Journal of neurosurgery. Pediatrics最新文献

Objective: Cervical fusion within the pediatric population presents unique challenges, because pediatric cervical fixation demands careful consideration of anatomical size, physiological differences, and significant prospective growth potential for young patients. In the present systematic review, the authors outline the indications for cervical fusion, summarize patient outcomes in the pediatric population, and characterize the various cervical fixation surgical techniques.

Methods: A retrospective literature review of pediatric cervical fusion was conducted in June 2024 via PubMed, in accordance with PRISMA guidelines and using appropriate search syntax and evidence schemes. The initial literature search yielded 1107 articles, with 259 articles undergoing a full-text review. Inclusion criteria included studies examining pediatric populations (age ≤ 18 years) requiring cervical spine surgical fixation between 2000 and 2024. Studies in which patients with cervical pathology were not surgically treated, those examining primarily adult populations > 18 years old (n = 504), case reports (n = 150), and non-English studies (n = 96) were excluded. Outcomes consisted of demographic variables, fusion rates, bone morphogenetic protein (BMP)/graft material used, and complications.

Results: In total, 106 studies between 2000 and 2024 examining 2086 patients were included in the review. The most common surgical indications across all studies included atlantoaxial instability (n = 49, 48.5%). Most studies reported cases involving occipitocervical (OC) junction pathology (n = 74, 69.8%) and using iliac crest autograft (n = 53, 50.0%) and rib autograft (n = 28, 26.4%). Allografting was used in 25 studies (23.9%) and BMP was used in 26 studies (24.5%). Overall, the fusion rate for pediatric patients undergoing cervical fusion was 95.8%, with OC fusion having comparable fusion rates (0.95 ± 0.02) to those without OC junction involvement (0.96 ± 0.01, p = 0.703). The overall complication rate was 14.9%. There were similar rates of complications compared to studies with and without OC fusion (OC: 0.15 ± 0.18, non-OC: 0.13 ± 0.17; p = 0.075).

Conclusions: Despite efforts to characterize the comparative advantages of different immobilization techniques, such as screw constructs versus wiring, and the use of bone graft materials including BMP, a comprehensive understanding of outcomes remains elusive. The overall fusion rate observed in the analyzed cohort aligns with prior research, yet complications persist, with a notable proportion necessitating reoperation or revision in those with OC pathology. Although the incorporation of BMP alongside autograft and allograft materials remains relatively uncommon, the potential benefits warrant further research, with longitudinal follow-up of fusion rates.

Objective: Dermal sinus tracts (DSTs) are rare congenital lesions resulting from errors of spinal cord disjunction, leading to a persistent connection between the cutaneous ectoderm and underlying neural elements. As patients are at increased risk of infection and irreversible neurological compromise due to tethering, resection and detethering are recommended as a prophylactic measure. The ideal timing of surgical intervention in an asymptomatic cohort, however, remains unclear.

Methods: A retrospective chart review was performed at a single institution from 1998 to 2022 of all patients surgically treated for lumbar DST by 10 different surgeons. Demographic, presentation, operative, and postoperative details were obtained. Five patients who presented with infectious or neurological symptoms were excluded from primary analysis. The age at the time of surgery was then analyzed as a continuous variable against the operative details and postoperative outcomes utilizing Spearman's correlation coefficient and the Mann-Whitney U-test.

Results: Fifty-two patients underwent prophylactic surgical excision of their DST as well as detethering. Overall, 65% of patients were female and the median age at diagnosis was 3 months, while the median age at the time of surgery was 7 months. An additional cutaneous finding was identified in 71% of patients, with hemangioma being most frequent (40%). Additional spinal lesions were radiographically identified in 29% of patients, including lipoma (19%), dermoid and epidermoid inclusion cysts (8%), and an arachnoid cyst (2%). Postoperative complications occurred in 8% (n = 4) of patients, primarily related to wound healing (3/4), with significant risk attributed to younger age at time of surgery (mean 3 months, range 1-5 months) (p = 0.01). During 56 months of follow-up, long-term rates of retethering (6%, p = 0.02) and abnormal neurological examinations (8%, p = 0.001) were associated with concurrent lipomas, but not with age at operation.

Conclusions: In a series of 52 pediatric patients undergoing prophylactic resection of a DST with detethering, the complication rate was 8% and was significantly associated with age < 6 months at the time of operation. Associated spinal lipomas significantly influenced long-term outcomes. When evaluating asymptomatic infants with DST, patient age is a significant factor in assessing the risks and benefits of surgical timing.

