The modernization of pediatric neurosurgery

Introduction It might be presumed that the discipline of pediatric neurosurgery is as youthful as the patients it serves. But this subspecialty of neurosurgery is at least 50 years old.Discussion This 2003 Donald D. Matson Memorial Lecture will examine the growth and development of childrens neurosurgical care from the aspects of its identity and continuing educational activity, the impact of technology, outcome measures, and the role of public advocacy.Presented at the Pediatric Sections of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, San Diego, Calif., 30 April 2003     

The rewards of pediatric neurosurgery

The author relates how he ended up somewhat unexpectedly as a pediatric neurosurgeon and how fortunate he feels to have become a pediatric neurosurgeon. He reflects on his life and on the importance of trying to do one's best. He comments about the importance of listening, empathizing, and being compassionate as characteristics of the pediatric neurosurgeon and notes that by trying one's best to be a good pediatric neurosurgeon one adopts more of these characteristics by learning from patients and their parents. He discusses the many ways in which the practice of pediatric neurosurgery and his involvement in the International Society for Pediatric Neurosurgery have created meaning in his life, which has led to a feeling of happiness and fulfillment.     

The third dimension in pediatric neurosurgery

Three-dimensional computerized imaging with current advanced software (Cemax) has resulted in superior visual ergonomics and rapid data acquisition utilizing standard computed tomography (CT) or magnetic resonance imaging. Consequently, within 15–20 min of a standard CT scan, the information is available to be employed for operative planning, allowing this useful tool to be practical in emergency situations, such as trauma. The advanced lifelike imaging permits excellent preoperative planning due to correct demonstration of the surgical anatomy. We present three patients to illustrate the applications of this technology: one with a skull base tumor, another with a complex ethmoidal encephalocele, and a third with severe craniofacial trauma. We have found this technique to have a significant impact on the management of pediatric neurosurgery patients with complex pathology.     

Radiopharmaceutical bone scanning in pediatric neurosurgery.

Radionuclide bone scanning is an extremely sensitive, safe and widely applicable investigative aid. In most circumstances it cannot be employed to the exclusion of plain radiography as the two procedures--one dynamic and the other static--complement each other. In children, bone imaging demonstrates physiologic characteristics of bone growth and early suture closure, delineates obscure tumors and infection, recent or old trauma not always visible on orthodox radiography and may solve the diagnostic dilemma of a child with heretofore undiagnosed head, neck or back pain.     

The future perspectives of pediatric neurosurgery

Pediatric neurosurgery as a subspecialty dealing primarily with such congenital and perinatal pathology as the dysraphic state, and various clinical entities having in common ventriculomegaly, is fast disappearing from the scene of neurosurgery in the industrialized world. Pari passu with this, one observes ever closer collaborative work between pediatric neurosurgeons and specialists in other pediatric disciplines such as oncology, radiology, orthopedics, and maxillofacial surgery: truly multidisciplinary activities. In addition, paramedical and specialized nursing personnel are participating actively, even in the decision-making and treatment-delivery aspects of pediatric neurosurgical care. The pediatric neurosurgeon is no longer the sole decision-maker, nor the automatic captain of the ship. Very probably, as in the whole history of human activities, new instrumentation will change somewhat what we do and with whom we collaborate. However, for the immediate future the major changes most probably will be expressions of socioeconomic readjustments, of ethical redefinitions, and of the to-and-fro movement into and out of pediatric neurosurgery by both neurosurgeons and ancillary medical personnel.     

Perspectives in pediatric neurosurgery

The new millennium beckons for novel advances in the diagnosis and treatment of pediatric neurosurgical conditions. Almost every aspect of pediatric neurosurgery has changed over the last decade. Undoubtedly with the application of knowledge in molecular biology to human disease many aspects of neurosurgery, especially neuro-oncology and the field of neuro-developmental anomalies, will change appreciably over the next decade. Overall, the trend in surgery in general and neurosurgery in particular is toward less invasive procedures and possibly non-surgical interventions. This review will briefly cover many of the important areas of pediatric neurosurgery. We will describe the state-of-the-art of our subspecialty and discuss possible future directions.     

