Patients with epilepsy who do not respond to pharmacotherapy are often offered a noninvasive diagnostic workup to localize an epileptogenic focus that might be treated with resection, neuromodulation, or ablation. Yet in many cases, this evaluation fails to identify surgical candidates. For example, patients with tuberous sclerosis, periventricular nodular heterotopia, or polymicrogyria may have clearly visible lesions on MRI, but the resulting epileptogenic onset zones/networks are often too complex for scalp electroencephalography to decode. Similarly, seizures arising from the cingulate gyrus originate in deep structures that are inaccessible to noninvasive techniques. In post-traumatic epilepsy without a dominant lesion such as mesial temporal sclerosis, injury is often too diffuse to define a clear seizure-onset zone. Stereoelectroencephalography (sEEG), with its ability to map deep brain networks in detail, offers a unique solution for these challenging cases. In this review, we highlight how sEEG has expanded surgical options and provided hope for seizure freedom in patients once considered medically and surgically untreatable, and we aim to encourage further study into its potential applications.

Foramen magnum stenosis (FMS) and ventriculomegaly are frequent in achondroplasia due to cranial base hypoplasia. While FMS can cause spinal cord compression, the optimal treatment strategy remains debated. We reviewed our single-center experience and explored factors influencing surgical decisions. We retrospectively analyzed 18 children with achondroplasia evaluated between 2008 and 2024. MRI was used to assess FMS by anterior-posterior diameter and cerebrospinal fluid (CSF) area at the foramen magnum level. Ventriculomegaly was defined as an Evans Index ≥0.30. CT was used to evaluate foramen magnum morphology and synchondrosis fusion. Surgical indications were based on imaging findings of compression and intramedullary changes. The median age at initial imaging was 9.5 months. Thirteen patients underwent foramen magnum decompression (FMD) and 5 were managed conservatively. The surgical group showed significantly smaller craniocervical junction CSF spaces compared with nonsurgical cases (p<0.05). Synchondrosis fusion occurred earlier in achondroplasia than in controls. Ventriculomegaly was present in 66%, but its severity did not correlate with FMD. All surgical cases achieved decompression without major complications. Of the 13 surgical patients, 9 were followed for more than one year (median follow-up: 122 months). Within this subgroup, 4 developed radiological bone regrowth with re-stenosis, but all remained asymptomatic and none required reoperation. FMS in achondroplasia poses major risks, yet its natural history and management remain unclear. Our findings support early imaging-based screening and timely intervention in cases with cord compression. While FMD effectively relieves compression, it does not address underlying ossification abnormalities, requiring continued surveillance. Premature synchondrosis fusion may play a key role, and future studies should consider combined surgical and medical approaches to improve outcomes.

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. 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. 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.

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. 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. 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). 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.

Plain Language SummaryEpilepsy is a condition that causes repeated seizures. When medications do not stop the seizures, surgery may be a helpful treatment – especially for children. For some children with drug-resistant epilepsy, surgery can stop or reduce seizures and improve thinking, development, and quality of life. However, not all children who need surgery are getting it. This review looked at research on which children receive epilepsy surgery and found important factors that influence the likelihood and type of medical interventions used. Children from lower income families, rural areas, and certain racial and ethnic groups – especially Black and Hispanic children – are less likely to have epilepsy surgery compared to white children from wealthier backgrounds. These differences, or disparities, are not necessarily because of how sick the children are, but often because of other barriers. For example, families may live far away from specialized epilepsy centers, making it hard to attend appointments or complete the long testing process before surgery. Insurance coverage, transportation, time off work, and language or communication challenges can also make it harder for some families to move forward with surgery. The review highlights the need to better understand these barriers and create solutions by improving access to epilepsy centers and creating more efficient referral processes for surgery. While epilepsy surgery can be life-changing for children with hard-to-treat seizures, not every child has an equal chance to get it. To improve care, we must focus on removing barriers and making sure all families have access to the best possible treatments.

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.