Pediatric neurosurgery increasingly utilizes precision medicine, but practitioners encounter challenges in translating complex data into individualized care. Digital twin (DT) bridges this gap by linking real-world data to a dynamic patient in-silico model, facilitating prediction and adaptive management as new data emerge. This narrative review explores the essential features of DTs, highlighting their relevance and associated risks in pediatric neurosurgery. The DT framework is structured around five components: the patient, a data connection, a patient-in-silico model, a clinician interface, and temporal synchronization. Foundational modeling approaches are summarized, spanning mechanistic simulations, artificial intelligence, and hybrid models that combine mechanistic structure with data-driven inference. Clinical translation is framed around uncertainty and calibration, along with interpretability and detection of distribution shifts. Potential applications are organized by concrete clinical questions in epilepsy surgery, pediatric neuro-oncology, cerebrovascular disease, hydrocephalus, and craniosynostosis. A translational pathway is outlined that progresses from decision-oriented prototypes and retrospective validation to prospective evaluation and interventional studies within learning health systems, supported by robust governance and auditable workflows. With meticulous validation and cautious deployment tailored to pediatric populations, DTs may enhance transparency, testability, and shared decision-making in precision pediatric neurosurgery.

While surgery of single-suture sagittal craniosynostosis (SS) is effective for cranial shape correction, its role in preventing neurocognitive impairment or intracranial pressure (ICP)-related sequelae is uncertain. We conducted a mini-survey of experts and a narrative literature review to evaluate current perspectives and evidence guiding treatment indications for SS. A mini-survey was distributed to 25 pediatric neurosurgery experts following a debate at the 2025 Varna meeting. Respondents were presented with clinical scenarios of infants with moderate or severe SS and queried regarding counseling on non-cosmetic consequences of nonoperative management. In parallel, a narrative PubMed literature review (December 2025) examined neurocognitive outcomes, ICP prevalence, treatment timing, surgical technique, and methods of ICP assessment in SS. Survey responses demonstrated marked heterogeneity in expert opinion. While many surgeons viewed cosmetic correction as the primary indication for surgery, others recommended intervention to mitigate uncertain risks of neurodevelopmental delay or elevated ICP. The literature consistently shows that most children with SS achieve normal-range intellectual functioning and attend regular schools, though mild and heterogeneous vulnerabilities in language, attention, motor skills, and learning are described compared to the normal population. These differences are also detectable in infancy, suggesting a prenatal contribution to altered brain development, that may persist despite surgery. Evidence linking surgery, age at intervention, or surgical technique to improved long-term neurocognitive outcomes is inconsistent. Untreated SS carries a variable risk of elevated ICP, which is imperfectly detected by non-invasive surrogates; postoperative ICP elevation occurs in a minority of cases. SS is generally associated with favorable neurocognitive and developmental outcomes, though mild neurodevelopmental differences and ICP-related risks warrant careful long-term surveillance. Given limited and heterogeneous evidence, individualized counseling and shared decision-making remain essential.

Ventriculoperitoneal shunt (VP) insertion is a common intervention in paediatric neurosurgery, and as outcomes for children with hydrocephalus improve, clinicians are increasingly asked to provide advice beyond the immediate postoperative period. Participation in sport is an important component of childhood development, yet there is limited evidence or consensus guidance to inform recommendations regarding contact sports for children with VP shunts. As a result, clinical advice is often based on individual experience rather that robust data. A structured electronic questionnaire was distributed to members of the British Paediatric Neurosurgery Group (BPNG). Participants were asked about their experience of rugby related VP shunt complications, the levels of rugby participation they would permit at different ages and whether they would recommend the use of protective head gear. Overall response rate of 42.8% was achieved (30 of 70 respondents). Only one respondent (3%) reported direct experience of rugby related shunt complication. All respondents would permit a 7-year-old with a VP shunt to participate in touch rugby. 80% would allow a 14-year-old to play contact rugby, and 77% would permit an 18-year-old to participate in professional or elite rugby. The use of a scrum cap was recommended by 77% of respondents. Most paediatric neurosurgeons support return to rugby for children with VP shunts, commonly recommending protective headgear. These findings support the importance of providing informed, individualised guidance for resuming play.

