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Targeted therapies for driver gene fusions in cancers have yielded substantial improvements in care. Here, the authors outline a case series of 6 patients with FGFR3-TACC3 fusion in primary brain tumors ranging from polymorphous low-grade neuroepithelial tumor of the young to papillary glioneuronal tumors and glioblastoma (GBM). Previous studies indicated the FGFR3-TACC3 fusion provides survival benefit to GBM patients. Consistent with this, 2 patients with GBM had unexpectedly good outcomes and survived for 5 and 7 years, respectively. In contrast, 2 patients with initially lower graded tumors survived only 3 years and 1 year, respectively. One patient received erdafitinib, a targeted FGFR inhibitor, for 3 months at late disease recurrence and no response was seen. There were varied histomorphological features, including many cases that lacked the characteristic FGFR3-TACC3 pathology. The findings of this cohort suggest that molecular testing is justified, even for glioma cases lacking classic histopathological signatures. Currently, FGFR3-TACC3 fusion gliomas are often classified on the basis of histopathological features. However, further research is needed to examine whether IDH1/2-wild-type tumors with FGFR3-TACC3 fusion should be classified as a subtype on the basis of this molecular fusion. Because patients with IDH1/2-wild-type GBM with FGFR3-TACC3 fusion have improved survival, routine molecular testing for this mutation in patients enrolled in clinical trials and subsequent stratification may be warranted.

Objective: Since the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions in 2003, many residency programs have adopted a night float system to comply with time constraints. However, some surgical subspecialities have been concerned that use of a night float system deprives residents of operative experience. In this study, the authors describe their training program's transition to a night float system and its impact on resident operative experience., Methods: The authors conducted a single-program study of resident surgical case volume before and after implementing the night float system at 3 of their 5 hospitals from 2014 to 2020. The authors obtained surgical case numbers from the ACGME case log database., Results: Junior residents received a concentrated educational experience, whereas senior residents saw a significant decrease from 112 calls/year to 17. Logged cases significantly increased after implementation of the night float system (8846 vs 10,547, p = 0.04), whereas cases at non-night float hospitals remained the same. This increase was concurrent with an increase in hospital cases. This difference was mainly driven by senior resident cases (p = 0.010), as junior and chief residents did not show significant differences in logged cases (p > 0.40). Lead resident cases increased significantly after implementation of the night float system (6852 vs 8860, p = 0.04). When normalized for increased hospital cases, resident case increases were not statistically significant., Conclusions: Transitioning to a night float call system at the authors' institution increased overall resident operative cases, particularly for lead resident surgeons. Based on the results of this study, the authors recommend the use of a night float call system to consolidate night calls, which increases junior resident-level educational opportunities and senior resident cases.

Objective: Vestibular schwannomas (VSs) are the most common neoplasm of the cerebellopontine angle in adults. Though these lesions are generally slow growing, their growth patterns and associated symptoms can be unpredictable, which may complicate the decision to pursue conservative management versus active intervention. Additionally, surgical decision-making can be controversial because of limited high-quality evidence and multiple quality-of-life considerations. Machine learning (ML) is a powerful tool that utilizes data sets to essentialize multidimensional clinical processes. In this study, the authors trained multiple tree-based ML algorithms to predict the decision for active treatment versus MRI surveillance of VS in a single institutional cohort. In doing so, they sought to assess which preoperative variables carried the most weight in driving the decision for intervention and could be used to guide future surgical decision-making through an evidence-based approach., Methods: The authors reviewed the records of patients who had undergone evaluation by neurosurgery and otolaryngology with subsequent active treatment (resection or radiation) for unilateral VS in the period from 2009 to 2021, as well as those of patients who had been evaluated for VS and were managed conservatively throughout 2021. Clinical presentation, radiographic data, and management plans were abstracted from each patient record from the time of first evaluation until the last follow-up or surgery. Each encounter with the patient was treated as an instance involving a management decision that depended on demographics, symptoms, and tumor profile. Decision tree and random forest classifiers were trained and tested to predict the decision for treatment versus imaging surveillance on the basis of unseen data using an 80/20 pseudorandom split. Predictor variables were tuned to maximize performance based on lowest Gini impurity indices. Model performance was optimized using fivefold cross-validation., Results: One hundred twenty-four patients with 198 rendered decisions concerning management were included in the study. In the decision tree analysis, only a maximum tumor dimension threshold of 1.6 cm and progressive symptoms were required to predict the decision for treatment with 85% accuracy. Optimizing maximum dimension thresholds and including age at presentation boosted accuracy to 88%. Random forest analysis (n = 500 trees) predicted the decision for treatment with 80% accuracy. Factors with the highest variable importance based on multiple measures of importance, including mean minimal conditional depth and largest Gini impurity reduction, were maximum tumor dimension, age at presentation, Koos grade, and progressive symptoms at presentation., Conclusions: Tree-based ML was used to predict which factors drive the decision for active treatment of VS with 80%-88% accuracy. The most important factors were maximum tumor dimension, age at presentation, Koos grade, and progressive symptoms. These results can assist in surgical decision-making and patient counseling. They also demonstrate the power of ML algorithms in extracting useful insights from limited data sets.

