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OBJECTIVE Venous thromboembolism (VTE) can cause significant morbidity and mortality in hospitalized patients, and may disproportionately occur in patients with limited mobility following spinal trauma. The authors aimed to characterize the epidemiology and clinical predictors of VTE in pediatric patients following traumatic spinal injuries (TSIs). METHODS The authors conducted a retrospective cohort analysis of children who experienced TSI, including spinal fractures and spinal cord injuries, encoded within the National Trauma Data Bank from 2011 to 2014. RESULTS Of the 22,752 pediatric patients with TSI, 192 (0.8%) experienced VTE during initial hospitalization. Proportionally, more patients in the VTE group (77%) than in the non-VTE group (68%) presented following a motor vehicle accident. Patients developing VTE had greater odds of presenting with moderate (adjusted odds ratio [aOR] 2.6, 95% confidence interval [CI] 1.4–4.8) or severe Glasgow Coma Scale scores (aOR 4.3, 95% CI 3.0–6.1), epidural hematoma (aOR 2.8, 95% CI 1.4–5.7), and concomitant abdominal (aOR 2.4, 95% CI 1.8–3.3) and/or lower extremity (aOR 1.5, 95% CI 1.1–2.0) injuries. They also had greater odds of being obese (aOR 2.9, 95% CI 1.6–5.5). Neither cervical, thoracic, nor lumbar spine injuries were significantly associated with VTE. However, involvement of more than one spinal level was predictive of VTE (aOR 1.3, 95% CI 1.0–1.7). Spinal cord injury at any level was also significantly associated with developing VTE (aOR 2.5, 95% CI 1.8–3.5). Patients with VTE stayed in the hospital an adjusted average of 19 days longer than non-VTE patients. They also had greater odds of discharge to a rehabilitative facility or home with rehabilitative services (aOR 2.6, 95% CI 1.8–3.6). CONCLUSIONS VTE occurs in a low percentage of hospitalized pediatric patients with TSI. Injury severity is broadly associated with increased odds of developing VTE; specific risk factors include concomitant injuries such as cranial epidural hematoma, spinal cord injury, and lower extremity injury. Patients with VTE also require hospital-based and rehabilitative care at greater rates than other patients with TSI.

To elucidate the pathogenesis of vein of Galen malformations (VOGMs), the most common and severe congenital brain arteriovenous malformation, we performed an integrated analysis of 310 VOGM proband-family exomes and 336,326 human cerebrovasculature single-cell transcriptomes. We found the Ras suppressor p120 RasGAP (RASA1) harbored a genome-wide significant burden of loss-of-functionde novovariants (p=4.79×10-7). Rare, damaging transmitted variants were enriched in Ephrin receptor-B4 (EPHB4) (p=1.22×10-5), which cooperates with p120 RasGAP to limit Ras activation. Other probands had pathogenic variants inACVRL1,NOTCH1,ITGB1, andPTPN11.ACVRL1variants were also identified in a multi-generational VOGM pedigree. Integrative genomics defined developing endothelial cells as a key spatio-temporal locus of VOGM pathophysiology. Mice expressing a VOGM-specificEPHB4kinase-domain missense variant exhibited constitutive endothelial Ras/ERK/MAPK activation and impaired hierarchical development of angiogenesis-regulated arterial-capillary-venous networks, but only when carrying a “second-hit” allele. These results illuminate human arterio-venous development and VOGM pathobiology and have clinical implications.

Introduction: An extension of the dermoid cyst below the nasal bone has been identified in 10% of patients in a large series of nasal dermoid cysts, but these are generally easily identifiable and connected to the tract. To date, no previous reports have documented a case with intraosseous dermoid cyst which was completely hidden in the nasal bone. Case Presentation: An 8 year-old previously healthy female was initially found to have a small pit on her nasal dorsum. The lesion developed local infection and she was initially treated with antibiotics two years prior to the current presentation. The lesion was diagnosed as a dermal sinus tract, and surgical removal was conducted at an outside hospital. In retrospect the pre-operative work-up imaging showed an occult intraosseous nasal bone extension, however, this was not appreciated at the initial surgery. She experienced repeat infections and underwent a second surgery with exploration under the nasal bones, however, the patient experienced recurrent postoperative local infections. The family presented to our institution for a second opinion. Our images interestingly illustrate the nasal dermoid cyst extending into the nasal bone at the nasofrontal junction without detectable extraosseous sub-nasal bone extension on the imaging. The patient proceeded with a third surgery for complete removal of the lesion via an extended vertical nasal incision. The nasal bones were removed in their entirety, the occult dermoid cyst with a small tract was located in the nasal bones and the undersurface of the bones were completely debrided. No intracranial extension was observed after careful investigation of the skull base. Particulate corticocancellous bone was used with fibrin sealant to reconstruct the defect. The nasal bones were then replaced. The pathology results were consistent with a dermoid cyst. The post-operative course was uncomplicated and she has not had a recurrence after the third surgery. Discussion/Conclusion: This case, despite an exploration under the nasal bones, initially received incomplete resection and experienced multiple infections because of failure to appreciate the portion hidden in the nasal bones. Our case was successfully treated with ostectomy of nasal bones without recurrence and complications. This procedure allows unobstructed visualization of the entire cyst leading to the complete removal of the lesion. This is an instructive case to show that portions of the cyst may remain hidden and lead to recurrent infection, and complete resection with sufficient exposure of the entire lesion is needed to successfully treat this condition.

Many patients with presumed idiopathic scoliosis are found to have Chiari I malformation (CM-I) on MRI. The objective of this study is to report on scoliosis progression in CM-I with no syringomyelia. A retrospective review of patients with scoliosis and CM-I was conducted from 1997 to 2015. Patients with syringomyelia and/or non-idiopathic scoliosis were excluded. Clinical and radiographic characteristics were recorded at presentation and latest follow-up. CM-I was defined as the cerebellar tonsil extending 5 mm or more below the foramen magnum on MRI. Thirty-two patients (72% female) with a mean age of 11 years (range 1–16) at scoliosis diagnosis were included. The average initial curve was 30.3° ± SD 16.3. The mean initial Chiari size was 9.6 mm SD ± 4.0. Fifteen (46.9%) experienced Chiari-related symptoms, and three (9%) patients underwent Posterior Fossa Decompression (PFD) to treat these symptoms. 10 (31%) patients went on to fusion, progressing on average 13.6° (95% CI 1.6–25.6°). No association was detected between decompression and either curve progression or fusion (p = 0.46, 0.60). For those who did not undergo fusion, curve magnitude progressed on average 1.0° (95% CI − 4.0 to 5.9°). There was no association between age, Chiari size, presence of symptoms, initial curve shape, or bracing treatment and fusion. Patients with CM-I and scoliosis may not require surgical treatment, including PFD and fusion. Scoliosis curvature stabilized in the non-surgical population at an average progression of 1.0°. These results suggest that CM-I with no syringomyelia has minimal effect on scoliosis progression.

