Pediatric Neurosurgery最新文献

Introduction: Primary fourth ventricle outlet obstruction (PFVOO) is a rare cause of obstructive hydrocephalus in children. Diagnosis often requires high clinical suspicion and advanced MRI sequences, and the optimal management remains a matter of debate.

Case presentation: We report a 3-year-old girl with unexplained tetraventricular hydrocephalus who presented with progressive macrocephaly, intermittent headaches, and atypical stereotyped head movements. She had previously undergone ventriculoperitoneal shunting in infancy, which failed after 18 months. High-resolution 3D-CISS MRI confirmed a patent aqueduct and a membranous obstruction at the foramen of Magendie, establishing the diagnosis of idiopathic PFVOO. An endoscopic third ventriculostomy (ETV) was performed uneventfully, and postoperative MRI confirmed ventricular size reduction. The patient remains clinically stable two years later, representing one of the longest pediatric follow-ups reported after ETV for PFVOO.

Conclusion: PFVOO should be included in the differential diagnosis of unexplained tetraventricular hydrocephalus in children when conventional imaging is inconclusive. Advanced MRI sequences such as 3D-CISS are valuable for identifying subtle outlet obstructions. This case, extending the pediatric follow-up to two years, reinforces ETV as a safe and durable first-line treatment option in selected patients with PFVOO.

Introduction: Postoperative recovery following adolescent idiopathic scoliosis (AIS) surgery includes multimodal pain management and physical therapy. Though virtual reality (VR) has been explored as a non-pharmacologic strategy for reducing pain and anxiety during bedside procedures, its impact on postoperative pain and opioid use following AIS correction has not been well characterized.

Methods: Adolescent patients undergoing spinal fusion for AIS between March 2024 and June 2025 were eligible for recruitment. Patients completed a 20-minute immersive underwater VR scenario prior to each postoperative inpatient physical therapy (PT) session. Pain scores (measured on a 10-point Likert scale) before and after PT, opioid usage, number of completed PT sessions, and length of hospitalization were recorded for study subjects and were compared to controls.

Results: Ten patients in the VR cohort were compared to 10 controls. There were no differences in sex (p=0.58), race (p=0.07), ethnicity (p>0.99), or average age at surgery (15.1 vs 15.8 years, p=0.30). Patients in the VR cohort had a greater average reduction in pain scores associated with postoperative PT compared to controls (-0.72 vs +0.61, p=0.02). Patients in the VR and control groups did not differ significantly with regard to total opioid usage in morphine equivalents (55.7 vs 49.9 mg, p=0.71), completed PT sessions (3.2 vs 3.2 sessions, p>0.99), or length of hospitalization (2.6 vs 2.4 days, p=0.53). Side effects of the VR intervention included fatigue (n=3), nausea (n=3), headache (n=2), eye strain (n=1), and dizziness (n=1).

Conclusion: Our pilot study demonstrated that an immersive VR session prior to each postoperative PT session significantly reduced the change in PT-associated pain scores among patients undergoing spinal fusion for AIS. Future investigations utilizing a randomized-controlled design will continue to elucidate the impact of VR on postoperative recovery for patients undergoing AIS correction.

We often identify our vocation with a calling. Pediatric neurosurgeons are vulnerable to burnout and moral injury given the high emotional stakes, relentless pursuit of precision, and the enduring demands of patient care. Physician wellness is a prerequisite for safe, high-quality care and professional longevity. This article highlights physician wellness as a critical issue in pediatric neurosurgery, explores the public health crisis of physician suicide and burnout, and outlines strategies to sustain performance and resilience through relationships, purpose, and self-compassion. We make recommendations based on the belief that wellness is not optional-it is essential to fulfill our calling as healers.

Background: Children with drug-resistant epilepsy often require invasive monitoring to guide surgical interventions.

