General Neurosurgeons Research Articles

Summary of study groups proceedings

1) Pediatric neurosurgery is the theory and art of surgical treatment of diseases of the child’s nervous system. 2) Pediatric neurosurgery should continue the develop as a specialty of neurosurgery, and this should be facilitated by organized neurosurgery. 3) Pediatric neurosurgery should be practiced in a pediatric environment, by a pediatric neurosurgeon. 4) Given the many variations in number, density and distribution of population in different countries, the general goal should be to concentrate pediatric neurosurgery patients either in a pediatric service of a general hospital, or in a children’s hospital. Also, given the many different economic and social realities in the European countries, it is stressed that the goal is not that of devising one module to be adopted and followed by all countries, but each health delivery system should find an individual way to implement this principle with criteria that will work in its specific conditions, according to the existing situation and and its feasible developments. 5) Though a comprehensive definition of pediatric neurosurgeon cannot be reached, there is agreement that a pediatric neurosurgeon is either a neurosurgeon whose activities, including training and clinical practice, are exclusively or primarily aimed at the treatment of neurosurgical afflictions of children; or a general neurosurgeon whose interests comprise such patients, and whose education and training are considered satisfactory to perform operations in this field properly. 6) Geographic and population realities may not permit complete professional dedication to pediatric neurosurgery, since it appears that a fully dedicated pediatric neurosurgeon requires a population of 3 million people for an adequate flow of case material. Consequently, it may not be uncommon for pediatric neurosurgery to be practiced by a general neurosurgeon. In these circumstances, such general neurosurgeons must be educated in pediatric neurosurgery principles, and keep abreast of pediatric neurosurgical progress. 7) It is not necessary, and in some cases it may not even be advisable, that pediatric neurosurgeons limit their activities to the pediatric field; yet, conversely, it is considered indispensable that all children with surgical afflictions of the CNS be seen by a neurosurgeon with proper pediatric expertise. Although it is recognized that the pediatric neurologist and the pediatric surgeon may familiarize themselves with the general principles of management of these afflictions, it is true that they have neither the educational preparation nor the full commitment that proper care of these children requires. 8) It is considered necessary for the pediatric neurosurgeon to work in a pediatric environment and to have access to the full range of pediatric specialists. The attitude, the behavior, and the perspectives of the pediatric neurosurgeon should be such as to recognize and welcome the participation and management decisions of other pediatric specialists. 9) Certain disease entities — craniofacial anomalies, spina bifida, epilepsy — should be treated in designated pediatric centers with special facilities and an adequate case load to permit excellence and efficiency. 10) Other disease entities — CNS tumors, dysraphism, hydrocephalus — requiring a multi-disciplinary approach, should be managed by a team of pediatric specialists, including the pediatric neurosurgeon. 11) The proper practice of pediatric neurosurgery requires full and free access to a dedicated operating room with state-of-the-art instrumentation and equipment, specifically geared to pediatric operations. 12) Modernization is recommended; however, the frequently outstanding results of centers with limited technical facilities and excellent organization must not be overlooked. 13) Great interest and a true sense of responsibility were expressed in developing and standardizing the attitude and means of communicating with the child and the family in an emotionally secure environment. The availability of accommodations for the parents within the hospital area is considered essential. 14) No conclusive recommendations were reached regarding a curriculum for the education of a pediatric neurosurgeon: this material is left for a future Symposium. Similarly, no other criteria were provided for research, either clinical or experimental, nor for epidemiologic studies or disease classifications. However, at least for the present, the importance of national and international societies as instruments of education is recognized.

Current Neurosurgical Treatment of Medulloblastomas in Children

To determine the current neurosurgical treatment of children with medulloblastomas, we reviewed the operative reports and neurosurgical report forms from 141 children with posterior fossa medulloblastomas treated on two current Children's Cancer Study Group (CCSG) protocols, CCG-921 for high-stage and CCG-923 for low-stage medulloblastoma. Most medulloblastoma operations were performed in major medical centers: 61% of the operations were performed in CCSG member institutions, 23% in CCSG affiliates and 16% in other institutions. The tumor T stage distribution was as follows: T1-4%, T2-15%, T3A-35%, T3B-36%, and T4-10%. Tumors infiltrated the brainstem in 38% of cases and were associated with hydrocephalus in 91% of cases. Hydrocephalus was managed by external ventricular drains in 50% and by shunts in 60%. Adjunctive instruments (e.g., microscope, ultrasonic aspirator) were used in 93% of the operations. Tumor removals were as follows: biopsy only 3%, partial removals 13%, subtotal removals 13%, near total removals 41% and gross total removals in 40%; 90% or more of the tumor was removed in 81% of the operations. Forty-seven percent of the operations were performed by pediatric neurosurgeons. Near total and gross total removals were performed significantly more often (p less than 0.05) by pediatric neurosurgeons than by general neurosurgeons. Postoperative morbidity was reported in 46% of cases, including neurologic morbidity in 26% of cases. There was no significant difference in patient morbidity between pediatric and general neurosurgeons.