Objective: Meningiomas are the most common primary intracranial tumor. Seizures are common sequelae of meningioma development. Meningioma patients with seizures can be effectively treated with resection, with reports of seizure freedom of 60%-90%. Still, many patients manifest persistent epilepsy. Determining factors associated with worsened seizure outcomes remains critical in improving the quality of life for these patients. The authors sought to identify clinical, radiological, and histological factors associated with worse seizure outcomes in patients with supratentorial meningioma and preoperative seizures., Methods: The authors retrospectively reviewed the charts of 384 patients who underwent meningioma resection from 2008 to 2020. The charts of patients with a documented history of preoperative seizures were further reviewed for clinical, radiological, operative, perioperative, histological, and postoperative factors associated with seizures. Engel class at last follow-up was retrospectively assigned by the authors and further grouped into favorable (class I) and worse (class II-IV) outcomes. Factors were subsequently compared by group using comparative statistics. Univariable and multivariable regression models were utilized to identify independent predictors of worse seizure outcome., Results: Fifty-nine patients (15.4%) were found to have preoperative seizures, of whom 57 had sufficient postoperative data to determine Engel class outcome. Forty-two patients (74%) had Engel class I outcomes. The median follow-up was 17 months. Distinct margins on preoperative imaging (p = 0.012), Simpson grade I resection (p = 0.004), postresection ischemia (p = 0.019), WHO grade (p = 0.019), and recurrent disease (p = 0.015) were found to be the strongest predictors of Engel class outcome in univariable logistic regression. MIB-1 index (p = 0.001) and residual volume (p = 0.014) at last follow-up were found to be the strongest predictors of Engel class outcome in univariable generalized linear regression. Postresection ischemia (p = 0.012), WHO grade (p = 0.022), recurrent disease (p = 0.038), and MIB-1 index (p = 0.002) were found to be the strongest independent predictors of Engel class outcomes in multivariable analysis., Conclusions: Postresection ischemia, higher WHO grade, elevated MIB-1 index, and disease recurrence independently predict postresection seizure persistence in patients with supratentorial meningioma. Further understanding of the etiology of these markers may aid in elucidation of this complex disease process and guide management to prevent worse outcomes.

The development of neurosurgery at Baylor College of Medicine began with the medical school's relocation to the new Texas Medical Center in Houston in 1943. An academic service was organized in 1949 as a section of neurosurgery within Baylor's Department of Surgery. Soon the practice, led by Dr. George Ehni, evolved to include clinical services at Methodist, Jefferson Davis (forerunner of Ben Taub), Texas Children's, the Veterans Affairs, and the University of Texas MD Anderson Cancer Center hospitals. A neurosurgery residency program was established in 1954. As the clinical practice expanded, neurosurgery was upgraded from a section to a division and then to a department. It has been led by four chiefs/chairs over the past 60 years-Dr. George Ehni (1959-1979), Dr. Robert Grossman (1980-2004), Dr. Raymond Sawaya (2005-2014), and Dr. Daniel Yoshor (2015-2020). Since the 1950s, the department has drawn strength from its robust residency program, its research base in the medical school, and its five major hospital affiliates, which have largely remained unchanged (with the exception of Baylor St. Luke's Medical Center replacing Methodist in 2004). The recent expansion of the residency program to 25 accredited positions and the growing strength of relationships with the "Baylor five" hospitals affiliated with Baylor College of Medicine portend a bright future.

Objective: Telemedicine has rapidly expanded in the recent years as technologies have afforded healthcare practitioners the ability to diagnose and treat patients remotely. Due to the COVID-19 pandemic, nonessential clinical visits were greatly limited, and much of the outpatient neurosurgical practice at the authors' institution was shifted quickly to telehealth. Although there are prior data suggesting that the use of telemedicine is satisfactory in other surgical fields, data in neurosurgery are limited. This study aimed to investigate both patient and provider satisfaction with telemedicine and its strengths and limitations in outpatient neurosurgery visits., Methods: This quality improvement study was designed to analyze provider and patient satisfaction with telemedicine consultations in an outpatient neurosurgery clinic setting at a tertiary care, large-volume, academic center. The authors designed an 11-question survey for neurosurgical providers and a 13-question survey for patients using both closed 5-point Likert scale responses and multiple choice responses. The questionnaires were administered to patients and providers during the period when the clinic restricted in-person visits. At the conclusion of the study, the overall data were analyzed qualitatively and quantitatively., Results: During the study period, 607 surveys were sent out to patients seen by telehealth at the authors' academic center, and 122 responses were received. For the provider survey, 85 surveys were sent out to providers at the authors' center and other academic centers, and 40 surveys were received. Ninety-two percent of patients agreed or strongly agreed that they were satisfied with that particular telehealth visit. Eighty-eight percent of patients agreed that their telehealth visit was more convenient for them than an in-person visit, but only 36% of patients stated they would like their future visits to be telehealth. Sixty-three percent of providers agreed that telehealth visits were more convenient for them than in-person visits, and 85% of responding providers stated that they wished to incorporate telehealth into their future practice., Conclusions: Although the authors' transition to telehealth was both rapid and unexpected, most providers and patients reported positive experiences with their telemedicine visits and found telemedicine to be an effective form of ambulatory neurosurgical care. Not all patients preferred telemedicine visits over in-person visits, but the high satisfaction with telemedicine by both providers and patients is promising to the future expansion of telehealth in ambulatory neurosurgery.