Summary: Both subdural monitoring and stereoelectroencephalography (sEEG) have benefits and limitations in identifying seizure onset and mapping brain function. sEEG allows for more anatomically diffuse sampling, including deep structures like the thalamus. Monitoring leads to a better understanding of epileptic networks and their proximity to eloquent cortex. This often guides the decision between resective/ablative therapies and neuromodulation. There is increasing interest in the use of thalamic stimulation in neuromodulation, although pediatric data are limited.

Key message: The increase in invasive monitoring in the USA coupled with the emergence of additional surgical treatments offers new hope to children with refractory epilepsy.

Introduction: Pediatric hydrocephalus is associated with congenital malformation syndromes, which may alter cerebrospinal fluid dynamics and increase the complexity of surgical management. We aimed to compare rates of shunt placement, reprogramming, revision, removal, and dysfunction in pediatric patients with hydrocephalus, with and without congenital syndromes.

Methods: We conducted a retrospective analysis using TriNetX, identifying pediatric patients with hydrocephalus. Cohort 1 included patients with congenital syndromes (N = 17,617). Cohort 2 included matched patients without syndromes (N = 17,617). Propensity score matching was performed across demographic and clinical variables. Outcomes included shunt placement, reprogramming, revision, removal, and dysfunction. Risk measures were calculated at 1-year follow-up.

Results: Shunt placement was similar between cohorts. However, syndromic patients had significantly higher rates of reprogramming (10.0% vs. 4.2%; odds ratio [OR]: 2.52; p < 0.001), revision (9.3% vs. 3.3%; OR: 3.03; p < 0.001), removal (2.0% vs. 0.9%; OR: 2.24; p < 0.001), and dysfunction (23.5% vs. 10.9%; OR: 2.52; p < 0.001). Intervention-free survival was lower in syndromic patients for all outcomes except initial shunt placement. Across single congenital syndromes, patients with hydrocephalus demonstrated elevated rates of shunt-related complications compared to matched controls. In conditions like Arnold-Chiari and encephalocele, the rates of shunt dysfunction exceeded 30%, with OR above 3.0 and highly significant p values. Alport syndrome, arhinencephaly, and craniosynostosis showed elevated risks for reprogramming, revision, and dysfunction. Down syndrome demonstrated higher dysfunction rates (27.1% vs. 14.3%; OR: 2.22). Despite identical shunt placement rates, the downstream need for surgical intervention diverged sharply, highlighting high-risk phenotypes.

Conclusion: Pediatric hydrocephalus associated with congenital syndromes carries a markedly higher risk of shunt-related complications. These findings support the need for clinical surveillance and individualized care strategies in this group.

Introduction: Decompression of posterior cranial fossa remains the mainstay of surgical treatment of Chiari malformation type I, though several surgical maneuvers have been differently combined to bony decompression aiming to increase the efficacy of surgery. In this context, intraoperative ultrasound (IOUS) claims to offer real-time feedback of adequacy of surgical decompression, thus accordingly tailoring the aggressiveness of surgery. The present review aims to highlight benefits, limitations, and areas in need of further investigation.

Materials and methods: A comprehensive literature search of PubMed, Scopus, and Google Scholar was performed for studies published in English in the last 30 years. The following keywords, including MeSH terms, were used to retrieve eligible papers: "Chiari Malformation Type I," "posterior fossa decompression," and "ultrasonography."

Results: A total of 3,189 results were collected. Duplicate records were then removed (n = 1,591). A total of 1,598 papers were screened, and 1,531 records were excluded through title and abstract screening; 65 studies were considered relevant to our research question and were assessed for eligibility. Finally, 23 articles were included in the review.

Conclusions: IOUS has been frequently used to evaluate the adequacy of surgical decompression, though this qualitative assessment remains subjective with obvious inter-operator variability. On the other side, a quantitative assessment has been more rarely used through the literature, as this approach is difficult to reproduce. Despite the obvious advantages of IOUS, further investigation is required to standardize this approach.