Background Tranexamic acid (TXA) reduces blood loss and transfusion in paediatric craniosynostosis surgery. The hypothesis is that low-dose TXA, determined by pharmacokinetic modelling, is non-inferior to high-dose TXA in decreasing blood loss and transfusion in children. Methods Children undergoing craniosynostosis surgery were enrolled in a two-centre, prospective, double-blind, randomised, non-inferiority controlled trial to receive high TXA (50 mg kg−1 followed by 5 mg kg−1 h−1) or low TXA (10 mg kg−1 followed by 5 mg kg−1 h−1). Primary outcome was blood loss. Low dose was determined to be non-inferior to high dose if the 95% confidence interval (CI) for the mean difference in blood loss was above the non-inferiority margin of –20 ml kg−1. Secondary outcomes were transfusion, TXA plasma concentrations, and biological markers of fibrinolysis and inflammation. Results Sixty-eight children were included. Values were non-inferior regarding blood loss (39.4 [4.4] vs 40.3 [6.2] ml kg−1 [difference=0.9; 95% CI: –14.2, 15.9]) and blood transfusion (21.3 [1.6] vs 23.6 [1.5] ml kg−1 [difference=2.3; 95% CI: –2.1, 6.7]) between high-dose (n=32) and low-dose (n=34) groups, respectively. The TXA plasma concentrations during surgery averaged 50.2 (8.0) and 29.6 (7.6) μg ml−1. There was no difference in fibrinolytic and inflammatory biological marker concentrations. No adverse events were observed. Conclusions Tranexamic acid 10 mg kg−1 followed by 5 mg kg−1 h−1 is not less effective than a higher dose of 50 mg kg−1 and 5 mg kg−1 h−1 in reducing blood loss and transfusion in paediatric craniosynostosis surgery. Clinical trial registration NCT02188576.

OBJECTIVEThe aim of this study was to retrospectively review, from a single busy pediatric neurosurgical service, a consecutive series of patients who had undergone surgery for a simple tethered spinal cord, which was defined by a thickened or fatty filum terminale with a normal conus. The hope was to contribute to benchmark data regarding the expected frequency of surgery for this condition.METHODSThe authors reviewed the electronic medical records of every patient with diagnosed simple tethered spinal cord, defined on spinal MRI as a thickened (> 2 mm in diameter) or fatty filum terminale, and who had undergone primary filum section at Boston Children’s Hospital between 2005 and 2011.RESULTSA total of 208 patients met the study inclusion criteria. At the time of surgery, patients ranged in age from 0.4 to 19.8 years. One hundred forty-four (69%) patients were symptomatic with one or more of the following: bowel/bladder dysfunction, 94 (45%); neurological dysfunction, 49 (24%); scoliosis, 44 (21%); or back pain, 44 (21%). Sixty-four (31%) patients were asymptomatic and were operated on prophylactically when filum pathology was discovered during the course of a workup for clinical syndromes such as anorectal anomalies and/or suspicious cutaneous lesions. No patients in this series were operated on if they had normal MRI studies, defined as a conus tip no lower than L3 and no distal tethering lesion visualized. Over the study period, approximately 1000 major surgical cases were performed in the department every year, only 30 of which were simple detethering procedures, representing well under 5% of the service’s operative volume and approximately 5 cases per surgeon per year. Clinical follow-up, available at a postoperative interval of 6.6 ± 3.8 years, demonstrated that approximately 80% of patients symptomatic with bowel or bladder involvement or neurological dysfunction had improvement or relief of their symptoms and that none of the patients treated prophylactically experienced new-onset symptoms that could be related to spinal tethering.CONCLUSIONSSimple detethering procedures were relatively uncommon in an active, well-established pediatric neurosurgical service and represented less than 5% of the service’s total case volume per year with an average of 5 cases per surgeon per year. No patients with normal MRI studies were operated on during the study period.

The New England Neurosurgical Society (NENS) was founded in 1951 under the leadership of its first President (Dr. William Beecher Scoville) and Secretary-Treasurer (Dr. Henry Thomas Ballantine). The purpose of creating the NENS was to unite local neurosurgeons in the New England area; it was one of the first regional neurosurgical societies in America. Although regional neurosurgical societies are important supplements to national organizations, they have often been overshadowed in the available literature. Now in its 70th year, the NENS continues to serve as a platform to represent the needs of New England neurosurgeons, foster connections and networks with colleagues, and provide research and educational opportunities for trainees. Additionally, regional societies enable discussion of issues uniquely relevant to the region, improve referral patterns, and allow for easier attendance with geographic proximity. In this paper, the authors describe the history of the NENS and provide a roadmap for its future. The first section portrays the founders who led the first meetings and establishment of the NENS. The second section describes the early years of the NENS and profiles key leaders. The third section discusses subsequent neurosurgeons who steered the NENS and partnerships with other societies. In the fourth section, the modern era of the NENS and its current activities are highlighted.

Background: Sports-related cervical spine injuries (CSI) are devastating traumas that can result in permanent disability and death. However, there is a paucity of literature on catastrophic CSI sustained in young athletes who require surgical intervention. The objectives of this study were to review injury characteristics, management, and outcomes in pediatric patients who sustained an operative CSI during youth sports. Methods: This was a retrospective review of patients treated at a Level 1 pediatric trauma center for CSI (2004-2019). Children

ImportanceUse of postoperative antimicrobial prophylaxis is common in pediatric surgery despite consensus guidelines recommending discontinuation following incision closure. The association between postoperative prophylaxis use and surgical site infection (SSI) in children undergoing surgical procedures remains poorly characterized.ObjectiveTo evaluate whether use of postoperative surgical prophylaxis is correlated with SSI rates in children undergoing nonemergent surgery.Design, Setting, and ParticipantsThis is a multicenter cohort study using 30-day postoperative SSI data from the American College of Surgeons’ Pediatric National Surgical Quality Improvement Program (ACS NSQIP-Pediatric) augmented with antibiotic-use data obtained through supplemental medical record review from June 2019 to June 2021. This study took place at 93 hospitals participating in the ACS NSQIP-Pediatric Surgical Antibiotic Prophylaxis Stewardship Collaborative. Participants were children (ExposuresContinuation of antimicrobial prophylaxis beyond time of incision closure.Main Outcomes and MeasuresThirty-day postoperative rate of incisional or organ space SSI. Hierarchical regression was used to estimate hospital-level odds ratios (ORs) for SSI rates and postoperative prophylaxis use. SSI measures were adjusted for differences in procedure mix, patient characteristics, and comorbidity profiles, while use measures were adjusted for clinically related procedure groups. Pearson correlations were used to examine the associations between hospital-level postoperative prophylaxis use and SSI measures.ResultsForty thousand six hundred eleven patients (47.3% female; median age, 7 years) were included, of which 41.6% received postoperative prophylaxis (hospital range, 0%-71.2%). Odds ratios (ORs) for postoperative prophylaxis use ranged 190-fold across hospitals (OR, 0.10-19.30) and ORs for SSI rates ranged 4-fold (OR, 0.55-1.90). No correlation was found between use of postoperative prophylaxis and SSI rates overall (r = 0.13; P = .20), and when stratified by SSI type (incisional SSI, r = 0.08; P = .43 and organ space SSI, r = 0.13; P = .23), and surgical specialty (general surgery, r = 0.02; P = .83; urology, r = 0.05; P = .64; plastic surgery, r = 0.11; P = .35; otolaryngology, r = −0.13; P = .25; orthopedic surgery, r = 0.05; P = .61; and neurosurgery, r = 0.02; P = .85).Conclusions and RelevanceUse of postoperative surgical antimicrobial prophylaxis was not correlated with SSI rates at the hospital level after adjusting for differences in procedure mix and patient characteristics.

