Journal of neurosurgery. Pediatrics最新文献

Objective: Hydrocephalus in children is mostly treated with a CSF-diverting shunt system as a lifelong implant. Presently, a variety of shunt valves are available on the market, but there is a lack of evidence guiding valve type selection for the management of pediatric hydrocephalus. The aim of this study was to compare two shunt valve types in the treatment of pediatric hydrocephalus.

Methods: A retrospective analysis of synchronized patient databases was conducted at two pediatric neurosurgical centers. At one center, an adjustable differential pressure (aDP) valve with a fixed gravitational unit was utilized (aDP group). At the other center, an adjustable gravitational (aG) valve was combined with a fixed differential pressure unit (aG group). Inclusion criteria were an age less than 2 years at shunt implantation and a follow-up of 3 years. Patient demographics, revision-free shunt and valve survival rates, total number of revisions per patient, and ventricle width were compared between the two institutional cohorts.

Results: Among 227 patients eligible for study inclusion, 141 received an aDP valve and 86 received an aG valve. The two patient cohorts showed no differences in overall revision-free shunt survival rates: 59.6% in the aDP group versus 58.1% in the aG group (p = 0.42, HR 0.8, 95% CI 0.6-1.3). The revision-free valve survival rate was significantly lower in the aDP group than in the aG group (69.5% vs 86.0%, p = 0.01, HR 2.3, 95% CI 1.3-3.9), but the revision-free nonvalve shunt components survival rate was higher (85.8% vs 65.1%, p < 0.001, HR 0.3, 95% CI 0.2-0.6). The total number of shunt revisions in the patients who underwent revision was significantly higher in the aG group (2 [IQR 1-2] vs 1 [IQR 0], p < 0.01). At follow-up, median valve settings were higher in the aDP group than in the aG group (10 [IQR 8-12]/30 [IQR 29-34] cmH2O vs 5 [IQR 0]/25 [IQR 20-25] cmH2O for lying/standing, respectively), which resulted in a significant, more pronounced reduction in the mean frontooccipital horn ratio as a measure of ventricle width in the aG group (-0.2 ± 0.1 vs -0.13 ± 0.09, p < 0.001).

Conclusions: Differences in valve and nonvalve component revision rates were inverted for the aDP and aG groups and may reflect subtle differences in shunt surgery strategies at the two centers. Overall, lower valve settings led to a greater reduction in ventricle width measurements. Head circumference and ventricular width may need further analysis as possible surrogate parameters for intracranial pressure-guided CSF diversion and should be combined with neurodevelopmental outcome parameters in future studies.

Objective: Selective dorsal rhizotomy (SDR) is a neurosurgical procedure to reduce spasticity in the lower extremities of children with cerebral palsy (CP). The aim of this study was to evaluate gait 30 years after SDR in a prospectively studied cohort to provide clinicians and parents/caregivers with information about the long-term outcomes of this surgery.

Methods: This cohort was assessed preoperatively with 2D gait analysis in 1985 and followed up at 1 and 3 years postoperatively (short-term outcomes) and at 10, 20, and 30 years postoperatively (long-term outcomes). In the current study, these 2D data were reinforced with 3D gait analysis, including gait graphs, 17 kinematic parameters, and Gait Deviation Index (GDI).

Results: Twelve adults with a mean (SD) age of 37.5 (3.3) years with spastic diplegic CP (Gross Motor Function Classification System levels I, II, and III in 4, 6, and 2 patients, respectively) who showed changes in the 2D gait parameters in the short term demonstrated stabilization of hip and knee range of motion and nondimensional temporal distance parameters in the long term (20-30 years), while hip and knee midrange values approached normative values. Although 3D gait analysis showed some abnormal parameters, 9 of the 17 kinematic parameters were within the normal range with a mean (SD) GDI of 73.6 (14.4).

Conclusions: The reduction in lower extremity muscle tone demonstrated on short-term follow-up was sustained in the long term, with some gait parameters approaching the norm in adulthood. Thirty years after SDR, adults with CP walked with a mild crouch gait and no signs of spasticity.

Objective: Sleep apnea is frequently associated with foramen magnum stenosis in patients with achondroplasia and considered a cause of sudden death. The aim of this study was to evaluate the results of respiratory polygraphy (RPG) before and after surgery in patients who underwent foramen magnum decompression (FMD) to elucidate the effectiveness for treatment of sleep apnea.

Methods: The findings of RPG, MRI, and otolaryngological fibroscopy were retrospectively reviewed in 22 children with achondroplasia who underwent FMD at a single institution from 2016 to 2022. The Mann-Whitney U-test was used to assess the association of sleep apnea to age at FMD; preoperative upper airway stenosis (UAS); preoperative Achondroplasia Foramen Magnum Score (AFMS); concomitance of endoscopic third ventriculostomy, ventriculoperitoneal shunt placement, or adenotonsillectomy after FMD; and type of predominant apnea as determined at the preoperative RPG evaluation. The Wilcoxon signed-rank test was used for comparisons of RPG results.