The role of the endoscopic transsphenoidal approach in pediatric neurosurgery

The endoscopic endonasal transsphenoidal approach to the sellar region for the removal of pituitary adenomas and of other neoplasms in the same area has proved its reliability and effectiveness for the very wide vision it offers, coupled with minimal surgical trauma. Indications and advantages of such a technique are reported, focused on the treatment of lesions of the sellar and parasellar environment in pediatric age-group patients, and based on a consecutive series of 100 patients, 3 of them adolescents, treated during the last 3 years.     

Split laminotomy in pediatric neurosurgery

Technique A novel technique of multilevel opening of the spinal canal is introduced into pediatric neurosurgery. Split laminotomy helps to preserve the spinal column integrity in cases of posterior exposure of the spinal canal. The spinal processes are cut in the midline and the laminae are separated and retracted while the lesion in the spinal canal is explored. At closure the lamina are simply sutured.Results and discussion Excellent postoperative results were obtained in patients from different age groups. Pediatric peculiarities of the new method are discussed.     

Application of the orbito-cranial approach in pediatric neurosurgery

OBJECTIVE: This study evaluates the benefits of and indications for the orbito-cranial approach (OCA) in pediatric patients. METHODS AND RESULTS: The authors report their recent experience of using the OCA in 9 pediatric patients, 6 boys and 3 girls. The patients' ages ranged from 3 to 17 years (mean 9.6+/-5.16 years). Follow-up periods varied between 6 and 21 months (mean 12.6+/-5.9 months). Five patients were operated on for craniopharyngiomas, 2 for chiasmatic-hypothalamic astrocytomas, 1 for a recurrent hypothalamic gangliocytoma, and 1 for a hypothalamic hamartoma. In 7 cases a neuronavigation system (BrainLab) was utilized. The lesions were removed totally in 5 patients, near-totally in 1, subtotally in 2, and partially in 1 patient. An average increase of 30% in the area of vertical exposure significantly decreased the need for brain retraction. There was no mortality in this series. The only complications connected with the surgical approach were transient subgaleal cerebro-spinal fluid collections in 7 of 9 children and a subgaleal-peritoneal shunt placement in another patient. CONCLUSIONS: Our experience with this series of patients suggests that the OCA is as safe and beneficial in pediatric patients as it is in adults. It facilitates tumor removal by providing shorter access to and better exposure of the suprasellar area, thereby minimizing brain retraction.     

Open-door laminoplasty in pediatric spinal neurosurgery

Multilevel laminotomy entails the risk of instability of the spine. In this paper, we propose an application of the open-door laminoplasty technique in pediatric spinal neurosurgery. A standard laminotomy is performed at one side while a groove is drilled out at the other side to preserve the internal periosteum of the lamina. This allows a rolling elevation without complete separation of the laminae. The advantages of such a method are discussed.     

Highly cited publications in pediatric neurosurgery

Object

The number of citations a publication receives can be used as a surrogate for the impact that article has made on its discipline. This study identifies and characterizes the most cited articles in pediatric neurosurgical journals as of April 2013.

Methods

We examined four clinical pediatric neurosurgery journals. The 100 most cited articles in the overall literature and the top 50 articles from 2002 to 2012 were examined. The following information was recorded for each article: number of authors, country of origin, citation-count adjusted for number of years in print, topic, and level of evidence.

Results

The 100 most cited articles appeared in three of the four journals: Child’s Brain, Pediatric Neurosurgery and Child’s Nervous System. Publication dates ranged from 1975 to 2006; 21 were prospective studies, 64 were retrospective, and 81 were either class 4 evidence (case series, n?=?70) or review articles (n?=?11). Citations ranged from 65 to 193 (mean of 90); average adjusted citation count per year was 4.5. The 50 most cited articles from 2002 to 2012 appeared in Child’s Nervous System, Pediatric Neurosurgery, and JNS: Pediatrics. Four were prospective studies, 25 were retrospective, and 38 of the total (76 %) were either class 4 evidence (n?=?24) or review articles (n?=?14). Citations ranged from 41 to 125 (mean of 54); average adjusted citation count per year was 6.3.

Conclusion

An original paper in pediatric neurosurgery having a total citation count of 50 or more, and an average citation count of 5 per year or more can be considered a high impact publication.