8%) respondents' practices consisted of > 50% patients aged ≤ 21 years, and 18 (75%) spent 4-8 weeks at the host program, which was longer than the 1 month funded by the stipend. Twenty-two (91.7%) respondents would recommend the traveling fellowship to a resident interested in pediatric neurosurgery, and 18 (75%) believed the traveling fellowship helped them decide to pursue a career in pediatric neurosurgery, while 17 (70.8%) found that the professional connections they made were the most useful aspect of the fellowship. Fifteen (62.5%) respondents believed that the stipend of $2500 was inadequate to cover the cost of traveling and housing.

Conclusions: The majority of respondents are currently practicing pediatric neurosurgeons, would recommend the traveling fellowship to residents interested in neurosurgery, and believed that the experience helped them decide to pursue a career in pediatric neurosurgery. Opportunities for improvement include increasing the stipend to more appropriately fund rotations that have mostly been longer than 1 month.

Objective: Endoscopic sagittal suturectomy (ESS) is commonly offered for sagittal craniosynostosis in infants, but the optimal timing of surgery remains controversial, with many clinicians only offering ESS surgery before 3 months of age. This study investigated whether patient age predicts craniometric correction and, more specifically, whether patients > 3 months of age at surgery manifest less correction. The effects of age on blood transfusion were also investigated.

Methods: A single-center retrospective review identifying patients with sagittal craniosynostosis who underwent ESS between 2009 and 2023 at Children's National Medical Center was performed. The authors stratified patients by age groups to compare outcomes and transfusion rates. Additionally, receiver operating characteristic (ROC) area under the curve (AUC) analysis was performed to identify optimal age cutoffs.

Results: In total, 107 patients were included. Stratifying age group by 0-2 months, 2-3 months, and > 3 months revealed that the > 3-month age group was less likely to achieve the target cephalic index (CI) at the final follow-up (48.8% vs 61.5% vs 25.0%, p = 0.031) and had less mean percentage CI change at the 6-month follow-up (17% ± 8% vs 18% ± 8% vs 12% ± 6%, p = 0.011), helmet discontinuation (18% ± 9% vs 18% ± 8% vs 12% ± 6%, p = 0.008), 1-year follow-up (15% ± 9% vs 17% ± 7% vs 10% ± 7%, p = 0.005), and final follow-up (14% ± 9% vs 15% ± 7% vs 8% ± 7%, p = 0.004). There were no differences in outcomes between groups when stratified as 0-2 months versus > 2 months of age. The only difference in outcomes between groups when stratified as 0-3 months versus > 3 months of age was the mean percentage change in CI at helmet removal (18% ± 8% vs 15% ± 7%, p = 0.044). Patients requiring transfusion were likely to be younger (median age 2 vs 3 months, p = 0.028). ROC curve analysis identified an age cut-point of 3.75 months as optimal for achieving the target CI correction at the final follow-up (AUC 0.58) and 2.75 months for transfusion avoidance (AUC 0.65).

Conclusions: Patients > 3 months of age may benefit from ESS for sagittal craniosynostosis. Further investigation is warranted to identify the optimal age for surgery and to investigate other variables influencing outcomes.

Objective: Combined sagittal and unilateral coronal synostosis is an uncommon multisuture synostosis. The objective of this study was to describe patient demographics, characterize craniofacial morphology, and report surgical outcomes for patients with combined sagittal and unilateral coronal synostosis undergoing surgical repair.

Methods: This was a retrospective cohort study performed as a joint effort between two US pediatric tertiary care institutions. Between 2003 and 2021, 10 patients with combined sagittal and unilateral coronal synostosis who underwent surgical repair were identified. Open repair involved fronto-orbital advancement and calvarial remodeling. Endoscopic repair involved endoscopy-assisted strip craniectomy of fused sutures with subsequent helmet therapy until 12 months of age. Craniofacial morphology was characterized from CT scans with parameters including the cephalic index (CI), orbital index (OI) asymmetry, nasal tip deviation, chin deviation, and anterior cranial fossa area ratio (ACFR). All patients had preoperative CT scans, and postoperative CT scans were analyzed when performed. Demographics, operative details, and complications were obtained via chart review.

Results: Patients were predominantly male (70%) with fusion of left coronal suture (80%). Four patients (40%) underwent open repair, and 6 patients (60%) underwent endoscopic repair. The median operation length was 87 minutes for endoscopic repair and 226 minutes for open repair. Two endoscopic patients (33%) and 2 open patients (50%) required blood transfusion. Four patients (3 endoscopic, 1 open) underwent secondary operations. Preoperatively (n = 10), patients had a median CI of 0.75, with OI asymmetry (median -35%), nasal tip (median 6.9°) and chin deviation (median 9.5°) contralateral to the involved coronal suture, and cranial base asymmetry (median ACFR 0.63). Postoperatively (n = 6), patients had improved CI (median CI 0.81), OI asymmetry (median -22%), chin deviation (median 5.1°), and cranial base asymmetry (median ACFR 0.75) but slightly worse nasal tip deviation (median 8.5°).

Conclusions: Combined sagittal and unilateral coronal synostosis resembles its isolated component phenotypes. Open and endoscopic repairs are safe. Morphological parameters trended toward improvement postoperatively.