Journal of neurosurgery. Pediatrics最新文献

Objective: Chiari malformation type I (CM-I) is a common condition characterized by the cerebellar tonsillar position below the foramen magnum. Radiographic measurements are important for diagnosing CM-I but have limited use in predicting the severity of the condition and the need for surgery. The fourth ventricle roof angle (FVRA), a measure of deformation or bowing of the roof of the fourth ventricle, has been presented as a tool for predicting brainstem dysfunction in patients with CM-I; however, this has not been validated. Utilizing a database of pediatric patients with CM-I from a large single center, this study aimed to validate the finding that the FVRA can serve as a predictor of brainstem dysfunction in pediatric CM-I and to present additional potential correlations of interest between the FVRA and symptoms and other radiographical measurements.

Methods: Radiographic measurements were retrospectively reviewed for 388 pediatric patients evaluated for CM-I at Children's of Alabama from November 2010 to 2017. Fourth ventricle bowing was determined to be present if the FVRA was > 65°. Univariate and multivariate logistic regression analyses were performed to identify significant associations with the FVRA, brainstem dysfunction, and surgery. Brainstem dysfunction was defined as the presence of lower cranial nerve dysfunction and/or sleep apnea.

Results: Multivariate logistic regression showed significant association of lower brainstem dysfunction with tonsillar position (OR 1.17, 95% CI 1.06-1.29), basilar invagination (OR 0.66, 95% CI 0.47-0.91), supraoccipital length (OR 0.86, 95% CI 0.77-0.96), and tussive headache (OR 6.62, 95% CI 1.95-22.46). The presence of bowing did not show a significant association with brainstem dysfunction in the multivariable model (OR 1.02, 95% CI 0.27-3.81), and it was not significantly associated with undergoing surgery after controlling for symptoms that always resulted in surgery (p = 0.483).

Conclusions: Univariate logistic regression analysis demonstrated that an FVRA greater than 65° is significantly associated with brainstem dysfunction. In a multivariate logistic regression model, however, the presence of bowing was not independently associated with brainstem dysfunction. As such, additional studies are needed before FVRA can be utilized clinically.

Objective: The role of timely nutritional support in the recovery of pediatric traumatic brain injury (PTBI) patients is crucial yet underexplored. The authors planned a retrospective study to investigate the timing of feeding initiation (early feeding [≤ 48 hours] or delayed feeding [> 48 hours]), feeding pattern, and causes of feeding delay/interruption in this cohort and studied the association of delayed feeding with outcomes in PTBI from a single center in a lower-middle-income country.

Methods: This retrospective, single-center study included PTBI patients ≤ 15 years of age admitted to the neurotrauma intensive care unit (NICU) within 24 hours of head injury over a period of 1 year. Demographic data, injury characteristics, and nutritional data were recorded from hospital electronic records. The outcome was measured in terms of NICU length of stay (LOS) and hospital LOS, infectious complications, neurological recovery at discharge, and mortality.

Results: One hundred PTBI patients were included, with mild (n = 28, 28%), moderate (n = 28, 28%), and severe (n = 44, 44%) traumatic brain injury (TBI). Patients had a median Glasgow Coma Scale (GCS) score of 9 (IQR 7, 13) at admission. Enteral nutrition was initiated early in 48% (n = 48) of patients. Only 39 of 100 patients reached 70% of their caloric target within 7 days. Causes of feeding interruption were planned surgical/radiological and airway procedures (n = 89, 59.0%), feed intolerance (n = 25, 16.6%), feed refusal (n = 22, 14.6%), and hemodynamic instability (n = 15, 9.9%). Early initiation of enteral feeding was positively associated with reduced NICU LOS (r = 0.25) and overall hospital LOS (r = 0.33). Patients receiving early nutrition had a shorter hospital LOS (5.5 vs 10 days, p = 0.043) and higher GCS score at discharge (15 vs 13, p = 0.002). In mild TBI cases, early feeding significantly reduced NICU (2.5 vs 7.5 days, p = 0.01) and hospital (3.5 vs 13 days, p = 0.002) LOSs and improved discharge GCS score (15 vs 14.5, p = 0.02). These benefits were not observed in moderate or severe TBI patients. In multivariate analysis, undergoing neurosurgery influenced hospital LOS and discharge GCS score, and admission GCS score predicted mortality. The in-hospital mortality rate was 17%.