Posterior fossa tumors are the most common solid pediatric neoplasms, and more than 60% of these tumors are associated with hydrocephalus, which can be managed using different strategies, including endoscopic third ventriculostomy (ETV), ventriculoperitoneal shunt (VPS), external ventricular drainage (EVD), or direct tumor resection without CSF diversion. The safest and most effective drainage method remains controversial, and most available studies are limited to single-center retrospective analyses, often constrained by small sample sizes. Therefore, multicenter prospective studies are needed to determine the optimal treatment strategy. This is a prospective, multicenter cohort study conducted across more than 20 pediatric neurosurgery centers in Latin America. Patients will be allocated into four groups according to the treatment selected for hydrocephalus (ETV, EVD, VPS, or resection). The primary outcome will be the number of surgical interventions related to the treatment of hydrocephalus during the follow-up period. Secondary outcomes will include mortality, infection, and other clinically relevant complications, analyzed as complementary endpoints. Patients will be followed prospectively for up to 12months after the index procedure, defined as the intervention performed for the treatment of hydrocephalus, and each group will include at least 50 patients. The REDCap online platform will be used for data collection in the PITCH study, enabling prospective data acquisition across multiple centers in Latin America. This will allow comparison of treatment modalities for obstructive hydrocephalus secondary to posterior fossa tumors (ETV, EVD, VPS, and resection) and evaluation of their impact during the first year after diagnosis.

: Background: Pediatric neurosurgery is practiced in a complex, demanding and high-stakes environment. Consequential and high-impact decisions are made while undertaking delicate operations on very young and vulnerable patients. Summary: The team dynamics in pediatric neurosurgery - how the team communicates, functions under stress, adapts and supports each member - is the prime determinant for success in this high-stakes milieu. Key messages: Building an effective team in pediatric neurosurgery requires focused vision and mission alignment, effective communication infrastructure, inspirational and transformative leadership as well as efficient mechanisms for conflict management, and burnout prevention.

Paediatric neurosurgery presents a unique set for the anaesthesiologist, necessitating a patient tailored approach for a diverse population, ranging from neonates to adolescents and from healthy to chronically ill children. Understanding the intracranial compartment as the sum of brain tissue, blood volume and cerebral spinal fluid is essential. Given that approximately a quarter of a child's cardiac output is dedicated to cerebral perfusion, intracranial bleeding might cumulate in haemorrhagic shock. Anaesthesiological measures to maintain homeostasis and their influences both on cerebral autoregulation and intracranial pressure need to be considered. Preoperative anaesthesiologic evaluation should incorporate neurological status and identification of underlying syndromes. Key perioperative considerations include airway management, strategic vascular access and haemotherapy. Anaesthetic requirements in common neurosurgical procedures for intracranial tumours, hydrocephalus, craniosynostosis as well as spinal surgery and traumatic brain injury are highlighted, while strategies to cope with complications such as seizure or air embolism are delineated.

The HIT network was established in 2000 to create a population-based structure aiming to improve survival rates and reduce late effects for children with central nervous system (CNS) tumors by conducting comprehensive clinical trials. The HIT network currently consists of 10 coordinating trial centers mandated by the German Society for Pediatric Oncology and Hematology (GPOH) to conduct clinical trials and research projects, and to provide counseling to local centers for individual patients. The network is complemented by 11 reference centers (neuropathology, tumor biology, neuroradiology, pediatric neurosurgery, cerebrospinal fluid [CSF], assessments, radiotherapy, genetics), biostatistical support, and currently 72 local treatment sites. Numbers of children and adolescents with newly diagnosed CNS tumors registered to trials and registries increased from approximately 500 to more than 600 per year, corresponding to >95% of affected HIT-eligible children and adolescents in Germany. Clinical counseling and upfront reference assessments ensure homogeneous clinical standards and avoid inadequate treatment of individual patients. Since 2007, the established reference services have been partially re-funded by German health insurances. The HIT network provides a unique structure for population-based state-of-the-art diagnostic assessments, treatment recommendations and counseling. It increases the "a priori" accuracy of stratification parameters, and the timely inclusion into clinical trials and tumor-specific registries. Favorable outcomes are achieved within the trials and registry landscape, for example, through consistent reference assessments, reducing the gap to real world data. Resulting data facilitate representative, unbiased high-quality research projects across all CNS tumor entities. Interdisciplinary cooperation and competitive scientific output are enhanced.

