Journal of neurosurgery. Pediatrics最新文献

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.

Objective: The incidence of nonsyndromic multisuture craniosynostosis is rare, accounting for < 5% of cases. Concurrent isolated bilateral lambdoid and sagittal synostosis (BLSS), colloquially known as Mercedes-Benz pattern synostosis, constitutes < 1% of all craniosynostosis cases. Patients with BLSS benefit from surgical correction in infancy to correct the characteristic frontal bossing, a high forehead with significant downward sloping toward the occiput, a prominent occiput with a notable point, and occipital concavity that starts immediately below that region. However, due to its rarity, there is a paucity of literature describing the surgical management of BLSS. In this study, the authors evaluated a single institution's clinical experience treating this condition with early endoscopic strip craniectomy (ESC).

Methods: Medical records for patients with a diagnosis of concurrent sagittal and bilateral lambdoid synostosis who underwent ESC between 2006 and 2023 at a single institution were reviewed for demographic, operative, and follow-up data. Patients with additional fused sutures or other syndromic diagnoses were excluded as those cases constitute a distinct pathology from pure Mercedes-Benz synostosis. All patients with less than 1 year of follow-up were also excluded.

Results: Seven patients underwent early ESC as the primary treatment for Mercedes-Benz pattern synostosis. The mean age at surgery was 3.0 months (range 1.60-5.97 months). The mean operative time was 67 minutes, with a time under anesthesia of 155 minutes. There were no complications intra- or postoperatively. No patients required readmission within 30 days or a subsequent surgical procedure. The mean length of follow-up was 3.5 years.

Conclusions: Early endoscopic surgery is a safe and effective treatment for infants with Mercedes-Benz synostosis. Based on clinical criteria and limited imaging in some cases, the children have done extremely well with no need for additional surgery, but additional long-term follow-up is in process.

Objective: Neurosurgery, particularly pediatric neurosurgery, is associated with high malpractice risks due to the complexity of procedures and potential for severe complications. However, comprehensive reviews of medical malpractice cases specifically involving pediatric neurosurgeons are scarce. This study aimed to analyze trends in malpractice litigation within the pediatric neurosurgical field in the United States.

Methods: A search was conducted of the LexisNexis and Westlaw legal databases for medical malpractice cases involving pediatric neurosurgeons from 1979 to 2022. Cases were included if they involved a pediatric neurosurgical condition, a patient younger than 21 years of age, and at least one defendant who was a pediatric neurosurgeon. Fourteen cases met the inclusion criteria and were analyzed for clinical conditions, allegations, outcomes, and other relevant factors.

Results: Most cases originated from the southern United States, with spina bifida/tethered cord and subdural hematomas being the most cited conditions. Allegations predominantly focused on failure to diagnose or treat (57%, 8/14 cases) particularly in relation to hydrocephalus and spina bifida. Nine cases favored the defendant, 1 resulted in a plaintiff's verdict, and the outcome of 4 cases was unknown or a mixed verdict. Plaintiff age typically ranged from younger than 3 years to more than 13 years.

Conclusions: These findings highlight the prevalence of specific conditions such as spina bifida and hydrocephalus in malpractice cases involving pediatric neurosurgeons. While most cases favored the defendant, these conditions and the high acuity of pediatric neurosurgical care continue to present significant risks. Future research incorporating insurance provider data could offer further insights into malpractice trends in this field. This study provides a detailed overview of malpractice claims in pediatric neurosurgery, identifying key conditions and trends. Understanding these patterns is crucial for enhancing risk management and patient care in pediatric neurosurgery.

Objective: Although pediatric head trauma (PHT) is a critical public health issue, comprehensive research on the anatomical distribution and frequency of impact locations is lacking. The authors aimed to elucidate trends in the mechanisms and anatomical locations of PHT using clinical data across all injury severity levels.

Methods: The medical records of 146 PHT patients aged 0-14 years treated by the authors' neurosurgery department were analyzed, excluding cases of suspected abuse. Clinical data and injury mechanisms were reviewed, and 152 PHTs were assessed to identify the trauma frequencies for 17 different anatomical locations of the head. The authors compared actual to expected PHT hits per region based on area ratios to determine the regions more susceptible to PHT.

Results: Most PHTs were minor, without even subcutaneous hematomas. Radiological imaging was performed in 32.2% of patients, revealing abnormalities in 19.2% of those cases. Larger hematomas correlated with these abnormalities, although there was no correlation between vomiting and imaging findings. Notably, 65.7% of the traumas occurred within a horizontal band from the frontal to the occipital region, similar to the area covered by a sports headband. The high injury concentration in this area was particularly focused on the center-forehead region, where susceptibility was significant (p < 0.001). Children younger than 6 years of age had a greater bias toward specific PHT-prone regions. This diminished with age, suggesting changing PHT mechanisms as children mature.

Conclusions: Certain head regions are more prone to accidental PHT, with region-specific susceptibility varying by age. This study can facilitate the design of optimal pediatric head protection and support clinical assessment of injury patterns.