Background Little data exists on surgical outcomes of sports-related cervical spine injuries (CSI) sustained in children and adolescent athletes. This study reviewed demographics, injury characteristics, management, and operative outcomes of severe CSI encountered in youth sports. Methods Children below 18 years with operative sports-related CSI at a Level 1 pediatric trauma center were reviewed (2004 to 2019). All patients underwent morden cervical spine instrumentation and fusion. Clinical, radiographic, and surgical characteristics were analyzed. Results A total of 3231 patients (mean, 11.3±4.6 y) with neck pain were evaluated for CSI. Sports/recreational activities were the most common etiology in 1358 cases (42.0%). Twenty-nine patients (2.1%) with sports-related CSI (mean age, 14.5 y; range, 6.4 to 17.8 y) required surgical intervention. Twenty-five were males (86%). Operative CSI occurred in football (n=8), wrestling (n=7), gymnastics (n=5), diving (n=4), trampoline (n=2), hockey (n=1), snowboarding (n=1), and biking (n=1). Mechanisms were 27 hyperflexion/axial loading (93%) and 2 hyperextension injuries (7%). Most were cervical fractures (79%) and subaxial injuries (79%). Seven patients (24%) sustained spinal cord injury (SCI) and 3 patients (10%) cord contusion or myelomalacia without neurological deficits. The risk of SCI increased with age (P=0.03). Postoperatively, 2 SCI patients (29%) improved 1 American Spinal Injury Association Impairment Scale Grade and 1 (14%) improved 2 American Spinal Injury Association Impairment Scale Grades. Increased complications developed in SCI than non-SCI cases (mean, 2.0 vs. 0.1 complications; P=0.02). Bony fusion occurred in 26/28 patients (93%) after a median of 7.2 months (interquartile range, 6 to 15 mo). Ten patients (34%) returned to their baseline sport and 9 (31%) to lower-level activities. Conclusions The incidence of sports-related CSI requiring surgery is low with differences in age/sex, sport, and injury patterns. Older males with hyperflexion/axial loading injuries in contact sports were at greatest risk of SCI, complications, and permanent disability. Prevention campaigns, education on proper tackling techniques, and neck strength training are required in sports at high risk of hyperflexion/axial loading injury. Level of evidence Level III-retrospective cohort study.

OBJECTIVE Bilateral coronal craniosynostosis in Apert syndrome is traditionally managed with open cranial vault remodeling procedures like fronto-orbital advancement (FOA). However, as minimally invasive procedures gain popularity, limited data exist to determine their efficacy in this syndromic population. This study examines whether endoscopic strip craniectomy (ESC) is inferior to FOA in correcting head growth in patients with Apert syndrome. METHODS The authors conducted a retrospective review of children with Apert syndrome over a 23-year period. Postoperative head circumferences until 24 months of age were compared for patients treated with ESC versus FOA by using normative growth curves. Intraoperative and postoperative morbidity was compared between groups. RESULTS The median postoperative follow-up for the FOA (n = 14) and ESC (n = 16) groups was 40 and 28.5 months, the median age at operation was 12.8 and 2.7 months, and the median operative time was 285 and 65 minutes, respectively (p < 0.001). The FOA group had significantly higher rates of blood transfusion, ICU admission, and longer hospital length of stay (p < 0.01). There were no statistically significant differences in premature reossification rates, complications, need for further procedures, or complaints of asymmetry. Compared to normative growth curves, all patients in both groups had head circumferences comparable to or above the 85th percentile at last follow-up. CONCLUSIONS Children with Apert syndrome and bilateral coronal craniosynostosis treated with ESC experience early normalization of head growth and cephalic index that is not inferior to those treated with FOA. Longer-term assessments are needed to determine long-term aesthetic results and the correlation between head growth and neurocognitive development in this population.

Background: Sports-related cervical spine injuries (CSI) are devastating traumas with the potential for permanent disability. There is a paucity of literature on operative CSI sustained in youth athletes. Hypothesis/Purpose: The aims of this study aims were to review injury characteristics, surgical treatment, and outcomes of severe pediatric CSI encountered in youth sports. Methods: We reviewed children less than 18 years old with operative sports-related CSI at a pediatric Level 1 pediatric trauma center between 2004−2019. All cases underwent modern cervical spine instrumentation and fusion. SCI were stratified according to the American Spinal Injury Association Impairment Scale (ASIA). Clinical, radiographic, and surgical characteristics were compared between groups of patients with and without spinal cord injury (SCI). Results: Three thousand two hundred and thirty-one children (mean, 11.3y±4.6y) were evaluated for CSI at our institution during the 16-year period. The majority of traumas resulted from sports/recreational activities and were seen in 1365 cases (42.3%). Of these, 171/1365 patients (12.5%) were admitted and 29/1365 patients (2.1%) required surgical intervention (mean age, 14.5y±2.88y; range, 6.4y–17.8y). Sports included: eight football (28%), seven wrestling (24%), five gymnastics (17%), four diving (14%), two trampoline (7%), one hockey (3%), one snowboarding (3%), and one biking injury (3%). Mechanisms were 19 hyperflexion (65%), eight axial loading (28%), and two hyperextension injuries (7%). The majority of operative CSI were fractures (79%) and/or subaxial defects (72%). Seven patients (30%) sustained SCI and three patients (10%) spinal cord contusion or myelomalacia without neurologic deficits. The risk of SCI increased with age (15.8y vs. 14.4y; p=0.03) and axial loading mechanism (71% vs. 14%; p=0.003). Postoperatively, two SCI patients (29%) improved 1 ASIA Grade and one (14%) improved 2 ASIA Grades. Increased complications developed in SCI than patients without SCI (mean, 2.0 vs 0.1 complications; p=0.02). Clinical and radiographic fusion occurred in 24/26 patients (92%) with adequate follow-up (median, 32 months). Ten patients returned to their previous activity and nine to sports with a lower level of activity. Conclusion: The overall incidence of sports-related operative CSI is low. Age- and gender discrepancies exist, with male adolescent athletes most commonly requiring surgery. Hyperflexion injuries had a good prognosis; however, older males with axial loading CSI sustained in contact sports were at greatest risk of SCI, complications, and permanent disability. [Figure: see text][Table: see text][Table: see text]

OBJECTIVEFew studies describe long-term functional outcomes of pediatric patients who have undergone lumbar microdiscectomy (LMD) because of the rarity of pediatric disc herniation and the short follow-up periods. The authors analyzed risk factors, clinical presentation, complications, and functional outcomes of a single-institution series of LMD patients over a 19-year period.METHODSA retrospective case series was conducted of pediatric LMD patients at a large pediatric academic hospital from 1998 to 2017. The authors examined premorbid risk factors, clinical presentation, physical examination findings, type and duration of conservative management, indications for surgical intervention, complications, and postoperative outcomes.RESULTSOver the 19-year study period, 199 patients underwent LMD at the authors’ institution. The mean age at presentation was 16.0 years (range 12–18 years), and 55.8% were female. Of these patients, 70.9% participated in competitive sports, and among those who did not play sports, 65.0% had a body mass index greater than 25 kg/m2. Prior to surgery, conservative management had failed in 98.0% of the patients. Only 3 patients (1.5%) presented with cauda equina syndrome requiring emergent microdiscectomy. Complications included 4 cases of postoperative CSF leak (2.0%), 1 case of a noted intraoperative CSF leak, and 3 cases of wound infection (1.5%). At the first postoperative follow-up appointment, minimal or no pain was reported by 93.3% of patients. The mean time to return to sports was 9.8 weeks. During a mean follow-up duration of 8.2 years, 72.9% of patients did not present again after routine postoperative appointments. The total risk of reoperation was a rate of 7.5% (3.5% of patients underwent reoperation for the same level; 4.5% underwent adjacent-level decompression, and one patient [0.5%] ultimately underwent a fusion).CONCLUSIONSMicrodiscectomy is a safe and effective treatment for long-term relief of pain and return to daily activities among pediatric patients with symptomatic lumbar disc disease in whom conservative management has failed.