Objective: Neurosurgical education in the US has changed significantly as a consequence of the novel coronavirus (COVID-19) pandemic. Institutional social distancing requirements have resulted in many neurosurgical programs utilizing video conferencing for educational activities. However, it is unclear how or if these practices should continue after the pandemic. The objective of this study was to characterize virtual education in neurosurgery and understand how it should be utilized after COVID-19., Methods: A 24-question, 3-part online survey was administered anonymously to all 117 US neurosurgical residency programs from May 15, 2020, to June 15, 2020. Questions pertained to the current use of virtual conferencing, preferences over traditional conferences, and future inclinations. The Likert scale (1 = strongly disagree, 3 = neutral, 5 = strongly agree) was used. Comparisons were calculated using the Mann-Whitney U-test. Statistical significance was set at 0.05., Results: One-hundred eight responses were recorded. Overall, 38 respondents (35.2%) were attendings and 70 (64.8%) were trainees. Forty-one respondents (38.0%) indicated attending 5-6 conferences per week and 70 (64.8%) attend national virtual conferences. When considering different conference types, there was no overall preference (scores < 3) for virtual conferences over traditional conferences. In regard to future use, respondents strongly agreed that they would continue the practice at some capacity after the pandemic (median score 5). Overall, respondents agreed that virtual conferences would partially replace traditional conferences (median score 4), whereas they strongly disagreed with the complete replacement of traditional conferences (median score 1). The most common choices for the partial replacement of tradition conferences were case conferences (59/108, 55%) and board preparation (64/108, 59%). Lastly, there was a significant difference in scores for continued use of virtual conferencing in those who attend nationally sponsored conferences (median score 5, n = 70) and those who do not (median score 4, n = 38; U = 1762.50, z = 2.97, r = 0.29, p = 0.003)., Conclusions: Virtual conferences will likely remain an integral part of neurosurgical education after the COVID-19 pandemic has abated. Across the country, residents and faculty report a preference for continued use of virtual conferencing, especially virtual case conferences and board preparation. Some traditional conferences may even be replaced with virtual conferences, in particular those that are more didactic. Furthermore, nationally sponsored virtual conferences have a positive effect on the preferences for continued use of virtual conferences.

OBJECT Brain metastases are the most common intracranial neoplasms and are on the increase. As radiation side effects are increasingly better understood, more patients are being treated with surgery alone with varying outcomes. The authors previously reported that en bloc resection of a single brain metastasis was associated with decreased incidences of leptomeningeal disease and local recurrence compared with piecemeal resection. However, en bloc resection is often feared to cause an increased incidence of postoperative complications. This study aimed to answer this question. METHODS The authors reviewed data from patients with a previously untreated single brain metastasis, who were treated with resection at The University of Texas M.D. Anderson Cancer Center (1993-2012). Data related to the patient, tumor, and methods of resection were obtained. Discharge Karnofsky Performance Scale (KPS) scores and 30-day postoperative complications were noted. Complications were considered major when they persisted for longer than 30 days, resulted in hospitalization or prolongation of hospital stay, required aggressive treatment, and/or were life threatening. RESULTS During the study period, 1033 eligible patients were identified. The median age was 58 years, 83% had a KPS score greater than 70, and 81% were symptomatic at surgery. Sixty-two percent of the patients underwent en bloc resection of their tumor, and 38% underwent piecemeal resection. There were significant differences between the 2 groups in terms of preoperative tumor volume, tumor functional grade, and symptoms at presentation, among others. The overall complication rates were 13% for patients undergoing en bloc resection and 19% for patients undergoing piecemeal resection (p = 0.007). The incidences of major complications and neurological complications were also significantly different. There was a trend in the same direction for major neurological complications, although it was not significant. Among patients undergoing piecemeal resection of tumors in eloquent cortex, 24% had complications (13% had major, 18% had neurological, 9% had major neurological, and 13% had select neurological complications; 4% died within 1 month of surgery). Among those undergoing en bloc resection of such tumors, 11% had complications (6% had major, 8% had neurological, 4% had major neurological, and 4% had select neurological; 2% died within 1 month of surgery). The differences in overall, major, neurological, and select neurological complications were statistically significant, but 1-month mortality and major neurological complications were not. In addition, within subcategories of tumor volume, the incidence of various complications was generally higher for patients undergoing piecemeal resection than for those undergoing en bloc resection. CONCLUSIONS The authors' results indicate that postoperative complication rates are not increased by en bloc resection, including for lesions in eloquent brain regions or for large tumors. This gives credence to the idea that en bloc resection of brain metastases, when feasible, is at least as safe as piecemeal resection.

