Pediatric Neurosurgical Practice Research Articles

The utility of routine intraoperative CSF during ventricular shunt insertion: a 10-year retrospective cohort study.

Ventricular shunt insertion is a common procedure in pediatric neurosurgical practice. In many areas of medicine there is a push toward rationalization of healthcare resources and a reduction in low-value tests or procedures. The intraoperative sampling of CSF at the time of shunt insertion is one traditional aspect of care that has not been rigorously evaluated. Additionally, the role of CSF cell counts and chemistry in predicting shunt dysfunction is often discussed but poorly studied. A recent meta-analysis found a correlation between elevated CSF protein levels and shunt failure in patients with tuberculous meningitis, but not other pathologies, which limits the generalizability of those findings to Western populations. The aims of this study were to assess the clinical utility of intraoperative CSF sampling during insertion of ventricular shunts and to describe any association of routine intraoperative CSF sample parameters with shunt failure or infection. A retrospective review of a prospectively maintained surgical database covering 10 years of consecutive cases from a quaternary Australian pediatric neurosurgical center serving a population of 5.3 million was conducted. Statewide electronic medical records were reviewed to collate data on demographics, postoperative imaging, CSF biochemistry, instances of shunt failure, shunt revisions, and mortality. Patients undergoing insertion of a new ventricular shunt were included, while all cases of shunt revision were excluded. During the study period, 1485 shunt procedures were performed, of which 427 involved the placement of a new ventriculoperitoneal shunt system. The mean patient age was 5.2 years (range premature-18 years). Of the 427 cases, 377 (88%) underwent routine CSF sampling. The most common indications for shunt revision were proximal catheter obstruction (51/173, 29%), followed by infection (29/173, 17%) and valve blockage (23/173, 13%). During the study period, 3 patients with existing intracranial hardware had overt ventriculitis identified at the time of intraoperative sampling, resulting in shunt removal. One patient with an existing ventricular reservoir had a delayed clinically significant infection identified on intraoperative cultures. Elevated CSF protein levels were associated with shunt failure during follow-up (area under the curve 0.625). The identified cutoff of 300 mg/L was significantly associated with a reduced time to shunt failure in both univariate and multivariate analyses. It may be reasonable to consider omission of routine intraoperative CSF sampling at the time of shunt insertion in patients without existing intracranial hardware. Elevated CSF protein levels are associated with a reduced time to shunt failure in a dose-dependent manner.

Application of extended reality in pediatric neurosurgery: A comprehensive review.

The integration of Extended Reality (XR) technologies, including Augmented Reality (AR) and Virtual Reality (VR), represents a significant advancement in pediatric neurosurgery. These technologies offer immersive and interactive 3D visualization capabilities, which enhance the precision and accuracy of surgical procedures. This comprehensive review systematically examines the current applications of XR in pediatric neurosurgery. The review adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, which provide criteria for reporting systematic reviews and meta-analyses. It also utilizes the PICOS (Population, Intervention, Comparison, Outcome, Study design) framework to formulate research questions and structure literature searches. A thorough search of multiple databases yielded 1,434 relevant articles, supplemented by an additional 55 articles obtained through manual searches. The review includes a detailed analysis of the XR workflow, its surgical applications, and associated outcomes. It emphasizes the practical benefits of XR in preoperative planning, intraoperative navigation, and postoperative assessment. Furthermore, the paper discusses the challenges, opportunities, and future prospects of XR in pediatric neurosurgery, including its effects on surgical outcomes, medical education, and patient care. By synthesizing technological developments with clinical applications, this review provides a comprehensive understanding of the multifaceted roles of AR and VR in pediatric neurosurgical practice. It covers innovative methods, applicable scenarios, datasets, and metrics, along with a comparative analysis of state-of-the-art techniques, considering differences in input data. Ultimately, this review aims to present an overview of the current landscape of XR in pediatric neurosurgery to inform future research and clinical practice.

Defining pediatric neurosurgery in low-income countries: a cross-sectional study in Ethiopia.