Study Design Retrospective case series. Objectives To describe the indications and outcomes of cervical fixation using modern instrumentation in a case series of pediatric Down syndrome (DS) patients. Summary of Background Data Cervical instability is the major cervical spine concern in children with DS. Although fixation techniques have advanced over the past quarter-century, the outcome of fixation with modern instrumentation for upper cervical instability in DS patients has not been thoroughly investigated. Methods We searched the orthopedic database at our institution for patients with a diagnosis of DS who had undergone a cervical spine fusion between 2006 and 2017. Patient demographics, diagnoses, surgical indications, surgical details, and complications were recorded. Preoperative imaging was reviewed to determine atlanto-dens intervals and spinal cord signal changes. Postoperative radiographs or CT scans were reviewed to determine union. Results Twelve DS patients met our inclusion criteria. The mean age at surgery was 9.3 years (range 3.8–18.8 years). Patients with secondary causes of instability included 7 patients with os odontoideum and 1 patient with a pars fracture. Three patients (25%) were identified on asymptomatic screening, with none of these having cord signal changes on magnetic resonance imaging (MRI). Modern implants (screws, plates, cages) were used in every patient in our series. The mean number of levels fused was 1.9 (range 1–5). The overall complication rate was 41.7% (5/12). Four patients required repeat surgery for nonunion. All patients with adequate radiographic follow-up demonstrated union (11/11, 100%). One patient was lost to follow-up. Conclusions Fixation for cervical instability is a critical component of the management of DS. A minority of patients receiving surgery were identified through asymptomatic screening. There was a high complication risk associated with surgery in our study; however, the addition of rigid fixation has lessened the complication rate compared with previous studies. Level of Evidence Level IV.

Introduction Traditionally, fluoroscopy and postoperative computed tomographic (CT) scans are used to evaluate screw position after pediatric cervical spine fusion. However, noncontained screws detected postoperatively can require revision surgery. Intraoperative O-arm is a 3-dimensional CT imaging technique, which allows intraoperative evaluation of screw position and potentially avoids reoperations because of implant malposition. This study's objective was to evaluate the use of intraoperative O-arm in determining the accuracy of cervical implants placed by a free-hand technique using anatomic landmarks or fluoroscopic guidance in pediatric cervical spine instrumentation. Methods A single-center retrospective study of consecutive examinations of children treated with cervical spine instrumentation and intraoperative O-arm from 2014 to 2018 was performed. In total, 44 cases (41 children, 44% men) with a mean age of 11.9 years (range, 2.1 to 23.5 y) were identified. Instability (n=16, 36%) and deformity (n=10, 23%) were the most frequent indications. Primary outcomes were screw revision rate, neurovascular complications caused by noncontained screws, and radiation exposure. Results A total of 272 screws were inserted (60 occipital and 212 cervical screws). All screws were evaluated on fluoroscopy as appropriately placed. Four screws (1.5%) in 4 cases (9%) were noncontained on O-arm imaging and required intraoperative revision. A mean of 7.7 levels (range, 5 to 13) were scanned. The mean CT dose index and dose-length product were 15.2±6.87 mGy and 212.3±120.48 mGy×cm. Mean effective dose was 1.57±0.818 mSv. There was no association between screw location and noncontainment (P=0.129). No vertebral artery injuries, dural injuries, or neurologic deficits were related to the 4 revised screws. Conclusions Intraoperative non-navigated O-arm is a safe and efficient method to evaluate screw position in pediatric patients undergoing cervical spine instrumentation. Noncontained screws were detected in 9% of cases (n=4). O-arm delivers low radiation doses, allows for intraoperative screw revision, and negates the need for postoperative CT scans after confirmation of optimal implant position. Level of evidence Level IV.

ObjectiveThe management of spinal aneurysmal bone cysts (ABCs) is complex and often requires multimodality therapy, including surgical intervention to stabilize the axial skeleton, and avoid neurologic injury or death. With en bloc resection, ABCs have a recurrence rate of 12%, which increases to >50% with subtotal resection. The use of doxycycline sclerotherapy has been reported to reduce the recurrence rate of non-spinal ABCs to 5% at >24 month follow-up. We retrospectively reviewed our institutional results for sodium tetradecyl sulfate (STS)/doxycycline sclerotherapy and surgical intervention for spinal ABCs, to assess our treatment paradigm for these tumors and inform our future approach to these lesions.MethodsThree cervical, two thoracic and two lumbar spine ABCs were treated in seven patients with spine-exclusive disease at our institution from 2011 to the present. The most common presenting complaint was pain. Each patient was retrospectively reviewed for clinical symptomology, number of treatments, technique and clinical follow-up. Qualitative assessment of improvement was based on the most recent clinical evaluation.ResultsThe cohort underwent a mean of three treatment sessions (range 2–15). All were treated with STS and/or doxycycline. Five patients underwent surgical intervention at some point, either before or following sclerotherapy. After the last sclerotherapy session, four patients reported stable or improved pain symptoms, while two reported progressive pain that required surgical intervention for that indication. One patient, who underwent both multiple rounds of sclerotherapy and surgical resection, died due to acute on chronic cervical spine collapse with cord compression and inability to control disease.ConclusionWe report our experience in the treatment of spinal column ABCs. Stabilization or improvement in pain was seen in four patients, while the remainder had progressive disease. Our multidisciplinary approach allows patients to receive the most appropriate treatment at presentation and thereafter, for symptom amelioration or spinal stability. Important future goals are to quantitatively assess changes in symptoms over time and to incorporate a reproducible radiographic endpoint for the assessment of treatment efficacy.