Object: Prediction of outcome from initial presentation after a gunshot wound to the head (GSWH) is essential to further clinical decision making. The authors' goals are to report the survival and functional outcomes of these patients, to identify prognostic factors, and to propose a scoring system that can predict their outcome., Methods: The records of 199 patients admitted with a GSWH with dural penetration between 1990 and 2008 were retrospectively reviewed. The inclusion criterion was a CT scan available for review. Patients declared brain dead on presentation were excluded, which yielded a series of 119 patients. Statistical analysis was performed using a logistic regression model., Results: Fifty-eight (49%) of the 119 patients died. Twenty-three patients (19%) had a favorable outcome defined as a 6-month Glasgow Outcome Scale (GOS) score of moderate disability or good recovery, 35 (29%) had a poor outcome (GOS of persistent vegetative state or severe disability), and 3 (3%) were lost to follow-up. Significant prognostic factors for mortality were age older than 35 years, nonreactive pupils, bullet trajectory of bihemispheric (excluding bifrontal), and posterior fossa involvement compared with unihemispheric and bifrontal. Factors that were moderately associated with higher mortality included intracranial pressure (ICP) above 20 mm Hg and Glasgow Coma Scale (GCS) score at presentation of 3 or 4. Upon multivariate analysis, the significant factors for mortality were bullet trajectory and pupillary response. Variables found to be significant for good functional outcome were admission GCS score greater than or equal to 5, pupillary reactivity, and bullet trajectory of unihemispheric or bifrontal. Factors moderately associated with good outcome included age of 35 years or younger, initial ICP 20 mm Hg or lower, and lack of transventricular trajectory. In the multivariate analysis, significant factors for good functional outcome were bullet trajectory and pupillary response, with age moderately associated with improved functional outcomes. The authors also propose a scoring system to estimate survival and functional outcome., Conclusions: Age, pupils, GCS score, and bullet trajectory on CT scan can be used to determine likelihood of survival and good functional outcome. The authors advocate assessing patients based on these parameters rather than pronouncing a poor prognosis and withholding aggressive resuscitation based upon low GCS score alone.

Object: Recent attempts to control health care costs focus on reducing or eliminating payments for complications, hospital-acquired conditions, and provider preventable conditions, with payment restrictions applied uniformly. A patient's preexisting comorbidities likely influence the perioperative complication incidence. This relationship has not previously been examined in pediatric neurosurgery., Methods: The authors conducted a retrospective assessment of prospectively collected relevant patient comorbidities and morbidity and mortality events at a large pediatric neurosurgical unit over a 5-year period. The authors examined the impact of specific comorbidities and the cumulative effect of multiple comorbidities on complication incidence., Results: A total of 1990 patients underwent 3195 procedures at the authors' institution during the 5-year study period. Overall, 396 complications were analyzed; 298 patients (15.0%) experienced at least one complication. One or more comorbidities were present in 45.9% of patients. Renal comorbidities were clearly associated with the increased incidence of complications (p = 0.02), and they were specifically associated with infection (p = 0.006). Neurological comorbidities had a borderline association with complications (p = 0.05), and they were specifically associated with death (p = 0.037). A patient's having more comorbidities did not correlate with an increased risk of a perioperative complication (p = 0.8275)., Conclusions: The complication incidence in pediatric neurosurgery is variable and may be influenced by the type of neurosurgical procedure and patient-related factors. While patient-related factors beyond the control of the provider can significantly impact complications and hospital-acquired conditions in pediatric neurosurgery, an increasing number of comorbidities do not correlate with an increased risk of complications per patient.

Cranial osteosarcoma is very rare in children, rendering the development of optimal treatment algorithms challenging. The authors present 3 cases of pediatric cranial osteosarcoma: a primary calvarial tumor, a cranial metastasis, and a primary osteosarcoma of the cranial base. A review of the literature demonstrates significant variation in the management of cranial osteosarcomas and the outcome for patients with these tumors. This series and literature review is presented to improve the understanding of pediatric cranial osteosarcoma and to reinforce the importance of maximal resection in optimizing outcome.

Object: Neuromuscular scoliosis is a challenging pathology to treat. Surgical correction can involve long fusion constructs extending to the pelvis. The deformity inherent in these patients makes it difficult to obtain adequate lateral intraoperative radiographs for traditional image-guided placement of iliac screws., Methods: A clinical and radiographic assessment of 14 patients with neuromuscular spinal deformity was conducted. From 2007 to 2013, 12 of these patients (mean age 14.25 years, range 10-20 years) underwent long spinal instrumentation (mean 15 levels, range 10-18 levels) and fusion to the pelvis, and 2 underwent placement of a growing rod construct with iliac screw placement at a single institution. The average length of follow-up was 33.7 months (range 6-64 months). Iliac screws were placed after identifying the posterior superior iliac spine and using only anteroposterior fluoroscopy (view of the inlet of the pelvis), rather than the technique of direct palpation of the sciatic notch. The accuracy of iliac screw placement was assessed with routine postoperative CT., Results: A total of 12 patients had 24 screws placed as part of a long-segment fusion to the pelvis, and 2 patients had two iliac screws placed as part of a growing rod construct for neuromuscular scoliosis. There were no iliac screw misplacements, and no complications directly related to the technique of iliac screw placement. For cases of definitive fusion (n = 12), the average coronal Cobb angle of patients with neuromuscular spinal deformity measured 62° before surgery and 44.3° immediately after surgery. The average preoperative thoracic kyphosis and lumbar sagittal lordosis measured 37.3° and 60.7°, respectively. Immediately after surgery, the thoracic and lumbar angles measured 30° and 41.1°, respectively. At last follow-up, the average coronal Cobb angle was maintained at 45.1°, and the thoracic and lumbar sagittal angles were maintained at 32.8° and 45.3°, respectively., Conclusions: A less invasive technique for iliac screw placement can be performed safely with a low likelihood of screw misplacement. This technique offers the biomechanical advantages of iliac fixation without the soft tissue exposure typically needed for safe screw insertion. The technique relies on identification of the posterior superior iliac spine and high quality anteroposterior fluoroscopic imaging for a view of the pelvic inlet.