Pediatric neurosurgical practice is prevalent in most low- and lower-middle-income countries but lacks comprehensive documentation of practice patterns, demographics, and case variety. This study aimed to present the current state of pediatric neurosurgery in Ethiopia, including workforce characterization, case variety, and relevant procedures. A survey was developed and distributed to all Ethiopian fully trained neurosurgeons (n = 50). Survey questions assessed sociodemographic variables, level of training, case variety, and neurosurgical practice. Statistical analysis was conducted to describe the current practice of pediatric neurosurgery. A total of 45 neurosurgeons responded (90%). Three respondents (7%) were women. There was only 1 fellowship-trained pediatric neurosurgeon, while most neurosurgeons were general neurosurgeons who served a pediatric patient population. Most neurosurgeons (56%) worked in the capital city, Addis Ababa, while another 13% worked in other urban settings. The top three indications for a pediatric neurosurgical procedure were neural tube defects (NTDs) (96%), hydrocephalus (93%), and trauma (60%). NTD-associated hydrocephalus was the most common hydrocephalus type seen (71%). The most common procedure for hydrocephalus was shunt insertion (96%). A prenatal diagnosis of NTD was made in < 10% of cases, as reported by 84% of respondents. The study highlights Ethiopia's need for more pediatric neurosurgeons. Suggested strategies to facilitate subspecialty training include the establishment of a fellowship program facilitated by the implementation of a nationwide pediatric neurosurgery registry. Promoting efforts for early diagnosis and treatment of pediatric conditions coupled with NTD prevention initiatives could improve pediatric neurosurgical care in Ethiopia.

Predictive Value of Sonographic Parameters on the Effects of Cranial Molding Helmet Therapy in Infants with Positional Plagiocephaly.

Positional plagiocephaly is a deformational cranial flattening frequently treated in pediatric neurosurgical practice. Positional maneuvers and orthotic helmet therapy are preferred therapeutic options for moderate-to-severe forms. Treatment response seems to be age-dependent. Nevertheless, predictive data are vague, and cost-efficiency might be a limiting factor for treatment. The purpose of this study was to investigate the early predictive value of sonographic parameters on the efficacy of orthotic helmet therapy through the assessment of changes in skull shape and correlation of the parameters with caliper cephalometry values and with age. A consecutive cohort of 49 patients < 10 months of age, undergoing orthotic helmet therapy for positional plagiocephaly, was recruited prospectively. The authors routinely assessed the patency of the lambdoid sutures by ultrasound and the following additional skull parameters were measured: suture width, adjacent full bone thickness, adjacent cortical bone thickness and occipital angle. Caliper cephalometric values, as well as demographic and clinical data were collected. Retrospective data analysis showed an inverse relation between both cortical and full skull bone thickness and early treatment efficacy, defined by a reduction in the occipital angle. The improvement of sonographic parameters correlated with the development of cranial caliper cephalometry values. In conclusion, the sonographic assessment of skull bone thickness is a safe and cost-effective tool to predict the early efficacy of orthotic helmet therapy in positional plagiocephaly and might, therefore, help the clinician to foresee the potential evolution of the deformity.

Pediatric neurosurgery through the lens of time-driven activity-based costing: a pilot study.

Time-driven activity-based costing (TDABC) is a method used in cost accounting that has gained traction in health economics to identify value optimization initiatives. It measures time, assigns value to time increments spent on a patient, and integrates the cost of material and human resources utilized in each episode of care. In this study, the authors report the first use of TDABC to evaluate costs in a pediatric neurosurgical practice. A clinical pathway was developed with a multifunction team. A time survey among each care team member, including surgeons, medical assistants (MAs), and patient service representatives (PSRs), was carried out prospectively over a 10-week period at a pediatric neurosurgery clinic. Consecutive patient encounters for Chiari malformation (CM), hydrocephalus, or tethered cord syndrome (TCS) were included. Encounters were categorized as new or established. Relative annual personnel costs, using the salary of a PSR as a reference (i.e., 1.0-unit cost), were calculated for all members using departmental financial data after adjustments. The relative capacity cost rates (minute-1) for each personnel, a representation of per capita cost per minute, were then derived, and the relative costs per visit were calculated. A total of 110 visits (24 new, 86 established) were captured, including 40% CM, 41% hydrocephalus, and 19% TCS encounters. Surgeons had the highest relative capacity cost rate (118.4 × 10-6), more than 10-fold higher than that of an MA or PSR (10.65 × 10-6 and 9.259 × 10-6, respectively). Surgeons also logged more time with patients compared with the rest of the care team in nearly all visits (p ≤ 0.002); consequently, the total visit costs were primarily driven by the surgeon cost (p < 0.0001). Overall, surgeon cost constituted the vast majority of the total visit cost (92%-93%), regardless of whether the visits were new or established. Visit costs did not differ by diagnosis. On average, new visits took longer than established visits (p < 0.001). This difference was largely driven by new CM visits (44.3 ± 13.7 minutes), which were significantly longer than established CM visits (29.8 ± 9.2 minutes; p = 0.001). TDABC may reveal opportunities to maximize value by highlighting instances of variability and high cost in each module of care delivery. Physician leaders in pediatric neurosurgery may be able to use this information to allocate costs and streamline value care pathways.