Retrospective case series.To report operative outcomes of contemporary surgical treatment of spondylolisthesis in the pediatric population.Surgical treatment of developmental spondylolisthesis is controversial, with limited data on complication and reoperation rates.A retrospective study followed pediatric patients with either L5-S1 high-grade spondylolisthesis (HGS) or L5-S1 symptomatic low-grade spondylolisthesis (LGS) for a minimum of two years. All patients underwent a contemporary, single-stage decompression, partial reduction, and posterior instrumented fusion (DRPF) or in situ stabilization by a combined orthopedic and neurosurgeon team at a single institution during 2005-2015. Clinical examination and radiographic data were collected preoperatively and at discharge, 1 year, 2 years, and terminal visit (defined as the last follow-up at2 years).Thirty-four patients (79% HGS), mean (±standard deviation) age at surgery 13.5 (±3.3) years, were followed for 4.8 (±2.3) years. The patients who underwent DRPF (n = 26) had mean lumbosacral angle increase from 79.8° (±20.8) to 92.5° (±16.1) (p.001) and mean listhesis reduce from 63.2% (±21.9) to 26.0% (±20.1) (p.001). Preoperatively, 18 (53%) had neurologic symptoms. At one- and two-year follow-up, new or residual neurologic symptoms were present in four patients (12%) (p.001). Postoperative symptoms were not significantly related to amount of reduction. Sixteen (47%) underwent reoperation at an average of 24.8 months, 10 for planned prominent instrumentation removal, and 6 for true complications.Surgical reduction and decompression of spondylolisthesis in the pediatric population restores spinopelvic alignment. We found no evidence that a greater amount of reduction was associated with a higher incidence of postoperative complications. However, patients should be advised that prominent instrumentation may require future removal. Although previous reports suggest complication rates and permanent neurologic sequelae in up to 20% after operative treatment of spondylolisthesis, our results suggest that a contemporary approach with a two-surgeon team may provide improved results.Level IV.

Comparative effectiveness research is needed to optimize treatment of unilateral coronal synostosis. This study compares perioperative morbidity, ophthalmic, and aesthetic outcomes of patients with nonsyndromic unilateral coronal synostosis treated by endoscopic suturectomy or fronto-orbital advancement.From 2004 to 2015, patients with unilateral coronal synostosis were reviewed and data recorded for operative details, reoperations, and aesthetic results using the Whitaker classification, severity of strabismus, and need for surgical correction. Categorical data were analyzed using the Fisher's exact test and continuous data were analyzed using the Wilcoxon rank sum test.Ninety-four patients were treated with endoscopic suturectomy (n = 60) or fronto-orbital advancement (n = 34). Median age at follow-up was 3.5 years (range, 1 to 9 years) for endoscopic suturectomy and 5.0 years (range, 2 to 11 years) for fronto-orbital advancement (p = 0.06). The endoscopic suturectomy group had a lower operative time (42 minutes versus 216 minutes), length of stay (1 day versus 4 days), blood loss (25 cc versus 260 cc), and transfusion rate (0 percent versus 88 percent). Two patients treated with fronto-orbital advancement required secondary intervention for intracranial pressure. Thirty-one percent (16 of 52) of the endoscopic suturectomy group and 65 percent (19 of 29) of the fronto-orbital advancement group developed clinically significant strabismus requiring surgical repair (p = 0.002). In the endoscopic suturectomy group, 88 percent (50 of 57) were Whitaker class I and 5 percent were class II. In the fronto-orbital advancement group, 41 percent (14 of 34) were class I and 44 percent class II. Need for bony revision (two of 57 versus three of 34) and need for secondary cranial procedure (two of 57 versus two of 34) were similar following endoscopic suturectomy and fronto-orbital advancement.For treatment of unilateral coronal synostosis, endoscopic suturectomy is associated with lower morbidity and comparable aesthetics. Patients treated with endoscopic suturectomy are half as likely to require strabismus surgery compared with those treated with fronto-orbital advancement.Therapeutic, III.

Orbital asymmetry in unicoronal synostosis impacts craniofacial appearance and can potentiate functional visual disturbances, such as strabismus. Surgical treatment aims to normalize overall cranial morphology, including that of the orbits. The purpose of this study was to compare postoperative changes in orbital asymmetry following 2 common procedures.Preoperative and 1-year postoperative computed tomography scans for patients with isolated, nonsyndromic unicoronal synostosis treated from 2007 to 2012, at 2 academic institutions were analyzed. Only patients treated by endoscopic suturectomy and postoperative helmeting or bilateral fronto-orbital advancement were included. Orbital index, depth, and volume asymmetry were determined for each patient both pre- and 1-year postoperatively. Student's t-tests were used to compare pre- and postoperative asymmetries within each treatment group. Regression analyses were used to examine postoperative change in asymmetry between treatment groups.Scans from 12 patients treated by fronto-orbital advancement and 23 treated by endoscopic suturectomy were analyzed. Differences between synostotic and nonsynostotic orbital index, depth, and volume were statistically significant both pre- and postoperatively. Statistically significant postoperative improvements in asymmetry were observed for orbital index, depth, and volume following suturectomy. Regression analysis indicated that the amount of pre- to postoperative change in all measures of asymmetry did not depend on surgical technique. Residual asymmetry following both procedures was apparent at 1 year postoperatively.Orbital asymmetry is improved, but not resolved following both fronto-orbital advancement and endoscopic suturectomy. Degree of improvement in symmetry is independent of surgical technique used.

Background Endoscopic suturectomy and helmeting represents a successful first-line surgical treatment for bilateral coronal craniosynostosis. Its effect on cranial morphology has not been previously described. Methods Patients were identified who had bilateral coronal craniosynostosis treated with endoscopic suturectomy and postoperative helmeting at Boston Children's Hospital between 2005 and 2013 and who underwent preoperative and postoperative computed tomography. Two normative patient populations were identified from our trauma registry with computed tomographic scans completed at the same age as our pretreatment and posttreatment scans. Craniometric indices were used to quantify the effect of treatment. Results Twenty-seven patients were identified who underwent bilateral coronal suturectomy. Twelve patients had preoperative and postoperative computed tomographic studies. Eight patients (66.7 percent) were syndromic. The average ages for preoperative and postoperative computed tomographic scan were 1.1 months (range, 0.03 to 2.6 months) and 19.6 months (range, 10.8 to 37.5 months). Thirteen patients with an average age of 1.1 months (range, 0.5 to 1.6 months) were identified as a preoperative control group. Fourteen patients with an average age of 18.5 months (range, 15.5 to 22.9 months) were identified as a postoperative control group. The anterior cranial height stabilized with treatment and the anterior cranial base length increased. The anterior cranial height-to-anterior cranial base length ratio significantly decreased with treatment (p = 0.128). Frontal bossing normalized with endoscopic suturectomy (craniosynostosis versus control: preoperatively, p = 0.001; postoperatively, p = 0.8). Cephalic indices also normalized with treatment (craniosynostosis versus control: preoperatively, p = 0.02; postoperatively, p = 0.13). No cases of hydrocephalus were observed. Conclusion Endoscopic suturectomy and helmeting improves anterior turricephaly and corrects frontal bossing and brachycephaly in patients with bilateral coronal craniosynostosis. Clinical question/level of evidence Therapeutic, IV.

OBJECTIVE Postoperative routine imaging is common after pediatric ventricular shunt revision, but the benefit of scanning in the absence of symptoms is questionable. In this study, the authors aimed to assess how often routine scanning results in a change in clinical management after shunt revision. METHODS The records of a large, tertiary pediatric hospital were retrospectively reviewed for all consecutive cases of pediatric shunt revision between July 2013 and July 2018. Postoperative imaging was classified as routine (i.e., in the absence of symptoms, complications, or other direct indications) or nonroutine. Reinterventions within 30 days were assessed in these groups. RESULTS Of 387 included shunt revisions performed in 232 patients, postoperative imaging was performed in 297 (77%), which was routine in 244 (63%) and nonroutine in 53 (14%). Ninety revisions (23%) underwent any shunt-related procedure after postoperative imaging, including shunt reprogramming (n = 35, 9%), shunt tap (n = 10, 3%), and a return to the operating room (OR; n = 58, 15%). Of the 244 cases receiving routine imaging, 241 did not undergo a change in clinical management solely based on routine imaging findings. The remaining 3 cases returned to the OR, accounting for 0.8% (95% CI 0.0%–1.7%) of all cases or 1.2% (95% CI 0.0%–2.6%) of cases that received routine imaging. Furthermore, 27 of 244 patients in this group returned to the OR for other reasons, namely complications (n = 12) or recurrent symptoms (n = 15); all arose after initial routine imaging. CONCLUSIONS The authors found a low yield to routine imaging after pediatric shunt revision, with only 0.8% of cases undergoing a change in management based on routine imaging findings without corresponding clinical findings. Moreover, routine imaging without abnormal findings was no guarantee of an uneventful postoperative course. Clinical monitoring can be considered as an alternative in asymptomatic, uncomplicated patients.