Background: Drug-resistant epilepsy (DRE) impacts at least 30% of pediatric epilepsy patients, adversely affecting neurodevelopment and quality of life, as well as risk of sudden unexplained death in epilepsy (SUDEP). While surgical intervention has proven to be an effective treatment for DRE, disparities in access to surgical care persist. Compared to adults, pediatric patients face unique challenges, including delayed recognition of surgical candidacy, limited access to specialized epilepsy centers, complex care coordination, and socioeconomic barriers.

Summary: This review explores the current state of pediatric epilepsy surgery, highlighting its effectiveness in achieving seizure freedom, improving neurocognitive outcomes, and reducing long-term healthcare costs. It further examines factors contributing to delays in surgical referrals, including physician and parental hesitancy, lack of access to specialized centers, and disparities in hospital resources.

Key messages: Surgery is an effective treatment for pediatric DRE with a favorable risk profile, potential for seizure freedom, improved neurodevelopmental outcomes, and potential reduction in SUDEP risk. Yet, surgery remains underutilized due to disparities driven by socioeconomic status, insurance, race, geography, and systemic barriers such as limited provider awareness, inconsistent referrals, and uneven distribution of National Association of Epilepsy Centers Level 4 hospitals. Future efforts should focus on research to further define disparities and evaluate evidence for systems-based solutions, increasing accessibility of specialized centers, enhancing referring provider education, dissemination and regular revisitation of pediatric-specific epilepsy surgical guidelines for referral, and implementing policy reforms to improve insurance coverage and care coordination for this pediatric patient population.

Introduction: The clamping force for surgical head immobilization must be sufficiently large enough to prevent slippage but not to induce fracturing. Motivated by an unmet need to detect skull fractures during surgery to trigger remedial action, we sought to demonstrate a method of viable measurement and interpretation of acoustic emissions (AEs) generated by a fracturing skull prior, during, and after a fracture.

Methods: Escalating clamping force via skull pins affixed to an Integra Life Sciences Mayfield® skull clamp was applied to a formalin-fixed cadaveric head. Variable and pathologic skull thickness was simulated by drilling the skull to reduce thickness at pin locations on the frontal or temporal bone. AE was monitored via an in-house developed device.

Results: This method produced a mixture of "punch-out type" skull fractures with some occurrences of larger area "cave-in" type fractures. The recorded AE waveforms, amplitudes, and temporal patterns showed the skull can fail not only immediately upon application of clamping but also in delayed manners seconds or minutes after force application. A stereotypical, escalating rate of event occurrence and amplitude was detectable prior to delayed fractures (foreshocks) up to a peak event correlating with macroscopic fracture. A stereotypical hyperbolic decay of event rates was detectable immediately post-fracture (aftershocks). Other acoustic sources like drilling were distinguishable.

Conclusion: Skull fractures produce stereotypical AE, possibly identifiable intra-operatively. Detecting patterns indicative of impending or recent fracture may allow for immediate intervention, avoiding severe complications. This represents the first reported evidence of detectable foreshock and aftershock AE sequences from bone fracture and points to striking parallels with seismicity generated by earthquakes, thus enabling tools from geophysics to be applied to detect imminent and recent bone failure.

Background: Human intracranial recordings and single-neuron recordings in particular have provided much knowledge on the mechanisms of human cognition and its impairment by disease. Improvements in recording technology, experimental design, and computational analysis methods have permitted an increasingly sophisticated understanding of uniquely human brain processes, including those underlying executive function, memory, and language. Despite the routine clinical use of intracranial recordings for invasive epilepsy monitoring in the pediatric population, there remains a significant gap between the associated research conducted in adult and pediatric neuroscientific investigation.

Summary: Single-neuron recordings in pediatric epilepsy patients are ethical, technically feasible, and safe. These data can provide mechanistic insights into the neurophysiology of the developing human brain.

Key messages: Routine use of invasive electrophysiological monitoring via stereoelectroencephalography studies in pediatric drug-resistant epilepsy offers opportunities to extend the utility of single-neuron recordings to the pediatric population and advance our knowledge of the neuronal basis of behaviors in children.