New CNS tumor classification: The importance in pediatric neurosurgical practice.

The management of the central nervous system (CNS) tumors in the pediatric population is crucial in neurosurgical practice. The World Health Organization (WHO) has evolved its classification of CNS tumors from the 19th century to the 5th edition, published in 2021, incorporating molecular advancements. This transition from morphology to molecular characterization is ongoing. This manuscript analyzes the modifications introduced in the 5th edition of WHO's CNS tumor classification, particularly focusing on pediatric tumor families. The paper integrates clinical, morphological, and molecular information, aiming to guide pediatric neurosurgeons in their daily practice and interdisciplinary discussions. The 5th edition of the WHO classification introduces a hybrid taxonomy that incorporates both molecular and histological components. The terminology shifts from "entity" to "type" and "subtype," aiming to standardize terminology. Tumor grading experiences changes, integrating molecular biomarkers for prognosis. The concept of integrated layered diagnosis is emphasized, where molecular and histological information is combined systematically. The 5th edition of the WHO CNS classification signifies a paradigm shift toward molecular characterization. The incorporation of molecular advances, the layered diagnostic approach, and the inclusion of clinical, morphological, and molecular information aim to provide comprehensive insights into pediatric CNS tumors. This classification offers valuable guidance for pediatric neurosurgeons, aiding in precise diagnosis and treatment planning for these complex neoplasms.

Spasticity and movement disorders in cerebral palsy.

To review the neurosurgical treatments of children with movement disorders associated with cerebral palsy (CP) during the previous decades, up to the present day. An extensive literature review was undertaken to identify important publications about this subject. My experience treating children with these disorders over the past three decades was included in the individual sections. Peripheral neurotomies have been developed for children with focal spasticity. For those with spastic paraparesis, selective lumbar rhizotomies were developed, and for those with spastic quadriparesis, intrathecal baclofen infusions were developed. Both effectively alleviate spasticity in the affected extremities. Generalized dystonia associated with CP has been treated with deep brain stimulation with mild improvement, but treatment with intrathecal baclofen and intraventricular baclofen improve those movements markedly. No effective treatment has been reported for children with athetoid CP. For those with choreiform CP, deep brain stimulation may be effective but intrathecal baclofen does not appear to be. Treatment of children with movement disorders associated with CP increased slowly in the 1970s and 1980s but accelerated rapidly in the 1990s with the introduction of lumbar dorsal rhizotomies and intrathecal baclofen. In the last 30years, tens of thousands of children with spasticity and movement disorders associated with CP have been treated by pediatric neurosurgeons, and their care has become an integral component of current pediatric neurosurgical practice.

Pediatric Neurosurgical Capacity for the Care of Children With CNS Tumors Worldwide: A Cross-Sectional Assessment.