Sagittal craniosynostosis is the most common form of nonsyndromic craniosynostosis.1 In unaffected patients without craniosynostosis, the morphology of the cranium is related to the underlying functional effects of the brain and dura: bones grow and head shape forms in the presence of patent cranial sutures.2 With premature sutural fusion, cranial morphology takes on characteristic shapes corresponding to the particular fused suture(s). Children with sagittal craniosynostosis exhibit varying degrees of scaphocephaly, which may include frontal bossing, an anteriorly displaced vertex, narrowed bi-parietal distance, and a bullet-shaped occiput.3 The effect on head shape is more significant when fusion occurs early in development.2,4 The head circumference typically increases as a result of excessive anomalous anterior-posterior skull growth.5 In all cases of craniosynostosis, surgical treatment is indicated for elevated intracranial pressure (ICP) and/or substantial alterations in normal anatomy and appearance. The risk of elevated ICP in single suture, nonsyndromic sagittal synostosis is estimated to be 10%–20%,6 but reports are inconclusive and often contradictory. Data regarding the probability of neurodevelopmental delay associated with the condition are likewise inconsistent; some suggest up to a 5-fold increased risk for developmental delays and learning deficits in infancy..7–9 Although there are numerous approaches in treating isolated sagittal craniosynostosis, there is currently no consensus among craniofacial surgeons or pediatric neurosurgeons regarding the optimal approach.10,11 Furthermore, the decision whether to operate at all in nonsyndromic patients with sagittal synostosis relies largely on intuition and individual surgical judgment, without objective data to clarify clinical management. Others have investigated similar decision-making processes for other forms of craniosynostosis.12 The goal of this study was to identify factors that prompt in cases of sagittal synostosis surgical intervention. Using a custom-engineered 3D design framework, we developed a novel survey tool to assess practice patterns among pediatric neurosurgeons and pediatric craniofacial surgeons around the world.

Endoscopic surgery for single-suture synostosis has been widely adopted since its introduction over 2 decades ago. Its role in syndromic synostosis is emerging, both as a primary treatment and as the first stage in a multimodal treatment paradigm aimed at preventing the vexing turribrachycephaly seen in these children. In this video, the authors review the technique for endoscopic treatment of bilateral coronal craniosynostosis and discuss both the benefits and some of the concerns to look out for over time. They also review the long-term outcomes in a consecutive series of patients treated in this fashion. The video can be found here: https://vimeo.com/516351348.

OBJECTIVE Cervical traction in pediatric patients is an uncommon but invaluable technique in the management of cervical trauma and deformity. Despite its utility, little empirical evidence exists to guide its implementation, with most practitioners employing custom or modified adult protocols. Expert-based best practices may improve the care of children undergoing cervical traction. In this study, the authors aimed to build consensus and establish best practices for the use of pediatric cervical traction in order to enhance its utilization, safety, and efficacy. METHODS A modified Delphi method was employed to try to identify areas of consensus regarding the utilization and implementation of pediatric cervical spine traction. A literature review of pediatric cervical traction was distributed electronically along with a survey of current practices to a group of 20 board-certified pediatric neurosurgeons and orthopedic surgeons with expertise in the pediatric cervical spine. Sixty statements were then formulated and distributed to the group. The results of the second survey were discussed during an in-person meeting leading to further consensus. Consensus was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). RESULTS After the initial round, consensus was achieved with 40 statements regarding the following topics: goals, indications, and contraindications of traction (12), pretraction imaging (6), practical application and initiation of various traction techniques (8), protocols in trauma and deformity patients (8), and management of traction-related complications (6). Following the second round, an additional 9 statements reached consensus related to goals/indications/contraindications of traction (4), related to initiation of traction (4), and related to complication management (1). All participants were willing to incorporate the consensus statements into their practice. CONCLUSIONS In an attempt to improve and standardize the use of cervical traction in pediatric patients, the authors have identified 49 best-practice recommendations, which were generated by reaching consensus among a multidisciplinary group of pediatric spine experts using a modified Delphi technique. Further study is required to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.

Objective: This case report aims to assess a potential association between cranial asymmetry, brain deformation, and associated developmental delay. Study Design: Two infants born at ≥37 weeks pursuing cranial orthotic treatment for severe Deformational Plagiocephaly (DP) (cranial vault asymmetry index >8.75%) underwent developmental assessment using Mullen Scales of Early Learning (MSEL) and non-sedated brain structural and diffusion magnetic resonance imaging (MRI) prior to and following cranial orthotic treatment. Results: In both infants with DP, tractography results revealed alterations in the white matter pathways of the brain. Both infants also had low to low/normal visual receptivity and fine motor skills. After cranial orthotic treatment, cranial asymmetry improved but did not completely resolve, tractography demonstrated a change toward normalized white matter pathways, and visual receptivity and fine motor skills improved. Conclusions: These preliminary findings suggest a potential link between DP, altered brain structures, and developmental assessment. Further investigation with a larger sample is warranted.

OBJECTIVES Pediatric neurocritical care as a conceptual service is relatively new, and implementation of such specialized services may improve outcomes for children with disorders of the brain or spinal cord. How many pediatric neurocritical care services currently exist in the United States, and attitudes about such a service are unknown. DESIGN Web-based survey, distributed by e-mail. SETTING Survey was sent to PICU Medical Directors and Program Directors of Pediatric Neurosurgery fellowship and Child Neurology residency programs. PATIENTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 378 surveys were distributed; 161 respondents representing 128 distinct hospitals completed the survey (43% response rate). Thirty-five percent (45/128) reported having a pediatric neurocritical care service. The most common type of service used a consultation model (82%; 32/39 responses). Other types of services were intensivist-led teams in the PICU (five hospitals) and dedicated PICU beds (two hospitals). Hospital characteristics associated with availability of pediatric neurocritical care services were level 1 trauma status (p = 0.017), greater numbers of PICU beds (χ [6, n = 128] = 136.84; p < 0.01), and greater volume of children with pediatric neurocritical care conditions (χ [3, n = 128] = 20.16; p < 0.01). The most common reasons for not having a pediatric neurocritical care service were low patient volume (34/119 responses), lack of subspecialists (30/119 responses), and lack of interest by PICU faculty (25/119 responses). The positive impacts of a pediatric neurocritical care service were improved interdisciplinary education/training (16/45 responses), dedicated expertise (13/45 responses), improved interservice communication (9/45 responses), and development/implementation of guidelines and protocols (9/45 responses). The negative impacts of a pediatric neurocritical care service were disagreement among consultants (2/45 responses) and splitting of the PICU population (2/45 responses). CONCLUSIONS At least 45 specialized pediatric neurocritical care services exist in the United States. Eighty percent of these services are a consultation service to the PICU. Hospitals with level 1 trauma status, greater numbers of PICU beds, and greater numbers of patients with pediatric neurocritical care conditions were associated with the existence of pediatric neurocritical care as a clinical service.