This Pediatric Issue of the Journal of Korean Neurosurgical Society addresses the digital and robotic transformation of pediatric neurosurgery. It reviews the emerging applications of artificial intelligence and related technologies across diagnosis, monitoring, surgical practice, education, and communication, while also considering the unique scientific and ethical challenges of their use in children. Together, these articles offer a timely perspective on the future of safer, more precise, and more personalized pediatric neurosurgical care.

OBJECTIVE The aim of this study was to evaluate the influence of age group (3–9 vs 10–18 years), sex, Gross Motor Function Classification System (GMFCS) level, and presence of dystonia on changes in multidimensional functional test outcomes at 24 months, along with extended assessment of long-term effects at 5 and 10 years, following selective dorsal rhizotomy (SDR). METHODS This is a prospective single-center observational study of all children aged 3–18 years with functionally significant bilateral spastic cerebral palsy who underwent SDR at a tertiary pediatric neurosurgery center between 2012 and 2025. Outcome evaluation followed a tiered, multimodal framework, and each domain was evaluated before SDR and at each follow-up assessment 3, 6, and 12 months and 2, 5, and 10 years after SDR if follow-up data were available. A linear mixed-effects model was used to assess longitudinal changes. RESULTS Between 2012 and 2025, 420 children who satisfied the study inclusion criteria underwent SDR. The mean age was 7.02 ± 3.02 years, and 62% of the patients were male. The most frequent GMFCS level before surgery was III. At 24 months after SDR, the 66-item Gross Motor Function Measure scores had improved significantly (mean difference 4.3 units, 95% CI 3.1–5.6, p < 0.001). Statistically significant improvements were also observed on the Timed Up and Go test, Pediatric Evaluation of Disability Inventory (PEDI) of self-care and mobility, 6-minute walk test distance, Functional Mobility Scale, Gillette Functional Assessment Questionnaire, and PEDI Computer Adaptive Test. Pain scores and Care and Comfort Hypertonicity Questionnaire scores decreased, whereas quality of life measures (Cerebral Palsy Quality of Life Questionnaire for Children, CPCHILD Questionnaire) showed marked gains by the extended follow-up. CONCLUSIONS SDR can lead to improvements in gross motor performance, quality of life, and overall functional outcomes at 24 months postoperatively. Future prospective multicenter studies incorporating a control group are required to investigate the effect and safety of SDR.

Anesthesia for pediatric neurosurgery represents a highly complex and challenging field, characterized by age-dependent physiological variability, heterogeneous patient populations, and the critical need to protect the developing central nervous system. Conventional clinical approaches often rely on adult-derived data, which may inadequately reflect the distinct neurophysiological and hemodynamic characteristics of neonates, infants and children. Recent advances in artificial intelligence (AI) have enabled the integration of multimodal perioperative data, including physiologic signals and neurophysiologic monitoring, with the aim of supporting clinical decision-making in complex surgical settings. This review summarizes the current landscape of AI applications relevant to pediatric anesthesia, with particular attention to preoperative risk assessment, airway management, and real-time prediction of intraoperative adverse events such as hypoxemia and hemodynamic instability. Although AI-based approaches have demonstrated encouraging results in adult populations, their application to pediatric neuroanesthesia remains limited. The integration of AI into this field faces several distinct challenges, including the scarcity of high-quality datasets for rare neurosurgical conditions, substantial heterogeneity across developmental stages, and difficulties in aligning model outputs with clinically interpretable physiologic mechanisms. Addressing these limitations will require the development of explainable, physiology-informed AI frameworks and disease-specific models tailored to conditions such as moyamoya disease or complex craniofacial reconstruction. Ultimately, AI should be positioned as an adjunctive decision-support tool that complements, rather than replaces, anesthesiologists' expertise. Through multidisciplinary collaboration and human-centered implementation, AI may contribute to improved perioperative safety and long-term neurodevelopmental outcomes in vulnerable pediatric neurosurgical patients.