Juvenile xanthogranuloma (JXG) is a rare disease that is part of a spectrum of histiocytic dendritic cell disorders. The authors report an unusual case of a 6-week-old male who presented with seizures. Neuroimaging revealed disseminated intracranial disease involving the optic apparatus, basal ganglia, lateral ventricles, and brainstem. The patient did not have any cutaneous lesions or evidence of extracranial disease. The patient underwent open biopsy of a large right midbrain lesion; pathology was consistent with JXG. He underwent postoperative chemotherapy and is doing well 7 months after surgery with regression of the intracranial lesions. To the best of the authors' knowledge, this is the first report of a neonate with disseminated intracranial JXG without cutaneous stigmata.

Object: Isolated cervical canal stenosis at the level of the atlas (C-1) is a rare cause of cervical myelopathy in the pediatric population. It has been associated with several genetic disorders including spondyloepiphysial dysplasia congenita, Down syndrome, and Klippel-Feil syndrome. The purpose of this study is to highlight the authors' experience with 4 additional pediatric cases, review the literature, and report a new association of this disease with Williams syndrome., Methods: The medical records and radiological imaging studies of 4 patients treated at Texas Children's Hospital for symptomatic hypoplasia of the atlas were retrospectively reviewed. Pertinent patient demographic data, clinical presentation, imaging findings, and outcomes after surgery were recorded. A thorough literature review was performed, allowing the authors to compare and contrast their 4 cases to surgical cases already published in the literature., Results: There were 11 boys and 1 girl in the aggregate series. The average age of the patients was 7 years (range 13 months-14 years), and the duration of symptoms prior to presentation was 6 months (range 0-36 months). The mean sagittal diameter of the spinal canal at the level of the atlas measured from the posterior aspect of the dens to the anterior aspect of the arch of C-1 was 11.9 mm (range 8.3-16 mm) in the aggregate series. In 2 new pediatric patients with hypoplasia of the atlas the disease was associated with Williams syndrome, which has not been previously described. Patients in the aggregate series were followed for an average of 18 months (range 3-50 months). Laminectomy of C-1 provided neurological improvement in all patients who presented., Conclusions: Isolated cervical spinal canal stenosis at the level of the atlas is a rare cause of cervical myelopathy. The authors hope that this report will prompt clinicians to consider it when searching for the origin of signs and symptoms of cervical myelopathy, especially in children.

The authors describe rare cases of congenital hypoplasia of the L-5 pedicles and the congenital absence of the left S-1 pedicle in 2 young girls, respectively, including the presentation, diagnosis, and treatment. Moreover, they review the literature on this clinical entity. The patients presented with intractable chronic low-back pain. Plain radiographs and 2D CT scanning revealed the presence of the aforementioned anomalies. Degenerative changes to adjacent level and contralateral facet joints were thought to be the result of overload and instability and seemed to have led to spondylolisthesis, micromotion at L-5 and S-1, and subsequent low-back pain. The pediatric patients were treated with posterior instrumented fusion with good functional outcomes at a minimum 3-month follow-up. To the best of the authors' knowledge, these are the first reports of intractable low-back pain and spondylolisthesis accompanied by hypoplastic-aplastic pedicles at the lumbosacral junction in children.

Object: Lateral mass screws are routinely placed throughout the subaxial cervical spine in adults, but there are few clinical or radiographic studies regarding lateral mass fixation in children. The morphology of pediatric cervical lateral masses may be associated with greater difficulty in obtaining adequate purchase. The authors examined the lateral masses of the subaxial cervical spine in pediatric patients to define morphometric differences compared with adults, establish guidelines for lateral mass instrumentation in children, and define potential limitations of this technique in the pediatric age group., Methods: Morphometric analysis was performed on CT of the lateral masses of C3-7 in 56 boys and 14 girls. Measurements were obtained in the axial, coronal, and sagittal planes., Results: For most levels and measurements, results in boys and girls did not differ significantly; the few values that were significantly different are not likely to be clinically significant. On the other hand, younger (< 8 years of age) and older children (≥ 8 years of age) differed significantly at every level and measurement except for facet angularity. Sagittal diagonal, a measurement that closely estimates screw length, was found to increase at each successive caudal level from C-3 to C-7, similar to the adult population. A screw acceptance analysis found that all patients ≥ 4 years of age could accept at least a 3.5 × 10 mm lateral mass screw., Conclusions: Lateral mass screw fixation is feasible in the pediatric cervical spine, particularly in children age 4 years old or older. Lateral mass screw fixation is feasible even at the C-7 level, where pedicle screw placement has been advised in lieu of lateral mass screws because of the small size and steep trajectory of the C-7 lateral mass. Nonetheless, all pediatric patients should undergo high-resolution, thin-slice CT preoperatively to assess suitability for lateral mass screw fixation.

