Does size matter? Minimally invasive approach in pediatric neurosurgery--a review of 125 minimally invasive surgeries in children: clinical history and operative results

Applications of supraorbital keyhole craniotomy in pediatric cranial trauma: illustrative series of two cases and systematic literature review

Minimally invasive (MIS) approaches to neurosurgical diseases continue to increase in popularity due to their association with decreased infection risk, shorter recovery time, and improved cosmesis. Cosmesis and lower morbidity are especially important for pediatric patients. The supraorbital keyhole craniotomy (SOKC) is one MIS approach shown to be effective for both neoplastic and vascular pathologies in pediatric patients. However, it is limited data on its use in pediatric trauma patients. Two cases employing SOKC in pediatric trauma patients are presented here along with a systematic review of the literature. We queried PubMed, Scopus, and Web of Science databases from inception to August 2022 using the Boolean search term: (supraorbital OR eyebrow OR transeyebrow OR suprabrow OR superciliary OR supraciliary) AND (craniotomy OR approach OR keyhole OR procedure) AND (pediatric OR children OR child OR young) AND "trauma". Studies that discussed the use of an SOKC in a pediatric patient having sustained trauma to the frontal calvarium and/or anterior fossa/sellar region of the skull base were included. Details were extracted on patient demographics, trauma etiology, endoscope use, and surgical and cosmetic outcomes. We identified 89 unique studies, of which four met inclusion criteria. Thirteen total cases were represented. Age and sex were reported for 12 patients, 25% of whom were male; the mean age was 7.5 years (range: 3-16). Pathologies included acute epidural hematoma (9), orbital roof fracture with dural tear (1), blowout fracture of the medial wall of the frontal sinus with supraorbital rim fracture (1), and compound skull fracture (1). Twelve patients were treated with a conventional operating microscope, while one underwent endoscope-assisted surgery. Only one significant complication (recurrent epidural hematoma) was reported. There were no reported cosmetic complications. The MIS SOKC approach is a reasonable option for select anterior skull base trauma in the pediatric population. This approach has been used previously for successful frontal epidural hematoma evacuation, which is often treated by a large craniotomy. Further study is merited.

Quality indicators for evaluating the 30-day postoperative outcome in pediatric brain tumor surgery: a 10-year single-center study and systematic review of the literature

OBJECTIVE

Surgery is the cornerstone in the management of pediatric brain tumors. To provide safe and effective health services, quantifying and evaluating quality of care are important. To do this, there is a need for universal measures in the form of indicators reflecting quality of the delivered care. The objective of this study was to analyze currently applied quality indicators in pediatric brain tumor surgery and identify factors associated with poor outcome at a tertiary neurosurgical referral center in western Norway.

METHODS

All patients younger than 18 years of age who underwent surgery for an intracranial tumor at the Department of Neurosurgery at Haukeland University Hospital in Bergen, Norway, between 2009 and 2020 were included. The primary outcomes of interest were classic quality indicators: 30-day readmission, 30-day reoperation, 30-day mortality, 30-day nosocomial infection, and 30-day surgical site infection (SSI) rates; and length of stay. The secondary aim was the identification of risk factors related to unfavorable outcome. The authors also conducted a systematic literature review. Articles concerning pediatric brain tumor surgery reporting at least two quality indicators were of interest.

RESULTS

The authors included 82 patients aged 0-17 years. The 30-day outcomes for unplanned reoperation, unplanned remission, mortality, nosocomial infection, and SSI were 9.8%, 14.6%, 0%, 6.1%, and 3.7%, respectively. Unplanned reoperation was associated with eloquent localization (p = 0.009), primary emergency surgery (p = 0.003), and CSF diversion procedures (p = 0.002). Greater tumor volume was associated with unplanned readmission (p = 0.008), nosocomial infection (p = 0.004), and CSF leakage (p = 0.005). In the systematic review, after full-text screening, 16 articles were included and provided outcome data for 1856 procedures. Overall, the 30-day mortality rate was low, varying from 0% to 9.3%. The 30-day reoperation rate varied from 1.5% to 12%. The SSI rate ranged between 0% and 3.9%, and 0% to 17.4% of patients developed CSF leakage. Four studies reported infratentorial tumor location as a risk factor for postoperative CSF leakage.

CONCLUSIONS

The 30-day outcomes in the authors' department were comparable to published outcomes. The most relevant factors related to unfavorable outcomes are tumor volume and location, both of which are not modifiable by the surgeon. This highlights the importance of risk adjustment. This evaluation of quality indicators reveals concerns related to the unclear and nonstandardized definitions of outcomes. Standardized outcome definitions and documentation in a large and multicentric database are needed in the future for further evaluation of quality indicators.

Bur Hole-Based Resections of Intrinsic Brain Tumors with Exoscopic Visualization

BACKGROUND

 The primary goal of brain tumor surgery is maximal safe resection while avoiding iatrogenic injury. As surgical technology increases, it is becoming more possible to resect these lesions using minimally invasive approaches. While keyhole surgeries are being advocated, the lower limit of these approaches is unclear. Bur hole-based approaches may represent a standardized minimally invasive approach. The exoscope may provide increased visualization over standard microscopic visualization, making this approach possible. This approach has yet to be described strictly for intra-axial brain tumors.

