Journal of neurosurgery. Pediatrics最新文献

Objective: Cranial fixation is essential to many neurosurgical procedures for ensuring patient head immobilization and optimal surgical outcomes. However, complications such as skull fractures, scalp lacerations, and clamp slippage remain underreported and understudied in the pediatric patient population. This study aimed to identify pediatric neurosurgeon perspectives on skull clamping risks and protocols.

Methods: An anonymous 19-question survey was distributed to 295 pediatric neurosurgeons with an email address registered with the American Board of Pediatric Neurological Surgery and/or the American Society of Pediatric Neurosurgeons. Questions addressed clamping practices, injury experiences, perceptions of current safeguards, and attitude toward injury detection and prevention systems.

Results: Of the 295 pediatric neurosurgeons contacted, 64 (21.7%) responded, and 48 (16.3%) completed the full survey. The median age at which respondents reported clamping pediatric skulls without additional support was 2 years, and the median minimum clamping pressure was reported to be 40 pounds. Surgeons reported substantial variability in clamping practices, particularly in minimum and maximum pressure thresholds, often citing patient-specific skull thickness as a key determinant. Injury reporting revealed that 31.5% of respondents experienced at least one skull fracture annually, 48.1% reported at least one scalp laceration annually, and annual slippage or clamp loosening was reported by > 70% of respondents. Additionally, surgeons who provided preoperative counseling regarding clamping risks were more likely to experience related risks. Overall, these surgeons expressed dissatisfaction with existing clamping technologies, citing inadequate safeguards for both injury prevention and detection. Seventy-three percent of surgeons expressed eagerness to adopt technologies capable of mitigating risks, and 65% expressed eagerness to adopt technologies capable of injury detection. These findings highlight the burden of clamp-related complications in pediatric neurosurgery and an interest in the development of safer, more reliable cranial fixation systems.

Conclusions: There are substantial challenges associated with the utilization of cranial fixation in pediatric patients. Exploring real-time intraoperative monitoring technologies may offer a promising avenue for improving patient safety and surgical outcomes.

Objective: Drug-resistant epilepsy (DRE) can arise early in life due to multiple structural abnormalities. In patients with the disorder, seizures can be difficult to control and can significantly impair neurodevelopment. Hemispherectomy is well described as a treatment for refractory hemispheric-onset epilepsy, but its use in infants has been limited due to concerns over surgical risk and physiological tolerance. The aim of this review was to summarize an institutional experience with hemispherectomy in infants to demonstrate the safety and efficacy of the technique.

Methods: A retrospective chart review was conducted to identify children younger than 1 year of age who had undergone a modified functional hemispherectomy combining elements of both hemispherotomy and anatomical resection to treat DRE at Seattle Children's Hospital from 2000 to 2024. The primary outcome was favorable seizure outcome, defined as Engel class I-II at the 1-year follow-up. Secondary outcomes included perioperative complications, development of postoperative hydrocephalus, need for long-term nutritional supplementation, and changes in the anti-seizure medication burden.

Results: Twenty-one children who had undergone functional hemispherectomy were identified, revealing a mean age of 6.2 months (range 0.93-12.3 months) at surgery. The most common etiology was hemimegalencephaly (n = 11, 52%). No serious cardiac, pulmonary, or coagulopathic adverse events occurred, although complications included asymptomatic cerebral venous sinus thrombosis (n = 1, 5%), postoperative hydrocephalus (n = 3, 14%), and electrolyte derangements (n = 1, 5%). The mean hospital stay was 12.5 days (range 6-34 days). Hydrocephalus developed > 12 months postoperatively in 2 (67%) of the 3 patients with this complication. The mean estimated blood loss was 345.8 mL (150-700 mL), and all patients received a transfusion during their surgery with a mean transfusion volume of 450.2 mL (60.4 mL/kg). Seizure outcomes were uniformly assessed at the last clinical follow-up, with a mean follow-up duration of 91.9 months (range 6.1-261.6 months). A favorable seizure outcome (Engel class I-II) was attained in 20 patients (95%), with an Engel class I outcome in 19 patients (90%).

Conclusions: An institutional experience demonstrated that functional hemispherectomy is a safe and well-tolerated procedure in infants and offers excellent seizure control outcomes in hemispheric-onset epilepsies. The surgical technique, a focus on minimizing operative blood loss, and multidisciplinary care of these patients are critical elements in ensuring the safety and success of this procedure. Future studies are needed to better characterize long-term functional and neurodevelopmental outcomes in this age group.