Efforts to address inequities in the treatment of pediatric CNS tumors and the burden of childhood cancer globally have prompted the designation of low-grade glioma as one of six index cancers for the World Health Organization Global Initiative for Childhood Cancer. Understanding the importance of neurosurgical interventions and evaluating pediatric neurosurgical capacity may identify critical interventions to improve outcomes for children with low-grade glioma and other CNS tumors. An online, cross-sectional survey assessing pediatric neurosurgical practice and capacity was distributed to members of the International Society of Pediatric Neurosurgery. The survey included 36 items covering domains including patient volume, available infrastructure, scope of practice, case distribution, and multidisciplinary care. Responses from 196 individuals from 61 countries, spanning all WHO regions, were included. Ninety-six (49.0%) were from high-income countries, 57 (29.1%) were from upper-middle-income countries, 42 (21.4%) were from lower-middle-income countries (LMICs), and 1 was (0.5%) from a low-income country. Most respondents had a catchment population of ≥ 1 million and indicated the availability of basic neurosurgical resources such as a dedicated neurosurgical operating theater and surgical microscope. The presence of a neurosurgical intensive care unit, inpatient rehabilitation services, and infection monitoring showed similar availability across country groups. Quantitative scoring of 13 infrastructure and service items established that fewer resources were available in low-income countries/LMICs and upper-middle-income countries compared with high-income countries. The volume of pediatric CNS tumor cases and case distribution did not vary according to World Bank country groups. This study provides a comprehensive evaluation of pediatric neurosurgical capacity across the globe, establishing variability of resources on the basis of the country income level. Our findings suggest that pediatric neurosurgeons in LMICs may benefit from key neurosurgical instrumentation and increased support for multidisciplinary brain tumor programs and childhood cancer research efforts.

Trends in United States pediatric neurosurgical practice during the COVID-19 pandemic

There is minimal information on COVID-19 pandemic’s national impact on pediatric neurosurgical operative volumes. In this study, using a national database, TriNetX, we compared the overall and seasonal trends of pediatric neurosurgical procedure volumes in the United States during the pandemic to pre-pandemic periods. In the United States, the incidence of COVID-19 began to rise in September 2020 and reached its maximum peak between December 2020 and January 2021. During this time, there was an inverse relationship between pediatric neurosurgical operative volumes and the incidence of COVID-19 cases. From March 2020 to May 2021, there was a significant decrease in the number of pediatric shunt (−11.7% mean change, p = 0.006), epilepsy (−16.6%, p < 0.001), and neurosurgical trauma (−13.8%, p < 0.001) surgeries compared to pre-pandemic years. The seasonal analysis also yielded a broad decrease in most subcategories in spring 2020 with significant decreases in pediatric spine, epilepsy, and trauma cases. To the best of our knowledge, this is the first study to report a national decline in pediatric shunt, epilepsy, and neurosurgical trauma operative volumes during the pandemic. This could be due to fear-related changes in health-seeking behavior as well as underdiagnosis during the COVID-19 pandemic.

Gastrulation : Current Concepts and Implications for Spinal Malformations.

It has been recognised for over a century that the events of gastrulation are fundamental in determining, not only the development of the neuraxis but the organisation of the entire primitive embryo. Until recently our understanding of gastrulation was based on detailed histological analysis in animal models and relatively rare human tissue preparations from aborted fetuses. Such studies resulted in a model of gastrulation that neurosurgeons have subsequently used as a means of trying to explain some of the congenital anomalies of caudal spinal cord and vertebral development that present in paediatric neurosurgical practice. Recent advances in developmental biology, in particular cellular biology and molecular genetics have offered new insights into very early development. Understanding the processes that underlie cellular interactions, gene expression and activation/inhibition of signalling pathways has changed the way embryologists view gastrulation and this has led to a shift in emphasis from the ‘descriptive and morphological’ to the ‘mechanistic and functional’. Unfortunately, thus far it has proved difficult to translate this improved knowledge of normal development, typically derived from non-human models, into an understanding of the mechanisms underlying human malformations such as the spinal dysraphisms and anomalies of caudal development. A paediatric neurosurgeons perspective of current concepts in gastrulation is presented along with a critical review of the current hypotheses of human malformations that have been attributed to disorders of this stage of embryogenesis.

Pediatric neurosurgery during the COVID-19 pandemic: update and recommendations from the Brazilian Society of Pediatric Neurosurgery.