Results: Of 22 patients (median age 8 months) included in the study, the RPG-determined respiratory event index (REI) was within the reference range (REI < 5) for 8 patients and indicated mild sleep apnea (REI 5-15) in 10 patients, moderate sleep apnea (REI 15-30) in 3 patients, and severe sleep apnea (REI ≥ 30) in 1 patient. Postoperatively, 21 patients (95.4%) showed REI improvement. Of the 14 patients with preoperative sleep apnea (REI of ≥ 5), 12 patients (85.7%) had at least 1 level of improvement in sleep apnea. In comparisons between pre-FMD and post-FMD indexes, the REI (p = 0.0009, p < 0.01) and Central Apnea Index (p = 0.03, p < 0.05) showed significant improvement, while the Obstructive Apnea Index (OAI) did not show significant differences. However, the type of predominant apnea according to preoperative RPG had no significant effect on the extent of improvement in the postoperative REI. In 7 patients for whom the predominant type of apnea was obstructive, the OAI improved during the follow-up period.

Conclusions: FMD was effective for improving sleep apnea in patients with achondroplasia associated with foramen magnum stenosis. Regardless of the type of sleep apnea, the decompressive surgery could be indicated when the patient has no significant UAS.

Objective: Recent advancements in pediatric neurosurgery have significantly enhanced patient care and monitoring. Despite these improvements, the complexity of these procedures continues to pose a high risk of adverse events (AEs). The current literature lacks comprehensive AE data, underscoring a critical gap in research. This study addresses this void by using a prospectively collected database from a premier neurosurgical tertiary center, aiming to develop critical care guidelines, optimize resource allocation, and foster interdisciplinary collaborations to mitigate AEs.

Methods: This prospective study enrolled pediatric patients undergoing neurosurgery between January 2020 and December 2023. AEs were defined as any undesirable outcomes occurring within 30 days postoperatively, with each event peer-reviewed at discharge.

Results: Among the 1008 patients studied, ranging from newborns to 17-year-olds (mean age 10.5 years), 82.5% underwent elective procedures and 14.4% emergency procedures. The overall incidence of surgery-related AEs was 9.2%, with 5.2% requiring revision surgery. Cranial pathologies, accounting for 36.3% of interventions, were the most common, with wound infections and CSF leaks the most prevalent. The mortality rate was notably low at 0.4%, primarily attributable to severe underlying conditions such as medulloblastoma progression and severe traumatic brain injuries. Non-surgery-related AEs occurred at a rate of 2.4%. Logistic regression analysis identified age as a significant protective factor against postoperative complications, with each additional year reducing the odds of complications by approximately 5.4% (odds ratio 0.946, p = 0.002). Gender, however, was not a significant predictor of adverse outcomes.

Conclusions: The study highlights a significantly low incidence of AEs in pediatric neurosurgery, demonstrating the effectiveness of systematic AE documentation and continuous data monitoring. Logistic regression analysis identified age as a significant protective factor against complications, while gender showed no significant association, underscoring the multifactorial nature of AE development. These findings provide actionable insights into patient risk stratification, particularly emphasizing the role of age, and contribute to enhancing patient education, guiding quality-based healthcare reforms, and supporting the implementation of prospective AE tracking systems to improve patient safety and care standards in pediatric neurosurgery.

Objective: Pediatric cavernous malformations (CMs) represent a challenging condition in neurosurgery due to their unpredictable nature and potential for neurological deficits. This study aimed to explore the management strategies for pediatric CM, focusing on identifying the factors that influence the choice between conservative and surgical treatment.

Methods: A systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted. The review included a comparative meta-analysis to summarize patient characteristics and outcomes stratified by treatment modality.

Results: Thirteen comparative studies with 775 patients were included, with 56.5% (438 patients) in the surgically managed group and 43.5% (337 patients) conservatively managed. The mean ± SD methodological index for nonrandomized studies (MINORS) was 12.4 ± 3.3. Equal proportions of males were in both groups. The surgical group had higher prevalence rates of seizure (51.3% vs 21.0%), signs of elevated intracranial pressure (6.2% vs 0.7%), and hemorrhage (65.9% vs 28.8%). Seizure (OR 3.8, 95% CI 2.4-5.8, p < 0.001, I2 = 2.0%) and hemorrhage (OR 4.6, 95% CI 1.5-13.7, p < 0.001, I2 = 61.8%) were predictors of surgical management. Lesion characteristics included more isolated lesions (79.4% vs 68.5%) and larger mean lesion size (2.1 cm vs 1.4 cm) in the surgical group. Clinical improvement was reported in 83.8% of surgically treated and 72.6% of conservatively treated patients (p = 0.277), while 77.5% of surgical patients were symptom free compared to 50.5% of conservative patients (p = 0.033) at last follow-up. No deaths were reported in either group.

Conclusions: Conservative management is safe for asymptomatic pediatric CMs. Symptomatic cases, especially with seizures or hemorrhage, often benefit from surgery. Surgical decisions should be individualized, and further research is needed to clarify predictors of surgical benefit.