Large language models (LLMs) are rapidly transforming healthcare, yet their implications for pediatric neurosurgery remain underexplored. This narrative review interprets LLM evolution through a neuroscientific lens familiar to pediatric neurosurgeons. We trace the parallel development of LLMs and the human brain: architecture evolving from sequential processing to attention mechanisms mirrors prefrontal cortex maturation; training stages parallel synaptic exuberance, adolescent pruning, and socialization; reasoning capabilities emerge through chain-of-thought prompting and reinforcement learning, analogous to deliberate cognitive processing. We then examine capabilities current LLMs lack but would require for artificial general intelligence-continual learning, multimodal perception, self-awareness, world models, and physical embodiment-mapping each to corresponding neural functions. Using a representative case of pediatric medulloblastoma, we illustrate how these technologies will reshape clinical practice, surgery, research, and education. Current frontier models deliver excellent medical performance with multimodal reasoning at low cost, yet pediatric neurosurgery presents a "long-tail" challenge where rare conditions and reliance on expert consensus demand domain-specific augmentation. The emergence of agentic artificial intelligence (AI), physical AI, and autonomous research systems signals a shift from AI as advisory tool to executing partner. LLMs externalize intellectual labor at unprecedented scale, redefining physicians as "responsible interpreters" who orchestrate AI while retaining judgment, accountability, and ethical authority. In pediatric neurosurgery, this role uniquely integrates metacognitive and emotional dimensions beyond AI's reach within the child-caregiver-physician relationship, enabling human-centered care and empowering neurosurgeons to actively shape AI integration rather than merely adapt to it.

Generative artificial intelligence (AI) has emerged as a transformative tool for creating high-quality visual materials in medical research and education. In pediatric neurosurgery, where ethical and legal constraints limit the use of real patient photographs, AI-assisted illustrations offer significant potential. However, concerns regarding clinical accuracy, intellectual property, and the protection of vulnerable pediatric patients necessitate rigorous oversight. We present a human-in-the-loop workflow that integrates generative AI with vector-based digital editing to produce scientifically accurate and ethically grounded medical illustrations. We reviewed current AI usage policies from major medical journals, including the International Committee of Medical Journal Editors (ICMJE) and the Journal of Korean Neurosurgical Society (JKNS). To demonstrate practical application, we developed illustrative examples for conditions such as sacral dimple, Crouzon syndrome, and Down syndrome using clinician-led sketches and AI-assisted refinement. Vector-based workflows facilitate the transformation of AI-generated raster drafts into editable, high-resolution graphics, allowing clinicians to correct "hallucinations" and ensure anatomical precision. While most journals prohibit listing AI as an author, they permit its use for conceptual figures provided there is transparent disclosure of the tools and prompts used. Our proposed workflow emphasizes that AI should function as a "constrained assistant" rather than an autonomous creator, ensuring that the final output remains non-identifiable and respectful of pediatric patients' dignity. Generative AI tools can significantly enhance visualization in pediatric neurosurgery when governed by strict ethical and technical safeguards. Adherence to journal policies and the maintenance of human-directed validation are essential to uphold scientific integrity and patient privacy in the era of AI-assisted publishing.

The pediatric brain represents a dynamic biological target characterized by rapid myelination and functional reorganization, which presents unique challenges for conventional, adult-centric artificial intelligence (AI) models. This review provides a structured overview of the evolution of AI applications in pediatric neuroimaging and neurosurgery, tracing the transition from early standardized pipelines and handcrafted imaging biomarkers to contemporary deep learning-based approaches for segmentation, prediction, and anomaly detection. Recent advances indicate a paradigm shift from static image interpretation toward dynamic and interactive intelligence, in which AI systems actively support clinical decision-making during surgery rather than functioning solely as diagnostic tools. This new paradigm is supported by four technological domains : brain foundation models designed to capture age-aware neurodevelopmental representations; spatial computing technologies for three-dimensional, context-aware-visualization; physical AI systems integrating robotic safety constraints; and multimodal AI agents that act as cognitive surgical copilots by synthesizing imaging, physiological, and intraoperative data in real time. By shifting the role of AI from preoperative assessment to intraoperative guidance, this paradigm offers new opportunities to enhance surgical precision, safety, and workflow efficiency in pediatric neurosurgery. This review aims to provide neurosurgeons with a conceptual framework for understanding and adopting next-generation AI technologies that align with the dynamic nature of the developing brain and the clinical demands of pediatric neurosurgical care.