Coronavirus disease (COVID-19) is a potentially severe respiratory illness that has threatened humanity globally. The pediatric neurosurgery practice differs from that of adults in that it treats children in various stages of physical and psychological development and contemplates diseases that do not exist in other areas. The aim of this study was to identify the level of knowledge and readiness of the healthcare providers, as well as to evaluate new preventive practices that have been introduced, psychological concerns, and the impact of the COVID-19 pandemic on pediatric neurosurgical units in Brazil. Pediatric neurosurgeons were given an online questionnaire developed by the Brazilian Society of Pediatric Neurosurgery to evaluate the impact of the COVID-19 pandemic on their clinical practice. Of a cohort of 110 active members of the Brazilian Society of Pediatric Neurosurgery, 76 completed the survey (69%). Ninety-six percent were aware of the correct use of and indication for the types of personal protective equipment in clinical and surgical practices, but only 73.7% of them had unrestricted access to this equipment. Ninety-eight percent of participants agreed or strongly agreed that the pandemic had affected their pediatric neurosurgical practice. The COVID-19 pandemic interfered with outpatient care in 88% of the centers, it affected neurosurgical activity in 90.7%, and it led to the cancellation of elective neurosurgical procedures in 57.3%. Concerning the impact of COVID-19 on surgical activity, 9.2% of the centers had less than 25% of the clinical practice affected, 46.1% had 26%-50% of their activity reduced, 35.5% had a 51%-75% reduction, and 9.2% had more than 75% of their surgical work cancelled or postponed. Sixty-three percent affirmed that patients had been tested for COVID-19 before surgery. Regarding the impact of the COVID-19 pandemic on the mental health of those interviewed, 3.9% reported fear and anxiety with panic episodes, 7.9% had worsening of previous anxiety symptoms, 60.5% reported occasional fear, 10.5% had sadness and some depressive symptoms, and 2.6% reported depressive symptoms. The COVID-19 pandemic has posed unprecedented challenges to healthcare services worldwide, including neurosurgical units. Medical workers, pediatric neurosurgeons included, should be aware of safety measures and follow the recommendations of local healthcare organizations, preventing and controlling the disease. Attention should be given to the psychological burden of exposure to SARS-CoV-2 in healthcare workers, which carries a high risk of anxiety and depression.

Pediatric neurosurgery in Asia and Australasia: training and clinical practice.

There are limited data on the pediatric neurosurgical workforce in Asia and Australasia. The training and clinical practice of pediatric neurosurgeons need to be characterized in order to identify gaps in knowledge and skills, thereby establishing a framework from which to elevate pediatric neurosurgical care in the region. An online survey for pediatric neurosurgeons was created in REDCap (Research Electronic Database Capture), collecting demographic information and data on pediatric neurosurgical training and clinical practice. The link to answer the survey was sent to the mailing lists of the Asian Australasian Society for Pediatric Neurosurgery and the Japanese Society for Pediatric Neurosurgery, disseminated during the 2019 Asian Australasian Pediatric Neurosurgery Congress, and spread through social media. The survey was open to neurosurgeons who operated on patients ≤ 18 years old in Asian Australasian countries, whether or not they had completed fellowship training in pediatric neurosurgery. Descriptive statistics were computed and tabulated. Data were stratified and compared based on surgeon training and World Bank income group. A total of 155 valid survey responses were analyzed, representing neurosurgeons from 21 countries. A total of 107 (69%) considered themselves pediatric neurosurgeons, of whom 66 (43%) had completed pediatric neurosurgery training. Neurosurgeons in East Asia commonly undergo a fellowship in their home countries, whereas the rest train mostly in North America, Europe, and Australia. A majority (89%) had operating privileges, and subspecialty pediatric training usually lasted from 6 months to 2 years. On average, trained pediatric neurosurgeons perform a higher number of pediatric neurosurgical operations per year compared with nonpediatric-trained respondents (131 ± 129 vs 56 ± 64 [mean ± SD], p = 0.0001). The mean number of total neurosurgical operations per year is similar for both groups (184 ± 129 vs 178 ± 142 [mean ± SD], p = 0.80). Respondents expressed the desire to train further in pediatric epilepsy, spasticity, vascular malformations, craniofacial disorders, and brain tumors. Both pediatric and general neurosurgeons provide neurosurgical care to children in Asia and Australasia. There is a need to increase pediatric neurosurgery fellowship programs in the region. Skill sets and training needs in pediatric neurosurgery vary depending on the country's economic status and between pediatric-trained and nonpediatric-trained surgeons.