Objective: The choice of surgical technique for decompression of the cervicomedullary junction remains controversial. The authors report their experience with using subpial tonsillectomy for Chiari malformation with and without associated syringohydromyelia.

Methods: Children from two institutions who underwent the subpial tonsillar resection technique for decompression of the craniocervical junction from 2014 to 2024 were included. Demographic information, relevant presurgical symptoms, surgical history, perioperative radiographic characteristics, postoperative outcomes, complications, reoperations, and 90-day readmissions were collected. Two outcomes were assessed at last follow-up: 1) status of presenting symptom(s); and 2) radiographic status of syringohydromyelia or isolated presyrinx edema, if present preoperatively.

Results: A total of 109 patients were identified with a mean age of 10.8 years. Seventy-eight (71.6%) of these patients presented with headaches, and 23 (21.1%) had medullary or lower cranial nerve dysfunction. Radiographically, 86 (78.9%) patients had Chiari type 1 and 23 (21.1%) had Chiari type 1.5. The mean (range) preoperative cerebellar tonsillar herniation was 14.0 (4.5-40) mm, and 49 (45%) patients had syringohydromyelia or presyrinx edema. The mean operative time was 152 minutes, and the mean length of stay was 3.49 days. Fourteen patients were readmitted within 90 days of surgery, 9 within the first 30 days, and 5 after 30 days. Of these 14 readmissions, 8 (57%) were for reasons attributable to the index operation. Over a mean follow-up of 3.70 years, headaches resolved or improved in 68 of 78 (87.2%) patients, and 18 of 23 (78.3%) patients with brainstem or lower cranial nerve dysfunction demonstrated improvement. Of the patients with syringohydromyelia who had follow-up (n = 45), 39 (86.7%) had complete resolution of their syringohydromyelia (n = 16) or > 50% reduction in diameter of the syrinx (n = 23). One patient was deemed a treatment failure, eventually needing a syringopleural shunt.

Conclusions: Subpial tonsillar resection for Chiari malformations is a safe and effective method to maximally decompress the craniocervical junction and immediately reestablish pulsatile cerebrospinal fluid flow out of the fourth ventricle. Most patients will experience improvement or resolution of their associated symptoms and significant reduction (> 50% diameter reduction) or resolution of their syringohydromyelia.

Objective: Transradial access (TRA) has gained popularity among neurointerventionalists due to its shorter procedure time and fewer complications compared to transfemoral access (TFA). The literature on the feasibility of TRA in pediatric patients undergoing intra-arterial chemotherapy (IAC) for retinoblastoma (Rb) is limited. This study compares procedural efficiency and postoperative recovery time among IAC patients undergoing TRA versus TFA.

Methods: The authors conducted a retrospective single-center study of pediatric patients undergoing IAC through TRA or TFA for Rb from January 2019 to January 2025. Outcomes of interest were procedure time, recovery time in the postanesthesia care unit, and dose of dexmedetomidine (mcg/kg) received during recovery. Inverse probability of treatment weights (IPTWs) was used to adjust for confounding variables between the two treatment groups (TRA vs TFA).

Results: Of 255 IAC procedures included, 14.9% (n = 38) of cases were performed through TRA and 85.1% (n = 217) through TFA. In the unadjusted analysis, TRA was associated with a mean 27.3-minute decrease in procedure time (95% CI -35.22 to -19.38 minutes, p < 0.001), 136.91-minute decrease in recovery time (95% CI -195.49 to -78.32 minutes, p < 0.001), and a 102.55-mcg/kg reduction in dexmedetomidine dose during the postoperative period (95% CI -120.33 to -84.78 mcg/kg, p < 0.001). After IPTWs adjustment, TRA was associated with a mean 33.17-minute decrease in procedure time compared to TFA (95% CI -39.38 to -26.97 minutes, p < 0.001) and a mean 2459.9-mGy⋅cm2 (95% CI -4139.24 to -780.52 mGy⋅cm2, p < 0.01) decrease in radiation exposure. TRA patients experienced a mean 158.58-minute decrease in recovery time (95% CI -214.95 to -102.23 minutes, p < 0.001) and also received lower doses of dexmedetomidine (mcg/kg) compared to TFA (mean -106.95, 95% CI -117.16 to -96.73 mcg/kg; p < 0.001). One patient in each group (TRA and TFA) developed bronchospasm. One patient developed ophthalmic artery occlusion during their third IAC procedure.

Conclusions: In pediatric patients undergoing IAC for Rb, TRA is associated with reduced radiation exposure, shorter procedure and recovery time, and lower sedation requirements compared to TFA.