Objectives: Congenital hydrocephalus, the most common reason for children's brain surgery, can lead to permanent brain developmental damage if the diagnosis and treatment are not timely. The investigators of this specific research sought to investigate the contribution of the combined use of artificial intelligence (AI) and multimodal analysis in spotting the early predictive markers, setting the right time for neurosurgery, and making prognostic accuracy better in congenital hydrocephalus cases. Methods: A retrospective–prospective multimodal analytical framework was applied, which involved the use of clinical, neuroimaging, and cerebrospinal fluid (CSF) biomarker data from children suffering from congenital hydrocephalus. The MRI and CT images were processed through standardized pipelines, and the automated ventricular segmentation was executed utilizing deep learning architectures, which consisted of 3D U-Net and attention-based CNNs. The clinical and biochemical characteristics were treated first through KNN imputation and then by PCA. Supervised machine learning models (support vector machines, random forests, XGBoost) and deep learning architectures (RNNs and LSTMs) were used to train the models for purposes such as risk stratification, prediction of disease progression, and evaluation of surgical outcomes. Results: The deep learning framework that was proposed exhibited impressive predictive performance, surpassing 95% in test accuracy and showing great precision, recall, and F1-scores. The model's data preprocessing greatly increased its robustness, while XGBoost performed better than traditional classifiers. LSTM models were able to predict disease progression more accurately in the longitudinal studies. The application of Explainable AI techniques brought to light ventricular enlargement, CSF dynamics, and periventricular changes as the most important features for prediction. Conclusion: The use of AI-based multimodal analysis leads to precise early risk classification and helps in making decisions about operations in children suffering from congenital hydrocephalus. Combining imaging, biomarkers, and longitudinal data creates a new and efficient way of treating pediatric neurosurgery with high precision, especially in places with limited resources.

Integration of a mobile robotic cone beam CT scanner in pediatric neurosurgery

Understanding conical penetration into layered biological materials requires capturing the coupled influences of anisotropy, curvature, layer architecture, and developmental evolution of material properties. However, existing computational studies typically assume adult bone, neglect multilayer skull structure, or simplify cortical anisotropy. Here, we develop a multilayer finite element framework that integrates age-dependent cortical thickness, diploë formation, anisotropic elastic behavior, and Hill-type anisotropic yield to resolve penetration mechanics across developmental stages. A data-driven strategy is used to estimate geometry and material properties by fitting a monomolecular growth model to experimental measurements of thickness, modulus, and strength spanning infancy through adulthood, producing a continuous and physiologically realistic map of skull property evolution. The model is validated against independent wedge-indentation experiments and reference finite element simulations, demonstrating close agreement in force-displacement behavior and subsurface stress distributions. Results reveal that age-driven changes in cortical thickness and stiffness produce more than a three-fold variation in penetration depth and a four-fold variation in penetration depth as a percentage of the outer cortical layer thickness, under identical loading. Marked differences in shear-stress localization and plastic-zone morphology highlight how layer geometry and anisotropic stiffness collectively govern penetration resistance. These findings provide new mechanistic insight into the indentation response and pin slippage of layered cranial bone and underscore the importance of age-specific material modeling. The framework has direct implications for biomechanical safety when using head-immobilization devices, particularly in pediatric neurosurgery, where predictive modeling of tool-bone interaction can inform improved device design, force recommendations, and clinical practice.

Paediatric brain tumours are the leading cause of cancerrelated mortality in children worldwide, yet outcomes differ markedly across regions. These differences reflect variation in health system capacity rather than tumour biology alone. This review examines global disparities in paediatric brain tumour surgery, with a focus on how limitations in diagnosis, surgical expertise, and perioperative care shape outcomes in low- and middle-income countries. In resource-limited settings, delays in diagnosis and restricted access to neuroimaging often result in children presenting with advanced disease, larger tumours, and associated hydrocephalus. These factors increase operative risk and limit the likelihood of safe and complete resection. Surgical outcomes are further influenced by constraints in perioperative care, including limited paediatric anaesthesia, intensive care support, and specialized nursing. Gaps in multidisciplinary coordination and restricted access to adjuvant therapies further compromise treatment completion. Long-term follow-up and survivorship care remain inconsistent in many settings, contributing to unrecognized recurrence and avoidable long-term morbidity. Addressing these disparities requires a shift from short-term solutions toward sustained health system strengthening. Priority areas include workforce development, regional surgical capacity, reliable diagnostic and pathology services, and robust cancer registries to support continuity of care and improve survival for children with brain tumours. Keywords: Paediatric neurosurgery, Brain Tumour, Healthcare Disparities, Global health, Lower middleincome countries.