Patient advice regarding participation in sport in children with disorders of cerebrospinal fluid (CSF) circulation: a national survey of British paediatric neurosurgeons

BackgroundManagement of children with disorders of cerebrospinal fluid (CSF) circulation is a common aspect of paediatric neurosurgical practice. Sport and physical activity play an integral role in the lives of patients in this age group. However, there is little evidence to support the dissemination of appropriate advice to children regarding such activities. The aim of this study was to evaluate the perspectives of clinicians across the UK regarding the participation of children with disorders of CSF circulation in sports.MethodsQuestionnaires were distributed to Consultant Paediatric Neurosurgeons practising across the UK via the Society of British Neurological Surgeons (SBNS). Five different patient scenarios were supplied, and participants were asked to choose whether they would advise participation in the following sports: Taekwondo, rugby, skiing, and football.ResultsAn overall response rate of 66.7% (36 out of 54 paediatric neurosurgeons) was achieved. The following percentages of clinicians advocated football, rugby, Taekwondo, and skiing across all scenarios: 96%, 75%, 77%, and 97%, respectively. The majority of responders (91.2%) relied on personal experience when providing advice, whilst 50% used available literature and 19.4% used available guidelines.ConclusionsThere is a paucity of evidence in the literature to support the dissemination of appropriate advice to children with disorders of CSF circulation regarding participation in sports. Our findings demonstrate that the majority of clinicians rely on personal experience to make such decisions, emphasizing the necessity of larger scale studies to inform evidence-based guidelines.

Applications of a robotic stereotactic arm for pediatric epilepsy and neurooncology surgery.

OBJECTIVE The ROSA device is a robotic stereotactic arm that uses a laser system to register the patient's head or spine with MR or CT images. In this study, the authors analyze their experience with this system in pediatric neurosurgical applications and present selected cases that exemplify the usefulness of this system. METHODS The authors reviewed all cases that utilized the ROSA system at their institution. Patient demographics, pathology, complications, electrode placement, laser ablation, and biopsy accuracy were analyzed. Patient disposition and condition at follow-up were also analyzed. RESULTS Seventeen patients underwent 23 procedures using the ROSA system. A total of 87 electroencephalography electrodes were placed, with 13% deviating more than 3 mm from target. Six patients underwent stereotactic needle biopsy, and 9 underwent laser interstitial thermotherapy (LITT). One patient who underwent LITT required a subsequent craniotomy for tumor resection. Another patient experienced an asymptomatic extraaxial hematoma that spontaneously resolved. No patient suffered neurological complications during follow-up. Follow-up from the last procedure averaged 180 days in epilepsy patients and 309 days in oncology patients. CONCLUSIONS The precision, ease of use, and versatility of the ROSA system make it well suited for pediatric neurosurgical practice. Further work, including long-term analysis of results and cost-effectiveness, will help determine the utility of this system and if its applications can be expanded.

The unwell child with a ventriculo-peritoneal shunt

A ventriculo-peritoneal shunt (VPS) is a device which diverts cerebrospinal fluid (CSF) from the ventricles to the abdomen and passes from there to the bloodstream. It consists of a silicon tube with a valve able to control the rate of drainage (regulated either by pressure or flow) and prevent back-flow. In a paediatric neurosurgical practice, shunting can account for half the operative caseload. Continued improvements in both materials and techniques have improved the rates of revision and infection. However, nearly half of the children with a VPS will experience a shunt revision at some point in their life. A blocked shunt is potentially life-threatening and it is important to for general paediatricians to understand some key principles when assessing a child with a VPS.

Fifteen-minute consultation: incidental findings on brain and spine imaging

Incidental findings on imaging of the brain and spine account for a large number of referrals to a paediatric neurosurgical practice. They can be cause of undue concern to the...

The Rebirth of Neuroendoscopic Choroid Plexus Coagulation as Treatment of Pediatric Hydrocephalus

Pediatric hydrocephalus is one of the most frequently diagnosed diseases in pediatric neurosurgical practice. Approximately 60% of the total cases of hydrocephalus in children are congenital or acquired in childhood. It is a typical surgical disease and if left untreated, most cases are lethal. Traditionally, shunts are the main treatment since 1940s. However, sometimes shunt dependency in children with hydrocephalus is a terrible problem, and is more dangerous in emerging countries than developed countries because of the difficulties that prevent access to prompt neurosurgical intervention, in cases of infection or shunt malfunction. In this scenario, mainly in obstructive hydrocephalus, Neuroendoscopic techniques such as Endoscopic Third Ventriculostomy (ETV) become vitally important in the management of these patients.