Objective: Although the anterior approach to cervical spine surgery is an important tool for managing pediatric spine conditions, there is limited literature on the topic. The aim of this single-institution study was to analyze the indications, surgical techniques, complication rates, and outcomes of anterior cervical spine surgery in pediatric patients.

Methods: A single-center retrospective review of pediatric patients (age < 18 years) who underwent anterior cervical spine surgery from 2010 to 2022 was performed. Data collected included demographics, surgical indications, presenting symptoms, operative techniques and outcomes, fusion rate as defined in the postoperative note, complications, returns to the operating room, and rates of proximal/distal junctional issues.

Results: A total of 64 patients (mean age 13.3 ± 3.9 years, 73.4% male) with a mean follow-up period of 16 months were evaluated. The most common indication for surgery was trauma (73.4%), followed by deformity/nontraumatic instability (21.9%) and neoplasia (4.7%). Syndromic etiologies necessitating surgery were present in 9.4% of patients (Klippel-Feil syndrome [6.2%], achondroplasia [1.6%], and diastrophic dysplasia [1.6%]). Some patients (35.9%) had neurological deficits at presentation (6.2% motor only, 4.7% sensory only, 25.0% with motor and sensory deficits). Most patients (85.9%) underwent anterior surgery alone, whereas 14.1% underwent staged anterior surgery followed by posterior fixation. Two-level fusions were most common (45.3%), followed by single-level fusions (26.5%) and fusions of 3 or more levels (28.1%). An anterior plate was used in most cases (98.4%), 10.9% of which were small static cervical plate constructs. A synthetic cage was used in 14.1% of cases, most of which were polyetheretherketone (88.9%). A structural allograft was used in 85.9% of cases. Perioperative complications affected 9.4% of patients (hoarseness [4.7%], dysphagia [1.6%], hematoma [1.6%], and vascular injury [1.6%]). Arthrodesis across the anterior instrumented levels was successful in 98.4% of patients. Pseudarthrosis requiring revision surgery occurred in 1 patient within 1 year of the index surgery. Proximal junctional kyphosis was observed in 10.9% of patients, and 6.4% of patients required an unplanned return to the operating room (C3 pseudarthrosis [1.6%], hematoma evacuation [1.6%], and posterior implant failure [3.1%]).

Conclusions: The authors report their single-institution experience with pediatric anterior cervical spine surgery. Most patients underwent anterior instrumented fusion alone with high rates of success. Larger, multicenter studies are needed to better elucidate factors that might contribute to unfavorable outcomes.

Objective: Disseminated pediatric low-grade gliomas (DPLGGs) are a rare subtype of an otherwise common tumor, characterized by leptomeningeal dissemination, with microtumors spreading throughout the CNS. The impact of this dissemination on CSF dynamics remains unexplored. The authors describe the occurrence, treatment, and impact of hydrocephalus on functional outcomes and survival in patients with DPLGG.

Methods: This study was a post hoc analysis of a multicenter international cohort study that identified 261 children diagnosed with DPLGG from 30 sites across 13 countries from 1988 to 2025. Demographic, histopathological, radiographic, dissemination pattern, hydrocephalus treatment, and functional outcome variables were collected. The primary outcomes were survival, CSF diversion failure, and time to failure (TTF). Group comparisons were conducted using independent-sample t-tests and chi-square tests. Multivariate logistic regression was performed examining predictors of hydrocephalus in DPLGG. Kaplan-Meier analysis was used to assess survival and TTF.

Results: One hundred forty-five (55.6%) patients developed hydrocephalus and required CSF diversion. Histopathological diagnosis differed between the groups (p = 0.02). Patients with diffuse leptomeningeal glioneuronal tumor had a 41% (OR 1.408, 95% CI 0.413-4.809) increase in odds of developing hydrocephalus relative to other histopathologies. Tumor dissemination pattern did not significantly impact hydrocephalus development (p = 0.381). There was, however, a significant association between the timing of hydrocephalus diagnosis and CSF diversion and dissemination pattern (p < 0.001). For initial CSF diversion, 124 patients (87.9%) received ventriculoperitoneal shunting (VPS) while the remaining patients underwent either endoscopic third ventriculostomy (ETV) (9.2%) or septostomy (2.9%). Fifty-nine (43.1%) patients who underwent CSF diversion required hydrocephalus reintervention at an overall median TTF of 4.96 months (IQR 0.8-22.4) months. TTF by CSF diversion modality showed no significant difference by Kaplan-Meier analysis (log-rank test, p = 0.90). There was no difference in overall survival (log-rank test, p = 0.95) between the hydrocephalus and nonhydrocephalus groups. However, hydrocephalus was associated with academic difficulties (p = 0.02) and concurrent endocrine disorders (p = 0.03).