External orthosis is the accepted and historical management of odontoid synchondrosis fractures; however, this conservative therapy carries a significant complication and fracture nonunion rate among young children. The purpose of this study was to evaluate the authors' own experience in the context of the literature, to explore surgical fixation as a primary treatment for unstable fractures. The authors retrospectively reviewed 2 cases of unstable odontoid synchondrosis fractures treated at their institution; both showed radiographic progression of deformity and subsequently underwent an open surgical reduction and fusion. A literature review was conducted to compare the authors' management strategy with those in published data. External orthosis for treatment of odontoid synchondrosis fractures has a strong history of success. However, in the literature, patients treated with a halo orthosis had a 43.3% rate of complications and an 11.4% risk of nonunion. There are radiographic findings that suggest instability, such as severe angulation and displacement of the odontoid process. Both patients in the present report underwent successful fusion without complication, as documented on CT scans obtained 3 months after surgery. Given the high rate of fusion attained with conservative therapy, it is recommended for most synchondrosis fractures. However, there is a recognized subgroup of synchondrosis fractures with severe angulation (> 30°) and displacement suggestive of significant ligamentous injury. In these patients, surgical fixation may be a safe and efficacious alternative to halo orthosis as the primary treatment.

Object: National and international meetings, such as the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS) meetings, provide a central location for the gathering and dissemination of research. The purpose of this study was to determine the publication rates of both oral and poster presentations at CNS and AANS meetings in peer-reviewed journals., Methods: The authors reviewed all accepted abstracts, presented as either oral or poster presentations, at the CNS and AANS meetings from 2003 to 2005. This information was then used to search PubMed to determine the rate of publication of the abstracts presented at the meetings. Abstracts were considered published if the data presented at the meeting was identical to that in the publication., Results: The overall publication rate was 32.48% (1243 of 3827 abstracts). On average, 41.28% of oral presentations and 29.03% of poster presentations were eventually published. Of those studies eventually published, 98.71% were published within 5 years of presentation at the meeting. Published abstracts were published most frequently in the Journal of Neurosurgery and Neurosurgery., Conclusions: Approximately one-third of all presentations at the annual CNS and AANS meetings will be published in peer-reviewed, MEDLINE-indexed journals. These meetings are excellent forums for neurosurgical practitioners to be exposed to current research. Oral presentations have a significantly higher rate of eventual publication compared with poster presentations, reflecting their higher quality. The Journal of Neurosurgery and Neurosurgery have been the main outlets of neurosurgical research from these meetings.

Object: Tethered cord release for a tight filum terminale is a common pediatric operation associated with low morbidity and mortality rates. While almost all would agree that keeping patients lying flat after the operation will prevent a CSF leak, the optimal period of doing so has not been determined. In this study, the authors examined whether a longer length of stay in the hospital for the sole purpose of maintaining patients flat correlates with a decreased rate of CSF leakage., Methods: Intraoperative and postoperative data were retrospectively collected in 222 cases of simple tethered cord release at 3 large children's hospitals. Risk factors for postoperative CSF leakage were identified., Results: Thirty-eight patients were maintained lying flat for 24 hours, 86 for 48 hours, and 98 for 72 hours at the individual surgeon's discretion. A CSF leak occurred in 13 patients (5.9%) and pseudomeningocele developed in 9 patients (4.1%). In the univariate analysis, operating time, use of the microscope, use of dural sealant, and duration of remaining flat after surgery failed to correlate with the occurrence of complications., Conclusions: A longer hospital stay for maintaining patients flat after a simple tethered cord release appears not to prevent CSF leakage. However, a larger patient cohort will be needed to detect small differences in complication rates.

Object: Translaminar screw (TLS) fixation can be used safely and efficaciously for upper cervical fusion in children. No published studies have evaluated this technique in the thoracic spine of the pediatric population, and thus the authors undertook such an analysis., Methods: The upper thoracic spines (T1-4) of 130 patients, consisting of 70 boys and 60 girls, were studied using CT scans. Laminar height and thickness, screw length, and screw angle were measured. Exclusion criteria included the following: patients older than 18 years of age, trauma or congenital abnormalities of the thoracic spine, or absent demographic information or imaging studies through T-4. Statistical analysis was performed using paired or unpaired Student t-tests (p < 0.05) and linear regression analysis., Results: The mean laminar heights for T-1, T-2, T-3, and T-4 were as follows: 12.3 ± 3.4, 13.0 ± 3.5, 13.4 ± 3.8, and 14.7 ± 4.1 mm, respectively. The mean laminar widths were 6.5 ± 1.3, 6.6 ± 1.3, 6.6 ± 1.3, and 6.6 ± 1.4 mm, respectively. The mean screw lengths were 29.9 ± 4.1, 25.2 ± 3.5, 22.7 ± 3.2, and 21.6 ± 3.1 mm, respectively. The mean screw angles were 47° ± 4°, 48° ± 4°, 51° ± 4°, and 53° ± 5°, respectively. There were no significant differences between the right and left sides. However, significant differences were found when comparing patients younger than 8 years with those who were 8 years or older, and when comparing boys and girls., Conclusions: Careful preoperative thin-cut CT with sagittal reconstruction is mandatory to determine if the placement of TLSs is feasible in the pediatric population. Based on CT analysis, the insertion of TLSs in the pediatric thoracic spine is possible in all patients older than 8 years and in many patients younger than 8 years. Boys could accept longer screws in the upper thoracic spine compared with girls.