Objective: Myelomeningocele (MMC) carries high morbidity and mortality. The Management of Myelomeningocele Study (MOMS) showed improved outcomes after prenatal compared to postnatal repair. However, it is unclear how the MOMS trial affected practice and outcomes in the Latin American region. The objective of this study was to review the literature published by or including patients from the Latin American region and the reported management patterns of MMC.

Methods: A systematic review of MMC repair was performed. Articles were included if the senior author or patient population was from a Latin American country or territory. Article characteristics such as senior author, title, year of publication, senior author department, and outcomes studied were extracted. Management of MMC repair was the primary outcome explored.

Results: A total of 71 studies satisfied all criteria for selection. Brazil (75%), Mexico (11%), Argentina (8%), Chile (7%), Costa Rica (1%), and Puerto Rico (1%) were represented countries or territories (some studies included patients from multiple countries). Neurosurgery (n = 23) was the most represented senior author department, followed by fetal medicine or fetal surgery (n = 15) and obstetrics (n = 14). Puerto Rico and Costa Rica described postnatal repair, while studies from Brazil, Chile, Argentina, and Mexico described prenatal repair. Brazil was the only country to prospectively study urological outcomes, reporting little to no improvement in urological outcomes with pre- versus postnatal repair. Prospective studies showed the safety and efficacy of endoscopic, microhysterotomy, and microneurosurgical approaches to in utero surgery.

Conclusions: Six countries or territories in the Latin American region have published articles on MMC repair. All recent papers describe a prenatal approach. Prospective studies show a trend toward open fetal microhysterotomy and microneurosurgery in the region and a need for more research on long-term urological outcomes following in utero repair.

Objective: Shunt infections are costly and stressful for families, patients, and providers. Many institutions use shunt checklists in an effort to reduce the risk of infection following shunt surgery. Such protocols often aim to limit operating room (OR) foot traffic, but there is little evidence that supports the theory that greater OR traffic increases the risk of acquiring a shunt infection through contamination of the air. The purpose of this study was to quantify foot traffic during shunt surgery at a children's hospital during a time period when a shunt checklist was used.

Methods: Starting in 2019, a premedical student was tasked with covertly collecting data on 50 shunt operations. Data were recorded in real time and documented in a prospectively updated database. Recording foot traffic through the OR door began at onset of skin prep; data points included patient and surgical details, operative length, and who entered the room and why. Each operation was followed for a minimum of 180 days for infection. The primary outcome was "door event," defined as any time a door to the OR was opened-fully or partially-with or without someone breaking the plane of the door (i.e., entering or exiting).

Results: Fifty operations were observed with no primary shunt infection (mean follow-up 29.8 months, range 6.5-63.3 months). One patient experienced a late secondary infection due to systemic post-COVID-19 inflammatory syndrome causing gastrointestinal bacterial translocation. The average operative time-from applying sterile skin prep until surgery stop time-was 69.8 minutes. Overall, there were 1012 door openings with 1088 personnel entering or exiting. The average number of door openings per operation was 20.24. OR personnel (42.7%) and neurosurgery staff (31.6%) were responsible for the largest number of door events, followed by the anesthesiology service (18.9%). The most cited reasons for door events were for supplies (31.2%) and scrubbing in (26.5%).

Conclusions: This study represents the first detailed analysis of OR traffic during pediatric shunt surgery. No patient developed a primary shunt infection. While minimizing OR traffic makes intuitive sense, it remains unknown whether a causal relationship exists. Further investigation is needed.

Objective: Spinal cord injury (SCI) trials have historically underrepresented pediatric patients. There are limited pediatric data examining the influence of surgical timing on complications and mortality for children and adolescents who have sustained complete traumatic SCI.

Methods: The following multicenter cohort study used Trauma Quality Improvement Program data from 2010 to 2020. The authors identified pediatric patients (aged < 18 years) who sustained complete traumatic SCI and underwent surgical intervention within 7 days of admission. Propensity score matching was performed between patients who underwent surgery within 24 hours versus ≥ 24 hours. The authors then assessed differences for the following outcomes: major in-hospital complications, immobility-related complications, length of stay (LOS), and mortality.