OBJECTIVEComparative effectiveness studies are needed for analyzing the clinical outcomes of treatment of sagittal craniosynostosis (SC) with endoscopic suturectomy (ES) or cranial vault remodeling (CVR).METHODSFrom 2004–2015, patients were consecutively reviewed and data recorded for operative details and complications. Cranial growth was measured by head circumference percentile (HCP) and cranial index (CI) Z-score. Aesthetic outcomes were compared using the Whitaker classification.RESULTSA total of 207 patients with nonsyndromic SC were treated with ES (n = 187) or CVR (n = 20). The ES group had a lower median operative duration (45 vs 195 minutes), length of stay (1 vs 3 days), and transfusion rate (2% vs 85%; p < 0.0001). Median age at follow-up was 3.0 years (interquartile range [IQR] 2.5–4.5, ES) and 3.9 years (IQR 2–5, CVR; p = 0.12). In both groups, HCP gradually decreased during a 3-year follow-up (p = 0.282). CI Z-scores were initially more favorable in the ES group (p < 0.05); 3 years following surgical intervention, Z-scores were equal between groups (p = 0.392). One nonsyndromic patient treated with ES (0.5%) demonstrated reossification and required secondary expansion. Most patients were Whitaker class I (99% of ES, 95% of CVR); 5% of CVR patients were class II and 1% of ES patients were class III. Four syndromic patients presented without clear evidence of a syndrome, were treated by ES, and subsequently required secondary expansion for raised intracranial pressure.CONCLUSIONSES is an effective treatment for nonsyndromic SC with comparable head growth, aesthetic outcomes, and less morbidity relative to CVR. In the absence of a syndrome, secondary cranial expansion following ES is rarely required.

Background The use of modern rigid instrumentation in pediatric cervical fusions decreases the risk of implant-related complications, both acute and long term. However, previous studies have indicated that acute implant-related issues still occur in the adult population. Reports of pediatric acute implant complications, occurring within 3 months of surgery, are under-represented in the literature. The purpose of this study is to document the prevalence of acute implant-related complications in a pediatric cervical fusion population. Methods A retrospective review of instrumented cervical fusions from August 2002 to December 2018 was conducted. Acute implant-related complications were defined as malposition, fracture, or disengagement of cervical instrumentation, including screws, rods, and plates, within 90 days of surgery. Results A total of 166 cases were included (55% male individuals) with an average age at surgery of 12.5 years (SD, ±5.28). Acute implant-related complications occurred in 5 patients (3%). All 5 patients had a syndromic diagnosis: Loeys-Dietz (n=1), osteopetrosis (n=1), neurofibromatosis (n=1), trisomy 20 (n=1), and achondroplasia (n=1). One case involved asymptomatic screw protrusion, 1 case lateral mass screw pull-out, 2 more had screw-rod disengagement, and the last experienced dislodgement of the anterior plate. The median time until the presentation was 25 days (range, 1 to 79 d). All patients (n=5) required surgical revision. Conclusions This case series suggests that the overall incidence of acute cervical implant failure is low. However, failure is more likely to occur in patients with underlying syndromes compared with patients with different etiologies. Intraoperative use of 3-dimensional computed tomography imaging is recommended to evaluate the screw position and potentially avoid later surgery.

OBJECTIVEPatients with trisomy 21 (Down syndrome; DS) often have atlantoaxial instability (AAI), which, if severe, causes myelopathy and neurological deterioration. Children with DS and AAI who undergo cervical spine fusion have a high rate of nonunion requiring revision surgery. Recombinant human bone morphogenetic protein–2 (rhBMP-2) is a TGF-β growth factor that is used to induce bone formation in spine fusion. Although previous studies in the adult population have reported no reduction in pseudarthrosis rates with the use of rhBMP-2, there is a lack of literature in the pediatric DS population. This study describes the use of rhBMP-2 in children with DS and AAI during revision to treat nonunion.METHODSA retrospective review of a cervical spine fusion database (n = 175) was conducted. This database included all cervical spine fusions using modern instrumentation at the authors’ institution from 2002 to 2019. Patients with DS who underwent a revision utilizing rhBMP-2 were included in the study. The number of prior fusions, use of rhBMP-2 in fusions, length of stay, halo use, and surgical data were collected. Postoperative complications and length of follow-up were also recorded.RESULTSEight patients (75% female) met the inclusion criteria. The average age at revision with rhBMP-2 was 11 years (range 3–19 years). All patients were diagnosed with nonunion after an initial cervical fusion. All revisions were posterior fusions of C1–2 (n = 2) or occiput to cervical (n = 6). All revisions included implant revisions, iliac crest bone grafting, and rhBMP-2 use. One patient required irrigation and debridement of an rhBMP-induced seroma. Another patient required return to the operating room to repair a dural tear. There were no neurological, infectious, airway, or implant-related complications. Revision utilizing rhBMP-2 achieved fusion in 100% (n = 8) of patients. The average length of follow-up was 42.6 months. All patients demonstrated solid fusion mass on the last radiograph.CONCLUSIONSThis is the first case series reporting the successful use of rhBMP-2 to facilitate cervical spine fusion in patients with DS after previous nonunion. In addition, few rhBMP-2–related postoperative complications occurred.

OBJECTIVEUnilateral lambdoid synostosis is the premature fusion of a lambdoid suture or sutures and represents the least common form of craniosynostosis, occurring in 1 in 40,000 births. Cranial vault remodeling (CVR) and endoscopic suturectomy with helmet therapy (ES) are surgical approaches that are used to allow for normal brain growth and improved craniofacial symmetry. The authors conducted a comparative outcomes analysis of patients with lambdoid synostosis undergoing either CVR or ES.METHODSThe authors conducted a retrospective consecutive cohort study of patients with nonsyndromic lambdoid synostosis who underwent surgical correction identified from a single-institution database of patients with craniosynostosis seen between 2000 and 2018. Cranial growth was measured in head circumference percentile and z score.RESULTSNineteen patients (8 female and 11 male) with isolated unilateral lambdoid synostosis were identified (8 right and 11 left). Six underwent CVR and 13 underwent ES. No statistically significant differences were noted between surgical groups with respect to suture laterality, the patient’s sex, and length of follow-up. Patients treated with ES presented and underwent surgery at a younger age than those treated with CVR (p = 0.0002 and p = 0.0001, respectively). Operating and anesthesia time, estimated blood loss, and ICU and total hospital days were significantly lower in ES (all p < 0.05). No significant differences were observed in pre- and postoperative head circumference percentiles or z scores between groups up to 36 months postoperatively. No patients required reoperation as of last follow-up.CONCLUSIONSEndoscopic management of lambdoid synostosis is safe, efficient, and efficacious in terms of intraoperative and long-term cranial growth outcomes when compared to CVR. The authors recommend this minimally invasive approach as an option for correction of lambdoid synostosis in patients presenting early in their course.