Convexity meningiomas are common tumors encountered by neurosurgeons. Retracting, grasping, and mobilizing large convexity meningiomas can be difficult and awkward as well as place unwanted forces on surrounding neurovascular structures. The authors present a safe alternative to traditional retraction and manipulation methods by using a modified bulb syringe connected to standard surgical suction to function as a vacuum retractor. This technique allows for rapid, safe, en bloc resection of large convexity meningiomas with little to no pressure on the surrounding brain. The authors present an illustrative case and describe and discuss the technique.

Object: Premature, low-birth-weight infants with posthemorrhagic hydrocephalus have a high risk of shunt obstruction and infection. Established risk factors for shunt failure include grade of the hemorrhage and age at shunt insertion. There is anecdotal evidence that the amount of red blood cells or protein levels in the CSF may affect shunt performance. However, this has not been analyzed specifically for this cohort of high-risk patients. Therefore, the authors performed this study to examine whether any statistical relationship exists between the CSF constituents and the rate of shunt malfunction or infection in this population., Methods: A retrospective cohort study was performed on premature infants born at Riley Hospital for Children from 2000 to 2009. Inclusion criteria were a CSF sample analyzed within 2 weeks prior to shunt insertion, low birth weight (< 1500 grams), prematurity (birth prior to 37 weeks estimated gestational age), and shunt insertion for posthemorrhagic hydrocephalus. Data points included the gestational age at birth and shunt insertion, weight at birth and shunt insertion, history of CNS infection prior to shunt insertion, shunt failure, shunt infection, and the levels of red blood cells, white blood cells, protein, and glucose in the CSF. Statistical analysis was performed to determine any association between shunt outcome and the CSF parameters., Results: Fifty-eight patients met the study entry criteria. Ten patients (17.2%) had primary shunt failure within 3 months of insertion. Nine patients (15.5%) had shunt infection within 3 months. A previous CNS infection prior to shunt insertion was a statistical risk factor for shunt failure (p = 0.0290) but not for shunt infection. There was no statistical relationship between shunt malfunction or infection and the CSF levels of red blood cells, white blood cells, protein, or glucose before shunt insertion., Conclusions: Low-birth-weight premature infants with posthemorrhagic hydrocephalus have a high rate of shunt failure and infection. The authors did not find any association of shunt failure or infection with CSF cell count, protein level, or glucose level. Therefore, it may not be useful to base the timing of shunt insertion on CSF parameters.

Object: Medical student exposure to neurosurgery is limited. To improve the educational interactions between neurosurgeons and medical students as well as neurosurgical medical student rotations or clerkships (NSCs) we must first understand the current status., Methods: Two questionnaires were sent, one to every neurosurgery course coordinator or director at each US neurosurgery residency program (99 questionnaires) and one to the associated parent medical school dean's office (91 questionnaires), to assess the current status of NSCs and the involvement of neurosurgeons at their respective institutions., Results: We received responses from 86 (87%) of 99 neurosurgery course coordinators or directors and 64 (70%) of 91 medical school deans' offices. Most NSCs do not have didactic lectures (53 [62%] of 86 NSCs), provide their medical students with a syllabus or educational handouts (53 [62%] of 86), or have a recommended/required textbook (77 [90%] of 86). The most common method of evaluating students in NSCs is a subjective performance evaluation. Of 64 medical school deans, 38 (59%) felt that neurosurgery should not be a required rotation. Neurosurgical rotations or clerkships are primarily offered to students in their 4th year of medical school, which may be too late for appropriate timing of residency applications. Only 21 (33%) of 64 NSCs offer neurosurgery rotations to 3rd-year students., Conclusions: There is significant room for improvement in the neurosurgeon-to-medical student interactions in both the NSCs and during the didactic years of medical school.

Object: Focal cortical dysplasia (FCD) is an important cause of intractable epilepsy and is at times treatable by resection. The now widespread use of MR imaging and recent advancement of functional imaging have increased the number of patients undergoing surgical treatment for FCD. The objective of this review is to critically examine and to provide a summary of surgical series on FCD published since 2000., Methods: Studies concerning surgery for FCD were identified from MEDLINE and references of selected articles and book chapters. Data from these included studies were summarized and analyzed to identify factors correlated with seizure outcome., Results: Sixteen studies were identified, and 469 patients met our selection criteria. Seizure-free outcome at 1-year postoperatively was achieved in 59.7% of the patients. Children and adults were equally likely to benefit from the surgery. Complete resection (OR 13.7, 95% CI 6.68-28.1; p < 0.0001) and temporal location (OR 2.15, 95% CI 1.26-3.69; p = 0.0073) were two positive prognostic indicators of seizure-free outcome. Utilization of invasive monitoring did not affect the chance of seizure remission, but firm conclusions could not be drawn because patients were not randomized., Conclusions: The advancement of modern imaging has transformed the process of surgical candidate selection for partial epilepsy due to FCD. Patients from recent surgical series were more homogeneous in their clinical presentations and might represent FCD as an independent pathological entity. This likely explained the improved surgical outcome for this group of patients. These reports also documented the increased utilization of functional imaging, but their efficacy needs to be verified with further studies.