Results: There were 837 patients with complete traumatic SCI managed across 297 trauma centers identified for study inclusion (70% underwent early surgery). After matching, 494 patients were available for analysis. Patients undergoing delayed surgery experienced longer ICU LOS (mean difference 3.74 days, 95% CI 0.91-6.57 days) and more major in-hospital complications (OR 1.77, 95% CI 1.16-2.73) and immobility-related complications (OR 2.09, 95% CI 1.25-3.56). There were no differences in mortality between groups. Younger age, non-White race, penetrating injuries, lower Glasgow Coma Scale score at admission, severe concomitant abdominal injuries, and motor vehicle collision injury mechanisms were associated with increased time to surgery.

Conclusions: The authors demonstrated an association between early surgery and shorter ICU LOS and reduced in-hospital complications. Future work is needed to quantify the impact of surgical timing on functional neurological outcomes and to explore upstream social determinants of health influencing timing of surgery.

Objective: Cerebral spinal fluid (CSF) diversion methods, including ventriculoperitoneal (VP) shunts, are the standard treatment for hydrocephalus. Hair clipping (HC) has been a routine neurosurgical practice of the great majority of neurosurgeons, due to the perception that this will either decrease the risk of shunt infection or allow for a faster, unimpeded opening and closing of the skin. The benefits of not cutting or clipping hair in terms of normalizing appearance and self-esteem are obvious. The purpose of this study was to assess whether the rate of shunt infection would differ between pediatric patients receiving operation via the hair-sparing (HS) approach versus HC.

Methods: A retrospective single-institution study comparing HS versus HC was conducted on pediatric patients undergoing long-term CSF shunt procedures at the Montreal Children's Hospital between August 2014 and April 2021. The primary outcome measure was shunt infection at 90 days and at long-term follow-up. Inclusion criteria were having at least 18 months of follow-up after long-term CSF shunt procedures, including insertions or revisions of VP shunts, ventriculoatrial shunts, cystoperitoneal shunts, subdural-peritoneal shunts, ventriculosubgaleal shunts, and ventriculosubgaleal reservoirs. Excluded procedures were those involving external ventricular drains, externalized shunts, Omaya reservoirs, endoscopic third ventriculostomies, and lumbar shunts.

Results: There were 434 CSF shunt procedures performed in 226 unique patients; 155 (35.71%) procedures were done using the HS approach versus 279 (64.29%) procedures via HC. At 90 days postoperatively, the infection rate was 1.29% in the HS group and 2.87% in the HC group, with an absolute risk difference of 1.58% (95% CI -1.07% to 4.23%, p = 0.24). At long-term follow-up (mean follow-up: 752 days and 716 days for the HS and HC groups, respectively), the rate of shunt infection remained at 1.29% for the HS group (no new infections) but rose to 4.66% for the HC group, with an absolute risk difference of 3.37% (95% CI 0.33%-6.41%, p = 0.03).

Conclusions: Performing CSF shunt procedures without cutting or clipping any hair has a very low risk of shunt infection, and certainly does not appear to increase the risk of infection (or malfunction) versus the hair removal approach. It is a safe alternative and should be considered due to its esthetic and psychological benefits regarding normalization of appearance and ease of resuming a normal life following shunt surgery.

Objective: Surgical intervention is commonly necessary for craniosynostosis. One of the preoperative concerns revolves around the cerebral venous drainage pattern and its potential involvement during surgery. Although there have been reports regarding venous drainage patterns in syndromic craniosynostosis, studies of nonsyndromic cases have been rare. In the present study, the aim was to study venous drainage patterns in nonsyndromic craniosynostosis.

Methods: Nonsyndromic cases at a single institute were retrospectively reviewed, and cerebral venous drainage in the posterior (transverse sinus [TS]) and anterior (cavernous sinus [CS] and para-CS [ParaCS]) venous routes was systematically investigated. The occipital sinus (OS) and emissary veins were also evaluated.

Results: A total of 89 nonsyndromic cases were evaluated, including 12 right coronal synostosis (RCS), 14 left coronal synostosis (LCS), 15 bilateral coronal synostosis (BCS), 36 sagittal synostosis, 6 metopic synostosis, and 6 combined metopic-sagittal synostosis cases. All venous studies were performed using MR venography. There was a significant difference among all six groups in TS dominance (p = 0.0108). In unilateral coronal synostosis (UCS; including RCS and LCS) cases, 76.9% had TS dominance on the opposite side of the synostotic suture (20 of 26 UCS, including 10 of 12 RCS and 10 of 14 LCS). There was a significant difference in the incidence of OS, with the highest incidence observed in the BCS group (33.3%, p = 0.027). CS/ParaCS venous drainage was observed in 94.4% of cases on the right side and 95.5% on the left side, showing no significant difference among the groups on both sides. No visible emissary vein was observed in any of the groups.