Global neurosurgery (GNS) has emerged as a field dedicated at addressing disparities in neurosurgical access, training, and workforce distribution worldwide. Persistent inequities adversely affect population health outcomes contributing to preventable morbidity and mortality. Addressing these gaps is an essential component of universal health coverage and United Nations Sustainable Development Goal 3 (SDG3). This study aimed to characterize U.S. academic engagement in GNS over the past decade, with emphasis on geographic focus, thematic and subspecialty trends, and institutional leadership. PubMed, Embase, and Scopus were searched for studies published between 2014 and 2025. Eligible publications included original research, case reports or series, reviews, technical or programmatic studies, and commentaries involving neurosurgical populations in World Bank-classified low- and lower-middle-income countries (LIC/LMIC) and at least one U.S.-affiliated author. Extracted data included publication type, country of focus, U.S. academic institution, neurosurgical subspecialty, and thematic domain. Descriptive statistics, chi-square tests, and linear regression analyses were performed. A total of 340 publications met inclusion criteria. U.S.-affiliated GNS output increased over time, with a mean annual increase of 5.9 publications. Collaborations involved 68 of 81 (81%) LIC/LMICs; however, research activity was unevenly distributed, as 57% of represented countries appeared in fewer than five publications. Sub-Saharan Africa accounted for 61% of country-specific publication instances. Most studies addressed general GNS topics (69%), while 31% focused on subspecialties. Education, training, and workforce development comprised 24% of publications. Among subspecialties, pediatric neurosurgery (36%) and trauma/traumatic brain injury (23%) predominated. Three journals accounted for 53% of publications, and three U.S. institutions contributed 37% of total output. Engagement in global neurosurgery has increased over the past decade but remains concentrated within a limited number of countries, subspecialties, journals, and institutions. These findings highlight opportunities to expand partnerships, and promote more equitable and inclusive neurosurgical scholarship.

Intrathecal baclofen (ITB) pumps are essential for managing spasticity and dystonia in children; however, they carry risks of hardware infection, withdrawal syndrome, and emergent failure. Management of these complications remains variable across institutions, and no unified, pediatric-specific workflow exists to date. We sought to develop and implement standard work tools (SWTs) to guide the evaluation and treatment of ITB pump infection and withdrawal in pediatric patients. Senior-level pediatric neurosurgery and physical medicine and rehabilitation (PM&R) physicians at a high-volume tertiary children's hospital (Ann and Robert H. Lurie Children's Hospital) collaboratively developed two structured SWTs addressing: (1) diagnosis and care of suspected ITB pump infection; and (2) structured weaning protocols to prevent and manage withdrawal during pump explantation or malfunction. SWTs were disseminated through detailed manuals and real-time clinical decision support. Their clinical utility was assessed through implementation in cases requiring pump interrogation or removal. The SWTs were successfully applied across multidisciplinary teams; collectively, they standardize pump interrogation, laboratory evaluation, drug conversion strategies, ITB dose-based weaning thresholds, and escalation procedures for severe withdrawal or infection. The tools enabled consistent management of both emergent and subacute presentations. We further demonstrate their effectiveness through two representative cases: one involving MSSA pocket infection requiring pump removal and structured withdrawal management, and another involving non-inflammatory wound breakdown with preserved pump function requiring coordinated interdisciplinary care. SWTs improve safety and timeliness in the management of ITB pump infections and baclofen withdrawal in children. The presented tools provide a reproducible framework for first-line providers and pertinent specialists, particularly for those who may not be familiar with key signs and varied presentations. Broader adoption may reduce variability in treatment while optimizing longitudinal ITB therapy outcomes in pediatric patients.

Social and ethical aspects of pediatric neurosurgery in Kenya.