Objective: Education in pediatric neurosurgery has formalized over the last 3 decades with the establishment and expansion of the pediatric neurosurgery fellowship. Both the increasing numbers of fellowship graduates concurrent with the increasing proliferation of regional pediatric hospitals have led to new graduates often practicing in isolation or in small practice groups. Ongoing postgraduate education was a noted need expressed by these young surgeons. This project endeavored to facilitate mentorship, collaboration, and ongoing education of junior pediatric neurosurgical attendings.

Methods: Recently graduated pediatric neurosurgeons were identified with the help of the American Board of Pediatric Neurological Surgery, and contacted to offer participation in a national, collaborative case conference through a synchronous and asynchronous online distance education platform. Practice environment data were collected by survey distribution and meetings were facilitated twice monthly.

Results: Initial meetings have been well received, with participation from more than 50 different individuals and averaging 8 attendees per session. Participants come from practices of 1-7 pediatric neurosurgeons across the country.

Conclusions: Ongoing education beyond the years of neurosurgical residency and pediatric fellowship are a necessity for a successful surgical career. Opportunities for education and mentorship must not be limited by geography and can be facilitated through distance learning methods.

Objective: Surgical readiness can translate to lives saved on the battlefield. Unfortunately, military surgeons today are faced with low surgical volumes at military treatment facilities (MTFs), resulting in limited surgical experience with not only trauma but also complex subspecialty surgical cases. To improve readiness, Army medicine supports military-civilian partnerships (MCPs) to allow active-duty soldiers to work in civilian institutions while on duty. The overarching goal is to increase exposure to trauma cases and provide skill maintenance for surgeons. Two models have evolved: one that includes a fully embedded military surgeon at a civilian institution and another that includes a part-time embedded military surgeon. In situations where there is a direct need for medical care in the civilian market, a part-time model, or memorandum of understanding (MOU), can provide call coverage for the local community as well as augment the military surgeon's experience. This study was performed to analyze surgical volume before and after implementation of a joint training agreement between an MTF and a civilian pediatric hospital.

Methods: The authors performed a retrospective review of a single military neurosurgeon's surgical volume before and after implementation of a joint training agreement between an MTF and the only statewide pediatric referral hospital. Surgical volume prior to the training agreement, in 2018, was obtained for a single surgeon at the MTF through the hospital's surgical database. After implementation of the training agreement, 2 years of surgical volume for the same surgeon was obtained through a prospectively maintained database. Each individual case was assigned a neurosurgical category. Average monthly case volume, percentage of pediatric versus adult case contributions, and surgical case varieties were calculated.

Results: The joint military training agreement, or MOU, began in January 2019. Pediatric neurosurgical volume and case complexity increased from an average of 3 cases/month at the MTF in 2018 to 5 cases/month in 2019 to 7 cases/month in 2020. More than 120 new urgent and emergency consults were produced per year after MOU implementation, 14 of which required traumatic cranial surgeries over the 2 years analyzed. In addition, the civilian pediatric hospital was able to provide 24/7 trauma and acute care neurosurgical coverage with the added military provider.

Conclusions: The authors demonstrate that an MCP can successfully benefit both the civilian community via improved pediatric call coverage and the military neurosurgeon via enhanced combat surgical readiness and skills, providing a blueprint to a unique targeted strategy for successful future MCPs. The significant case volume growth and diversity seen over the first 2 years suggest greater longitudinal benefit over shorter "just-in-time" predeployment-type training oppor

Objective: Endoscopic third ventriculostomy (ETV) is advocated as a shunt-free alternative for managing hydrocephalus to mitigate the complications associated with ventriculoperitoneal shunt (VPS). However, its efficacy in treating pediatric tuberculous meningitis-related hydrocephalus (TBMH) remains uncertain. The authors' review aimed to evaluate the safety and effectiveness of ETV compared to VPS.

Methods: The authors searched PubMed, Embase, and Cochrane for articles comparing ETV with VPS in the pediatric population. They included studies evaluated success rate, mortality, postprocedural complications, and infections. A random-effects model was used, with heterogeneity assessed with I2 and sensitivity analysis.

Results: A pooled analysis of 369 patients from 5 studies (2 randomized controlled trials and 3 observational studies), including 162 patients who underwent ETV and 207 VPS, revealed no significant difference in the success rates between ETV and VPS for TBMH (OR 0.72, 95% CI 0.45-1.14, p = 0.159, I2 = 0%). Furthermore, no significant differences in the postoperative complication (OR 0.59, 95% CI 0.08-4.17, p = 0.599, I2 = 75%), mortality (OR 0.78, 95% CI 0.23-2.65, p = 0.684, I2 = 0%), or infection (OR 0.52, 95% CI 0.09-2.87, I2 = 11%) rates were observed.

Conclusions: The authors' meta-analysis shows no significant differences in success rates, mortality risk, and incidence of complications and infections between ETV and VPS for children with TBMH. However, the broad confidence intervals and limited number of included studies introduce significant uncertainty. Therefore, while no statistically significant differences have been demonstrated, the equivalence of these treatments cannot be conclusively affirmed, and the potential for clinically significant differences remains.