Designing a safe and sustainable pediatric neurosurgical practice: the English experience.

The 2001 Report of the Public Inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995 stated that there must be standards for hospitals as a whole and that hospitals, which do not meet these standards, should not be able to offer services within the National Health Service (NHS). In 2013, agreed standards for pediatric neurosurgery were produced. Between 2001 and 2013 several key documents were published, which formed the background to the review that produced these standards:, the 'Safe and Sustainable' review. The process had the mission statement, 'Safe, sustainable and world class. Not ordinary, OK or just good enough.' In April 2013, the new commissioning structure of NHS England came into being. Clinical Reference Groups (reporting directly into the new structure) and pediatric neurosurgical operational delivery networks are taking the Safe and Sustainable pediatric neurosurgery standards and models of care into practice in England. Effective outcome data collection will allow us to assess whether these networks will improve equity of access for English children to world-class pediatric neurosurgical care and reduce the variation in outcomes seen at the present time.

Cavidad porencefálica reversible secundaria a disfunción valvular

The surgical treatment of hydrocephalus is one of the most commonly procedures of modern pediatric neurosurgical practice, and cerebrospinal fluid shunts are the main means of treatment of hydrocephalus, being independent of site of obstruction and ventricular shunt complications are frequent, especially in children. The most common complications are shunt obstructions, mechanical disconnections, overdrainage and infection. A 7.5-year-old girl with ventriculoperitoneal shunt presented with intermittent headache. A head computed tomography scan revealed a cyst located in right temporal lobe. After ventriculoperitoneal shunt revision, a gradual resolution of the cyst was demonstrated on computed tomography. Cerebrospinal fluid porencephaly is a rare postoperative complication of a ventricular shunt that results from dysfunction of the distal catheter, especially in children with taut ventricles.

Effect of introduction of antibiotic-impregnated shunt catheters on cerebrospinal fluid shunt infection in children: a large single-center retrospective study

Infection after both primary and revision shunt surgeries remains a major problem in pediatric neurosurgical practice. Antibiotic-impregnated shunt (AIS) tubing has been proposed to reduce infection rates. The authors report their experience with AIS catheters in their large pediatric neurosurgery department. The authors conducted a retrospective case review of consecutive shunt operations performed before (1993-2003) and after (2005-2009) introduction of AIS tubing, with analysis of shunt infection rates and causative organisms identified. The historical control group consisted of 1592 consecutive shunt operations (657 primary insertions), and the AIS study group consisted of 500 consecutive shunt operations (184 primary insertions). Patients ranged in age from 0-17 years. In the historical group, 135 infections were identified (8.4%). In the AIS study group, 25 infections were identified (5%), representing a significant reduction (p < 0.005). The latency to diagnosis of infection was 23 days in the historical group and 139 days in the AIS study group. The infection rates in infants 0-6 months of age were 12.2% (historical group) and 6.7% (AIS group, p < 0.005), and in infants 7-12 months of age the rates were 7.9% (historical group) and 2.7% (AIS group, p < 0.005). In the historical control group, the frequency rank order of causative organisms was coagulase-negative staphylococcus (51.9%), Staphylococcus aureus (31.6%), streptococcus or enterococcus spp. (8.8%), gram-negative organisms (4.4%), and Propionibacterium acnes (2.2%). Organisms responsible for infections in AIS were S. aureus (40%), followed by streptococcus or enterococcus spp. (20%), P. acnes and coagulase-negative staphylococcus (both 16%), and gram-negative organisms (4%). No unusually antibiotic-resistant bacteria were identified in either group. The authors further subdivided the AIS group into those undergoing primary AIS insertion (Subgroup 1), those undergoing revision of non-AIS systems using AIS components (Subgroup 2), and those undergoing revision of AIS systems using AIS components (Subgroup 3). Infection rates were 1.6% in Subgroup 1, 2.5% in Subgroup 2, and 11.7% in Subgroup 3. Staphylococcus aureus was the most common organism identified in infections of the Subgroups 2 and 3. Use of AIS tubing significantly improves shunt infection rates in both general pediatric and infant populations with no evidence of increased antibiotic resistance, which is in agreement with previous studies. However, the increased infection rate in revision surgery in children with AIS catheters in situ raises questions about their long-term application.