Conclusions: Early enteral feeding was initiated in 48% of PTBI patients. Common delays/interruptions were due to planned procedures. Early enteral feeding was associated with shorter NICU and hospital LOSs. However, a definite association of early enteral feeding with improved neurological outcomes could not be established.

Objective: Neurosurgeon scientists play a unique role in advancing neuroscience research. While previous publications have explored trends in federal and foundation funding among neurosurgeons, funding is often dominated by neurosurgical oncologists and functional neurosurgeons. Less is known about the research efforts of pediatric neurosurgeons. The aim of this study was to survey the members of the American Society of Pediatric Neurosurgeons (ASPN) to provide an overview of past research experience, current involvement, funding, and research priorities among pediatric neurosurgeons, and to gather insights that could shape future efforts to advance pediatric neurosurgical research.

Methods: A survey was developed using the REDCap platform and distributed to all ASPN members via email. Survey questions used branching logic and were organized into 5 sections: 1) demographics, 2) research experience during training, 3) research experience as an attending physician, 4) research priorities, and 5) multicenter consortiums.

Results: One hundred thirty-nine respondents completed more than half of the survey, for an overall response rate of 52.1%. Most respondents (96.4%) participated in research during their training, but only 38.1% had received a grant during training. In contrast, 83.9% of respondents were actively engaged in research as an attending physician, and 48.7% reported active funding (60.7% federal, 41.8% from foundations, and 42.9% internal). Furthermore, 74.8% of respondents reported being a member of a multicenter research consortium, and 82.4% agreed that multicenter research is important. Seventy percent of respondents agreed that the ASPN should facilitate multicenter consortium-based pediatric neurosurgical research, offering free-text responses with the following suggestions: 1) set aside time at the annual meeting to discuss multicenter research (22.9%); 2) encourage collaboration and facilitate networking (42.9%); 3) provide centralized core services such as a data coordinator and biostatistician (12.9%); and 4) provide training, education, and mentoring (7.1%).

Conclusions: The survey provided a cross-sectional analysis of the pediatric neurosurgical research landscape, highlighting the current state of research experience, funding, and the perspectives of pediatric neurosurgeons regarding research priorities. Despite the challenges, there is clear recognition of the importance of multicenter research collaboration. These findings reinforce the ongoing necessity of organized initiatives to support pediatric neurosurgical research and offer actionable insights into how organized pediatric neurosurgery can contribute to this critical endeavor.

Objective: Selective dorsal rhizotomy (SDR) is a proven surgical treatment of spastic diplegia to improve function in patients suffering from spasticity compared to physical therapy alone. Few studies have addressed the benefit for those with spastic hemiplegia. The aim of this study was to describe and evaluate the efficacy of SDR in patients with spastic hemiplegia.

Methods: A retrospective chart review was performed on pediatric patients (< 18 years of age) who underwent SDR at Monroe Carell Jr. Children's Hospital from July 2013 through January 2024 with a diagnosis of spastic hemiplegic cerebral palsy. Patients underwent pre- and postoperative physical therapy testing at approximately 1 year. Any patients found to have spastic triplegia with asymmetrical hypertonia in the lower extremities, or those without postoperative evaluations, were excluded. Outcome measures included the modified Ashworth Scale (mAS), Gross Motor Function Measure-66 (GMFM-66), timed (10 m) walk test, Gross Motor Function Classification System (GMFCS), and the Pediatric Quality of Life Cerebral Palsy (PedsQL CP) module. Pre- versus postoperative comparisons were performed using a Wilcoxon signed-rank test and the differences were considered statistically significant when p values were < 0.05.