Conclusions: A significantly higher predominance of left TS was found in RCS cases, in contrast with the typical right-side predominance seen in the normal population. In addition, the majority of UCS cases exhibited TS dominance on the opposite side of the synostotic suture. Furthermore, the present results showed a significant difference in the prevalence of OS, which was predominantly observed in BCS cases. These findings could be explained by the induction effect on venous sinuses by the compensatory growth of the skull according to Virchow's law, suggesting that synostotic sutures induce compensatory skull expansion in regions farthest (diagonally) from the affected sutures, thereby enlarging nearby venous sinuses.

Objective: Pediatric cerebral vasospasm (PCV) is associated with aneurysmal subarachnoid hemorrhage (aSAH), but aSAH is uncommon in children. No universal guidelines exist for PCV management. The authors sought to assess variations in practice patterns in pediatric aSAH and PCV management.

Methods: A REDCap survey was circulated by the AANS/CNS Pediatric Section and the Pediatric Neurocritical Care Research Group assessing PCV management practices.

Results: A total of 58 responses were received. The proportion of responses received from each region ranged from 19% in the Northeast to 28% in the Midwest. Of all respondents, 88% reported practicing at academic institutions. Neurosurgeons constituted 79% of respondents, and intensivists 17%; 85% primarily managed children. Most providers treated 1-3 aSAHs annually and a minority (21%) reported protocolized aSAH management at their centers. PCV prevention used permissive hypertension (90%), chemoprophylaxis (86%), and strict fluid-volume management (83%). PCV was typically assessed using serial neurological examination (60%) and transcranial Doppler (TCD) studies (72%). Treatment of PCV included permissive hypertension (50%) and endovascular interventions (81% intraarterial verapamil, 35% nitroprusside, and 67% angioplasty). Balloon angioplasty was more common than stent retriever-plasty.

Conclusions: Pediatric PCV is rare and primarily treated by specialists at academic institutions. Although some elements of management are commonly used, wide variability exists in the strategies used for PCV prevention, detection, and treatment. Management strategies for pediatric PCV may be extrapolations from adult paradigms, but standardized guidelines are lacking. Prioritization should be given to the development of such guidance to enable the development of more robust evidence-based practices in the future.

Objective: The objective of this study was to describe the technical aspects and postnatal neurosurgical outcomes of a prenatal, 3-miniport fetoscopic myelomeningocele (MMC) repair technique providing a multilayered closure using cryopreserved decellularized human umbilical cord (HUC) matrix allograft for duraplasty.

Methods: The authors conducted a subanalysis of an ongoing prospective cohort study analyzing the neurosurgical outcomes of 57 of 92 consecutive patients who underwent multilayered fetoscopic surgical MMC repair using HUC matrix allograft for duraplasty at their institution from December 2016 to March 2022, including more than 24 months of postnatal follow-up.

Results: Of 92 patients who underwent fetoscopic MMC repair, 88 had duraplasty using cryopreserved HUC matrix allograft. Fifty-seven patients had at least 24 months of follow-up data. The mean gestational age at the time of surgical repair was 24.8 ± 0.7 weeks. The average operative time from skin incision to closure was 260 ± 43.4 minutes, in which 79% of this time was used for the fetoscopic portion. No patient required intraoperative emergency delivery. At birth, there were no cases of CSF leak or complete wound dehiscence. Six (11.5%) of 52 patients experienced superficial wound dehiscence, and only 2 (3.5%) required surgical revision. At 30 months, 54.8% of patients were noted to be independent ambulators, 35.5% were therapeutic ambulators, and 9.7% remained wheelchair users in this subset of patients. The rate of hydrocephalus requiring CSF diversion was 35.3%, and 84.3% of patients had complete reversal of hindbrain herniation at birth. Eight (15.7%) of 51 patients had spinal inclusion cysts noted on routine follow-up spinal imaging, but only 2 (3.9%) required surgical intervention due to radiological progression without neurological symptoms.

Conclusions: A laparotomy-assisted, 3-miniport fetoscopic approach for prenatal MMC multilayered repair offers excellent access and visualization for an effective watertight closure. The use of HUC matrix allograft as a dural substitute was shown to be effective with a low rate of neurosurgical postnatal complications.