Conclusions: This study represents the largest and most comprehensive cohort of patients with DPLGG to date. While histopathology and tumor location were associated with hydrocephalus in this cohort, the dissemination pattern was not directly associated with hydrocephalus incidence but rather the timing of hydrocephalus diagnosis. Hydrocephalus does not impact survival in patients with DPLGG; however, it is associated with worse functional outcomes.

Objective: Trigeminal neuralgia (TN) is a rare, debilitating craniofacial pain disorder that is uncommon in children, representing 1%-1.5% of cases. While adult TN is well-documented, data on pediatric presentations, treatment patterns, and healthcare disparities remain limited. This study characterizes demographic trends, procedural interventions, and inpatient cost trends for pediatric patients with TN using a national dataset.

Methods: The authors conducted a retrospective cohort study using the National Inpatient Sample from 2011 to 2020 to identify patients with TN younger than 18 years. Demographics, insurance status, geographic region, and procedural interventions were extracted. Outcomes included procedure rates, discharge disposition, and total hospital charges. The chi-square test, t-test, and an ANOVA were used to assess the associations between demographics, interventions, and costs.

Results: A total of 214 pediatric TN admissions were identified over the 10-year period. The mean patient age was 13.5 (SD 3.75) years, and 66.8% were female. A majority of patients were White (71.4%) and privately insured (63.4%). Overall, 55 patients (25.7%) underwent procedures, most commonly anesthesia application to the cranial nerve and nerve decompression. Patients receiving procedures were significantly older (14.3 vs 13.2 years, p = 0.012), more likely to be privately insured (p = 0.043), and more frequently from the West South-Central region (p < 0.001). No significant differences were observed based on race or income quartile. Total inpatient charges over the decade exceeded $4.5 million US, with most patients discharged home posttreatment.

Conclusions: This study represents the largest known national cohort of pediatric patients with TN. While most patients were managed nonoperatively, a notable portion underwent procedural interventions, particularly older children and those with private insurance. Geographic disparities were evident, warranting further investigation into referral patterns and healthcare access. These findings underscore the need for broader, multicenter efforts to optimize diagnosis and equitable treatment for pediatric TN.

Objective: Hydrocephalus due to intraventricular hemorrhage (IVH) during prematurity represents a challenging form of CSF circulation disturbance. It remains unresolved as to which temporary measures are best for intracranial pressure relief before sufficient body weight is reached to perform shunt implantation. The international Treatment of Posthemorrhagic Hydrocephalus in neonates (TROPHY) registry was designed to compare the safety and efficacy of 4 different methods of temporary treatment. The aim of this study was to investigate 6-month follow-up data from the TROPHY registry to characterize and compare perioperative measures, reoperations, complications, and shunt dependency among the different treatment methods.

Methods: An online registry designed for multicenter international prospective data collection was reviewed for patients with complete datasets that included 6-month follow-up data. Eligible patients were neonates with IVH and progressive ventricular enlargement necessitating surgical pressure relief. Four possible methods of intervention were assessed: ventricular access device (VAD) placement, external ventricular drainage (EVD), ventricular subgaleal shunt (VSGS) placement, and neuroendoscopic lavage (NEL). Preoperative data, perioperative aspects of surgery, and 6-month follow-up data were collected in a standardized manner.

Results: Of 238 patients with posthemorrhagic hydrocephalus (PHH) included in this analysis, 47 received a VAD, 34 received EVD, 75 received a VSGS, and 82 received NEL. After 6 months of follow-up, differences were seen in the rate of unilateral frontal tissue defect at the entry point (p < 0.001, highest in the NEL group and lowest in the VAD group), multiloculated hydrocephalus (p < 0.05, highest in the EVD group and lowest in the NEL group), parenchymal defect (p < 0.05, highest in the VAD and lowest in the EVD group), and the proportion of patients needing a permanent shunt (p < 0.001, highest in the VSGS group and lowest in the NEL group). No significant differences were seen in rates of complications or revisions among the groups.

Conclusions: Analysis of 6-month follow-up TROPHY registry data provided further insights into treatment options for PHH after neonatal IVH. NEL had the lowest probability of needing a shunt at 6 months. Further research will be performed to draw clearer conclusions.