Results: Twenty-one patients underwent SDR for spastic hemiplegic cerebral palsy with pre- and postoperative physical therapy assessments. The patients were 52.4% male, 81.0% White, with a median age of 5 years at the time of surgery. The most common etiology for spastic hemiplegia was stroke (52.4%). All patients had a preoperative GMFCS level of I (85.7%) or II (14.3%). The median percentage of rootlets cut during the procedure was 60% on the affected side. The sum of the mAS extremity score was improved by 5 points (p < 0.001), the GMFM-66 score was improved by a median of 3.1 (p = 0.002), while the PedsQL CP module improved by a median of 12.3 percentage points (p = 0.003). Orthotic use was reduced from 90.5% preoperatively to 66.7% at follow-up.

Conclusions: SDR is an effective treatment in patients with spastic hemiplegia resulting in significant improvement in motor function, quality of life, and tone.

Objective: The relationship between Chiari malformation type I (CMI) and tethered cord syndrome (TCS) is not well understood. The aim of this study was to examine conus position and rates of TCS and tethered cord release (TCR) in pediatric patients with CMI at a tertiary hospital.

Methods: The medical records of children with a diagnosis of CMI based on MRI of the lumbar spine from 2010 to 2023 were retrospectively reviewed. Conus position on MRI, tonsil position below the foramen magnum, presence of fatty filum or filum terminale lipoma, and rates of CMI decompression and TCR were recorded. Age- and sex-matched controls were randomly selected from a cohort of patients who obtained an MRI of the spine for any reason. Conus position was coded and then compared using the Student t-test. Categorical variables were compared using the chi-square test.

Results: A total of 657 pediatric patients with CMI were included. The mean ± SD tonsil position was 11.7 ± 5.6 mm below the foramen magnum, and 44.7% of patients underwent CMI decompression. The conus terminated at or above the L2-3 disc space in 97% of CMI patients. There was no statistical difference in conus position between CMI patients and controls (p = 0.09). Nine patients (1.4%) in the CMI cohort had symptomatic TCS and underwent TCR. This proportion was not statistically different compared to the control group: 11 patients (1.7%) had symptomatic TCS and underwent TCR (p = 0.1).

Conclusions: Most patients with CMI had a normal conus position (97%), and conus position was not different between CMI and control patients. The number of patients with symptomatic TCS was not statistically different between CMI and control patients.

Objective: The posterior fossa is the most common location for primary brain tumors in pediatric patients, and these infratentorial lesions are the leading cause of solid-tumor mortality. Resection remains a cornerstone of managing many of these tumors. However, the overall rate of perioperative complications in pediatric patients who have undergone posterior fossa tumor resection and the associated risk factors have not been explored. Therefore, the authors of this paper aimed to explore the association between clinical characteristics and the likelihood of complications with the intention of guiding patient counseling and directing areas for quality improvement to expand value-based care.

Methods: This is a retrospective cohort study utilizing the National Surgical Quality Improvement Program Pediatric data from 2012 to 2022 to track 30-day perioperative complications in patients 18 years of age or younger who underwent posterior fossa tumor resection. The primary outcome was postsurgical complications within 30 days. A generalized additive model was used to evaluate the relationship of clinical (e.g., age, pulmonary or cardiac conditions) and surgical (e.g., CSF diversion, operating time) factors with 30-day complications.

