From decompressive craniectomy to cranioplasty and beyond-a pediatric neurosurgery perspective.

PURPOSE: Decompressive craniectomy (DC) is an established neurosurgical emergency technique. Patient selection, optimal timing, and technical aspects related to DC and subsequent cranioplasty remain subjects of debate. For children, the overall degree of evidence is low, compared with randomized controlled trials (RCTs) in adults. METHODS: Here, we present a detailed retrospective analysis of pediatric DC, covering the primary procedure and cranioplasty. Results are analyzed and discussed in the light of modern scientific evidence, and conclusions are drawn to stimulate future research. RESULTS: The main indication for DC in children is traumatic brain injury (TBI). Primary and secondary DC is performed with similar frequency. Outcome appears to be better than that in adults, although long-term complications (especially bone flap resorption after autologous cranioplasty) are more common in children. Overt clinical signs of cerebral herniation prior to DC are predictors of poor outcome. CONCLUSIONS: We conclude that DC is an important option in the armamentarium to treat life-threatening intracranial hypertension, but further research is warranted, preferentially in a multicenter prospective registry.

Conservative and operative management of iatrogenic craniocerebral disproportion-a case-based review.

INTRODUCTION: Craniocerebral disproportion (CCD) can occur as a sequela after shunting in early infancy. It can be understood as a disorder closely related to slit ventricle syndrome and chronic overdrainage syndrome. Here, we present two exemplary cases and summarize the pathophysiological, diagnostic, and therapeutic approaches to CCD. CLINICAL PRESENTATION: Two premature babies underwent shunting for posthemorrhagic hydrocephalus and presented in later childhood with recurrent episodes of symptomatic raised intracranial pressure (ICP) at 2 and 8 years of age, respectively. DIAGNOSIS AND MANAGEMENT: Both patients had unchanged ventricular size on cranial imaging and fulfilled the clinical diagnostic criteria of CCD. After confirming shunt patency, ICP monitoring was performed to diagnose intermittent intracranial hypertension. Different treatment pathways were pursued: While readjustment of a programmable shunt valve was sufficient to alleviate the raised ICP in the first case, a cranial expansion surgery was necessary in the second case. OUTCOME AND CONCLUSIONS: Both children were treated successfully after thorough assessment and careful choice of treatment approaches. This review provides detailed insight into CCD and highlights the importance of individual and critical decision-making in these complex patients.

Pediatric neurosurgery malpractice claims in Germany.

PURPOSE: There is limited data regarding malpractice claims in pediatric neurosurgery. Aim of this study was to analyze the rate, subject, and outcome of malpractice claims faced by pediatric neurosurgeons. METHODS: We analyzed malpractice claims in pediatric neurosurgical patients assigned to the review board of North Rhine Medical Council from 2012 to 2016. Claims were categorized as "medical error" or "adverse event, no medical error." Severity was graded from negligible (grade 1) to death (grade 6). RESULTS: Of 391 pediatric malpractice claims, seven (1.8%) concerned pediatric neurosurgery. Claims were related to cranial surgery (N = 5), spinal surgery (N = 1), and a neuro-interventional procedure (N = 1). Of operative cases, three were shunt operations, two were cranioplasty procedures, and one was a spinal fusion. Complications of medical care (adverse events) had occurred in all cases. A medical error was detected in only one case. Severity of damage was grade 2 (transient minor) in three, grade 3 (transient major) in one, and grade 5 (permanent major) in three cases, respectively. CONCLUSIONS: Pediatric neurosurgery accounted for 1.8% of all pediatric malpractice claims. In 14% of these claims, a medical error was confirmed. Malpractice claim rate thus appears to be lower than expected for a high-risk specialty. , adverse events were confirmed in all cases, a negligent medical error was rare. Adverse event rate appears to be a predictor for malpractice claim burden, highlighting the importance of surgical checklists, standard operating procedures and morbidity and mortality surveillance.

Primary bone tumors of the spine revisited: A 10-year single-center experience of the management and outcome in a neurosurgical department.

OBJECTIVE: To report a large clinical series of primary bone tumors of the spine (PBTS) and review the current concepts of management. MATERIALS AND METHODS: We retrospectively analyzed a clinical series of PBTS treated over the last decade (2004-2014) in the spine unit of a large European tertiary care center. Every PBTS was identified from an electronic medical-record system. Analysis comprised medical records and clinical imaging. Overall survival and outcome was measured using the Glasgow Outcome Scale (GOS) at six weeks, six months and one year postoperatively. Surgical management and adjuvant/neoadjuvant strategies were analyzed. A thorough review of the current literature was performed. RESULTS: A total of 79 patients were included. Of these, 44 (55.7%) were male. The age ranged from 9 to 90 years (mean 55), and most patients were adults (93.6%). Local pain was the most common symptom and was present in 91.1% of the patients. The majority of the tumors occurred in the thoracic spine (52 patients, 65.8%). Overall 86% (68 patients) of PBTS were classified as malignant and at the time of diagnosis, 7 patients (8.9%) presented with non-spinal metastasis. The most common histologic types were hematopoietic tumors (72.2%), followed by chondrogenic ones (12.7%). Within hematopoietic tumors, plasmacytoma was the most frequent type (49 patients, 62%). In 12 patients (15.2%) recurrences were seen during the follow-up period. Overall mean survival of benign PBTS was 100%, malignant non-hematopoietic PBTS 50% and, malignant hematopoietic PBTS 84% at one year, respectively. At six weeks and one year after the initial surgery, 79% and 54% of the patients presented a GOS >3, respectively. CONCLUSION: PBTS were almost exclusively seen in adults. Malignant tumors were markedly more frequent than benign tumors, with hematopoietic tumors being the most common type. For PBTS, early surgery is important in order to restore spinal stability and decompress the spinal cord. This allows pain reduction and prevention of neurological deficits.

Scanning electron microscopic surface analysis of cryoconserved skull bone after decompressive craniectomy.

Bone flaps removed during decompressive craniectomy are commonly frozen at -80 °C and stored until cranioplasty. Histological integrity and regenerative capacity have been shown for cryoconserved bone. The effects of cryoconservation on the surface structure are unknown, although these might cause mechanical instability or facilitate bacterial adhesion. This study evaluates the surface structure of cryoconserved bone by scanning electron microscopy. Five patients were identified who could not receive their autologous bone flaps after decompressive craniectomy. These redundant bone specimens were obtained after cryoconservation for 6-8 months and the outer surface was analyzed by scanning electron microscopy. We found varying surface structures which did not correlate with any variables, such as patient age, gender or duration of freezing, and probably reflect physiological interindividual variation. Pathological findings, such as microscopic crack formation, were not observed. Cryoconservation for up to 8 months does not appear to alter the surface structure of skull bone on scanning electronic microscopy.