Posterior reversible encephalopathy syndrome (PRES) has been described in the setting of malignant hypertension, renal disease, eclampsia, and immunosuppression. In addition, a single case of intraoperative (posterior fossa craniotomy) PRES has been reported; however, this case occurred in an adult. The authors present a clinically and radiographically documented case of intraoperative PRES complicating the resection of a posterior fossa tumor in a 6-year-old child. During tumor resection, untoward force was used to circumferentially dissect the tumor, and excessive manipulation of the brainstem led to severe hypertension for a 10-minute period. An immediate postoperative MR image was obtained to rule out residual tumor, but instead the image showed findings consistent with PRES. Moreover, the patient's postoperative clinical findings were consistent with PRES. Aggressive postoperative management of blood pressure and the institution of anticonvulsant therapy were undertaken. The patient made a good recovery; however, he required a temporary tracheostomy and tube feedings for prolonged lower cranial nerve dysfunction. Posterior reversible encephalopathy syndrome can occur as a result of severe hypertension during surgery, even among young children. With prompt treatment, the patient in the featured case experienced significant clinical and radiographic recovery.

Object: Local recurrence (LR) of a resected brain metastasis occurs in up to 46% of patients. Postoperative whole-brain radiation therapy (WBRT) reduces that incidence. To isolate factors associated with the risk of LR after resection, the authors only studied patients who did not receive adjuvant radiotherapy., Methods: The authors reviewed data from 570 cases involving patients who had undergone resection of a previously untreated single brain metastasis at The University of Texas M. D. Anderson Cancer Center between 1993 and 2006 without receiving postoperative WBRT. All tumors were measured preoperatively on MR images. The resection method (en bloc resection [EBR] or piecemeal resection [PMR]) was noted at the time of surgery. Predictors of LR were assessed using the Cox proportional hazards model., Results: The median patient age was 58 years, 55% were male, and 88% had a Karnofsky Performance Scale Score > or = 80. The most common primary cancers were those of the lung (28%), skin (melanoma, 21%), kidney (19%), and breast (11%). Piecemeal resection was performed in 201 patients (35%) and EBR in 369 (65%). Local recurrence developed in 84 patients (15%). The histological type of the primary cancer did not significantly predict LR; however, 7 of 22 patients with sarcoma developed LR (p = 0.16). The authors identified 2 variables that increased the risk of LR. Undergoing PMR carried a significantly higher LR risk than EBR (crude hazard ratio [HR] 1.7, 95% CI 1.1-2.6, p = 0.03). Tumors exceeding the median volume (9.7 cm(3)) had a significantly higher LR risk than those that were < 9.7 cm(3) (crude HR 1.7; 95% CI 1.1-2.6; p = 0.02). In the multivariate analysis, small tumors removed by EBR had a significantly lower LR risk., Conclusions: The LR risk of a single brain metastasis is influenced by biological factors (such as tumor volume) and treatments (such as the resection method). Early administration of postoperative WBRT may be particularly warranted when such negative tumor-related prognostic factors are noted or when treatment-related ones such as PMR are unavoidable.

Object: The authors tested the hypothesis that patients with metastatic posterior fossa lesions (MPFLs) treated with resection have a higher risk of leptomeningeal disease (LMD) than those with MPFLs treated with stereotactic radiosurgery (SRS)., Methods: Between 1993 and 2004, 379 patients with MPFLs were treated with resection or SRS at The University of Texas M. D. Anderson Cancer Center. The authors' primary study outcome was the incidence of LMD, as diagnosed with cerebrospinal fluid cytological analysis and/or neuroimaging., Results: Resection was performed in 260 patients, whereas 119 patients underwent SRS. The median patient age was 56 years, 51% of patients were male, and 93% had a Karnofsky Performance Scale score>or=70. The most common primary cancers were those of the lung, breast, and kidney, as well as melanoma. Leptomeningeal dissemination of cancer occurred in 33 patients: 26 in the resection group and 7 in the SRS group (resection group: rate ratio [RR] 2.06, 95% confidence interval [CI] 0.89-4.75, p=0.09). Piecemeal tumor resection (137 cases) was associated with a significantly higher risk of LMD than en bloc resection (123 cases; RR 3.4, 95% CI 1.43-8.12, p=0.006) or SRS (RR 3.37, 95% CI 1.41-8.04, p=0.006), and there was no significant difference in the risk for LMD between en bloc resection and SRS (en bloc resection: RR 0.98, 95% CI 0.34-2.81, p=0.98). The multivariate RR and significance associated with piecemeal resection, however, were consistent, with a strong effect (RR 2.45, 95% CI 1.19-5.02, p=0.02) and no indication of biases associated with tumor size, location, or cystic/necrotic appearance., Conclusions: There is an increased risk of LMD after piecemeal resection of an MPFL. This increase, although clinically and statistically significant, is not as alarming as previously reported and is absent when en bloc removal is achieved. Further assessment of the role of resection in a controlled prospective setting is warranted.