Results: Approximately 1 in 3 pediatric patients (1314/4044) experienced a perioperative complication within 30 days of posterior fossa tumor resection. The most common complications were bleeding or a need for transfusion (15.0%) and unplanned reoperation (14.6%). The rate of unplanned, related readmissions within 30 days was 8.5%. Variables significantly associated with greater odds of complications included an American Society of Anesthesiologists status of IV or V, emergent or urgent surgery, malignant tumor, sepsis/septic shock/systemic inflammatory response syndrome, structural CNS abnormality, steroid use, the need for ventricular catheter or CSF diversion, a history of pulmonary conditions, and a history of nutritional support. The probability of complications was highest in patients younger than 1 year of age relative to that in older patients. Longer operation times were also associated with an increased probability of perioperative complications.

Conclusions: While high, the perioperative complication rate of 33% is comparable to previously reported rates for pediatric intracranial tumor resection in smaller sample sizes. The study results suggest that several clinical and surgical factors are associated with a greater risk of perioperative complications in children undergoing posterior fossa tumor resection. Understanding the impact that this has on surgical morbidity can inform risk stratification and presurgical counseling for patients and their families.

Objective: This study investigates the potential of artificial intelligence (AI), specifically ChatGPT 4o, to revolutionize the readability of patient education materials in pediatric neurosurgery. The American Medical Association and the National Institutes of Health recommend that educational materials be written at a 3rd- to 7th-grade reading level for accessibility. However, existing resources often exceed this range, hindering comprehension for many patients.

Methods: This study analyzed 38 patient education materials on hydrocephalus, spina bifida, tethered cord syndrome, cerebral palsy, Chiari malformation, and craniosynostosis from 7 top-ranked US children's hospitals. The Flesch-Kincaid grade level calculator was used to assess readability before and after AI modification.

Results: ChatGPT effectively reduced the mean reading level from 10.60 (SD 0.57) to 6.18 (SD 0.28; p < 0.05), achieving the target 6th-grade level across all conditions.

Conclusions: Despite some limitations in maintaining word count and precise grade-level control, the results demonstrate the promising potential of AI in significantly enhancing the accessibility of pediatric neurosurgical education materials, which may lead to more inclusive patient communication and understanding.

Objective: Limited health literacy (HL) is associated with worse clinical outcomes across medical specialties. The association between limited HL and neurosurgical outcomes remains largely unknown. In this systematic review, the authors synthesized the existing literature on the association between limited patient and/or caregiver HL and neurosurgical outcomes.

Methods: A systematic search was conducted in PubMed, Embase, CINAHL, and JBI EBP from inception to February 12, 2025, following PRISMA guidelines. Study quality was assessed using the Newcastle-Ottawa Scale. The study design, sample size, population of interest, neurosurgical diagnoses/procedures, HL assessment used, pertinent findings, and related demographic factors were collected.

Results: The search yielded 698 article titles and abstracts, of which 37 underwent full-text review and 6 met inclusion criteria for this systematic review. These 6 studies included 695 neurosurgical patients and/or caregivers and used various methods to assess HL. Neurosurgical outcomes were grouped into the following categories: 1) delivery and timing of neurosurgical care, 2) hospital admission and discharge, and 3) quality of life (QOL) and well-being. Study results were split evenly across these 3 categories, with 2 studies that explored the delivery and timing of neurosurgical care, 2 that examined hospital admission and discharge, and 2 that investigated QOL and well-being. Study designs included 2 prospective observational studies, 3 cross-sectional studies, and 1 qualitative study. Sample sizes ranged from 27 to 300 patients, including pediatric, adult, and mixed (pediatric and adult) populations, as well as caregivers of pediatric and adult patients. All 6 studies were conducted outside the United States. Limited HL was found to be associated with delays in neurosurgical care, increased rates of discharge against medical advice, decreased patient independence, and worse psychological well-being.

Conclusions: This systematic review highlights the paucity of studies on neurosurgical outcomes among patients and/or caregivers with limited HL, while suggesting that limited HL is associated with worse neurosurgical outcomes. In addition, the lack of studies conducted in the US indicates a geographic gap in the literature. The authors provide a call to action and concrete steps to address the critical need for further research on HL to achieve more equitable neurosurgical care.