To evaluate patient outcomes of minimally invasive endoscopic strip craniectomy (ESC) for craniosynostosis.This is a retrospective cohort analysis (2004-2018) of 500 consecutive infants with craniosynostosis treated by ESC with orthotic therapy at a single center. Operative outcomes included transfusions, complications, and reoperations as well as head circumference change based on World Health Organization percentiles. Multivariable logistic regression was used to identify risk factors associated with blood transfusion. Paired t tests were used for within-patient comparisons and Fisher exact test to compare syndromic and nonsyndromic subgroups.ESC was associated with low rates of blood transfusion (6.6%), complications (1.4%), and reoperations (3.0%). Risk factors for transfusion included syndromic craniosynostosis (P = .01) and multiple fused sutures (P = .02). Median surgical time was 47 minutes, and hospital length of stay 1 day. Transfusion and reoperation rates were higher among syndromic patients (both P .001). Head circumference normalized by 12 months of age relative to World Health Organization criteria in infants with sagittal, coronal, and multisuture craniosynostosis (all P .001).ESC is a safe, effective, and durable correction of infantile craniosynostosis. ESC can achieve head growth normalization with low risks of blood transfusion, complications, or reoperation. Early identification of craniosynostosis in the newborn period and prompt referral by pediatricians allows families the option of ESC vs larger and riskier open reconstruction procedures.

Retrospective case series. The objective was to assess the long-term outcomes on scoliosis following Chiari-I (CM-I) decompression in patients with CM-I and syringomyelia (SM). A secondary objective was to identify risk factors of scoliosis progression. The association between CM-I with SM and scoliosis is recognized, but it remains unclear if CM-I decompression alters the long-term evolution of scoliosis in patients with associated syringomyelia. A retrospective review of children with scoliosis, CM-I, and SM during 1997–2015 was performed. Congenital, syndromic, and neuromuscular scoliosis were excluded. Clinical and radiographic characteristics were recorded at presentation, pre-decompression, after 1-year, and latest follow-up. A scale to measure syringomyelia area on MRI was used to evaluate SM changes post-decompression. 65 children with CM-I, SM, and scoliosis and a mean age of 8.9 years (range 0.7–15.8) were identified. Mean follow-up was 6.9 years (range 2.0–20.4). Atypical curves were present in 28 (43%) children. Thirty-eight patients (58%) underwent decompression before 10 years. Syringomyelia size reduced a mean of 70% after decompression (p

OBJECTIVEPediatric cervical deformity is a complex disorder often associated with neurological deterioration requiring cervical spine fusion. However, limited literature exists on new perioperative neurological deficits in children. This study describes new perioperative neurological deficits in pediatric cervical spine instrumentation and fusion.METHODSA single-center review of pediatric cervical spine instrumentation and fusion during 2002–2018 was performed. Demographics, surgical characteristics, and neurological complications were recorded. Perioperative neurological deficits were defined as the deterioration of preexisting neurological function or the appearance of new neurological symptoms.RESULTSA total of 184 cases (160 patients, 57% male) with an average age of 12.6 ± 5.30 years (range 0.2–24.9 years) were included. Deformity (n = 39) and instability (n = 36) were the most frequent indications. Syndromes were present in 39% (n = 71), with Down syndrome (n = 20) and neurofibromatosis (n = 12) the most prevalent. Eighty-seven (48%) children presented with preoperative neurological deficits (16 sensory, 16 motor, and 55 combined deficits).A total of 178 (96.7%) cases improved or remained neurologically stable. New neurological deficits occurred in 6 (3.3%) cases: 3 hemiparesis, 1 hemiplegia, 1 quadriplegia, and 1 quadriparesis. Preoperative neurological compromise was seen in 4 (67%) of these new deficits (3 myelopathy, 1 sensory deficit) and 5 had complex syndromes. Three new deficits were anticipated with intraoperative neuromonitoring changes (p = 0.025).Three (50.0%) patients with new neurological deficits recovered within 6 months and the child with quadriparesis was regaining neurological function at the latest follow-up. Hemiplegia persisted in 1 patient, and 1 child died due a complication related to the tracheostomy. No association was found between neurological deficits and indication (p = 0.96), etiology (p = 0.46), preoperative neurological symptoms (p = 0.65), age (p = 0.56), use of halo vest (p = 0.41), estimated blood loss (p = 0.09), levels fused (p = 0.09), approach (p = 0.07), or fusion location (p = 0.07).CONCLUSIONSAn improvement of the preexisting neurological deficit or stabilization of neurological function was seen in 96.7% of children after cervical spine fusion. New or progressive neurological deficits occurred in 3.3% of the patients and occurred more frequently in children with preoperative neurological symptoms. Patients with syndromic diagnoses are at higher risk to develop a deficit, probably due to the severity of deformity and the degree of cervical instability. Long-term outcomes of new neurological deficits are favorable, and 50% of patients experienced complete neurological recovery within 6 months.

The authors conducted a cross-sectional survey of Massachusetts school nurses examining return-to-learn practices for children recovering from concussion in prekindergarten through high school. Regardless of school setting, all students received academic accommodations to support learning during recovery. School nurses perceived less benefit to prolonged cognitive rest (>4 days) for high school students relative to students in elementary school, but provided academic accommodations to them for comparatively longer periods of time (10-14 days vs 6-10 days). In all settings, respondents indicated a need for improved communication among treating physicians, parents, and school personnel, as well as improved education and standardized management tools for younger children and those who sustain non-sport-related injuries. Despite serving children at different developmental stages, school return-to-learn practices are essentially the same in primary and secondary schools, highlighting the need for standardized, developmentally appropriate return-to-learn plans and additional education for the providers and school personnel who implement them.

Objectives/Hypothesis To review the presentation of congenital pediatric nasal dermoid and present guidelines for its evaluation and management. Study Design Retrospective chart review from 1970 to 2014 at a tertiary referral children's hospital. Methods The medical records of all patients diagnosed with a nasal dermoid during the study period were reviewed for demographics, lesion characteristics, imaging, operative details, and outcomes. Results Ninety-six patients underwent excision of a congenital nasal dermoid during the study period. The mean age at presentation was 3.1 years (range, 0.1–19.3 years). Thirty-four (35%) females and 62 (65%) males were included. The most common presentation was a nasal dorsal mass in 66 (69%) patients. Ninety-two (96%) of the patients underwent preoperative imaging. Seventy-eight (82%) of the patients did not show any clinical or radiographic evidence of intracranial extension preoperatively. Eighty-five (89%) of the patients underwent extracranial excision, and 11 (11%) underwent combined intracranial and extracranial excision. Eight patients (8%) presented with recurrence, on average 3.3 years (range, 1–6 years) after initial excision. Mean follow-up time was 8 years (range, 1–18 years). Conclusion Preoperative imaging of nasal dermoid is crucial to evaluate for intracranial extension, thus facilitating complete removal. Thin section, high-resolution magnetic resonance with contrast provides excellent detail of the extent of the nasal dermoid including intracranial extension. Thin-section high-resolution computed tomography with multiplanar reformatted images provides complimentary information regarding the bone anatomy of the frontonasal region. Surgical strategy is dictated by preoperative imaging and is dependent on the extent of the lesion, but limited facial incisions are preferred. Level of Evidence 4. Laryngoscope, 2015