MATERIAL AND METHODS

 All patients who underwent a bur hole-based surgery of an intra-axial tumor with exoscopic visualization by the senior author from January 2018 to December 2019 were prospectively identified and patient information and outcomes were collected.

RESULTS

 Fifteen consecutive patients underwent surgical resection of an intrinsic brain tumor using a bur hole-based approach with exoscopic visualization. The average ± standard deviation age was 57.9 ± 24.2 years. The pathology was a metastatic brain tumor in eight patients (53%), low-grade glioma in four patients (27%), and high-grade glioma in three patients (20%). The average percent resection was 100 ± 1%, where 14 (93%) underwent gross total resection. Following surgery, the median (interquartile range) Karnofsky performance scale (KPS) score was 90 (90-90), where 11 (73%) and four patients (27%) had improved and stable KPS, respectively. Zero patients had complications. The average length of stay following surgery was 1.4 ± 0.5 days, where nine patients (60%) were discharged on postoperative day 1.

CONCLUSION

 This study shows that intra-axial tumors can be resected through a bur hole-based approach with exoscopic visualization with extensive resection, minimal morbidity, and early discharge rates.

[microsurgery 'burr hole' for intracranial tumors and mesial temporal lobe epilepsy]

PURPOSE

In recent years, neurosurgery has been characterized by a clear tendency towards the development of minimally invasive and less traumatic surgical approaches. To minimize the degree of injury to the brain tissue, we have proposed burr hole-based microsurgical approaches.

MATERIAL AND METHODS

In the period between February 2016 and February 2019, more than 500 microsurgical interventions were performed through a 14 mm burr hole using a technique that we called burr-hole microneurosurgery; to date, 200 of these have been analyzed. The age of patients varied from 16 to 79 years (median, 38 years). Female patients predominated - 1.6:1. Surgery for intracranial lesions with various locations was performed in 176 cases; in the remaining 24 cases, patients with hippocampal sclerosis underwent selective amygdalohippocampectomy.

RESULTS

Various surgical approaches were used: transcortical approach in 81 (40.5%) cases; retro-sigmoid approach in 38 (19%); sub-temporal approach in 32 (16%); infratentorial supracerebellar approach in 25 (12.5%); interhemispheric approach in 17 (8.5%); telovelar approach in 5 (2.5%); trans-eyebrow approach in 2 cases. The resection degree was evaluated in 167 patients with planned maximum tumor resection. Resection was total and almost total in 145 (87%) patients, subtotal in 15 (9%), and partial in 7 (4%). The surgery duration varied from 35 to 300 min (mean, 80 min). The extubation time after surgery ranged from 5 min to 5 days (mean, 70 min). In 195 (97.5%) cases, patients were verticalized within the first 3 days after surgery.

CONCLUSION

The proposed burr hole technique enables successful surgery in patients with various intracranial pathologies, using a smaller trepanation window compared to that in keyhole surgery. The proposed burr hole technique minimizes injury to the brain substance, significantly reduces patient's exposure to anesthesia, and decreases the entire duration of surgery.

Analysis of factors that influence neurosurgical length of hospital stay among newly diagnosed pediatric brain tumor patients

BACKGROUND

Postoperative length of stay (LOS) carries a high burden of healthcare costs. In resource-intense specialties such as neurosurgery, it is imperative to identify factors that influence LOS to improve care. The current study investigates the potential for variables that affect clinical presentation, tumor characteristics, treatment modalities, and postoperative complications to impact overall LOS in pediatric brain tumor patients.

METHODS

A retrospective cohort study design was used with patients enrolled in the McMaster Pediatric Brain Tumor Study Group database. All patients up to 18 years of age, presenting with a newly diagnosed brain tumor admitted to and discharged from neurosurgery, were included. Patients were sorted into three cohorts: short LOS (≤3 days), extended LOS (≥20 days), and control LOS (4-19 days).

RESULTS

Of the 124 patients included, 20 (65% male; median age: 9.1 years; range, 0.8-17.4 years) were considered short LOS, 28 (61% male; median age: 4.7 years; range, 0.4-14.7 years) were considered extended LOS, and 76 (57% male; median age: 8.5 years; range, 0.3-17.9 years) were considered control LOS. Variables that prolonged LOS were emesis at presentation (P < 0.001), developmental delay (P = 0.02), multiple surgeries (P = 0.004), tumor location (P < 0.05), subtotal resection (P = 0.02), feeding tube (P < 0.001), adjuvant chemoradiotherapy (P < 0.001), and posterior fossa syndrome (P = 0.004).

CONCLUSIONS

This study identifies variables related to clinical presentation, tumor characteristics, treatment modalities, and postoperative complications associated with extended LOS. These findings uncover novel predictors of LOS that can be used to guide future research and improve health resource management.

Frontal Keyhole Craniotomy for Resection of Low- and High-Grade Gliomas

BACKGROUND

Minimally invasive techniques are increasingly being used to access intra-axial brain lesions.

OBJECTIVE

To describe a method of resecting frontal gliomas through a keyhole craniotomy and share the results with these techniques.

METHODS

We performed a retrospective review of data obtained on all patients undergoing resection of frontal gliomas by the senior author between 2012 and 2015. We describe our technique for resecting dominant and nondominant gliomas utilizing both awake and asleep keyhole craniotomy techniques.

RESULTS

After excluding 1 patient who received a biopsy only, 48 patients were included in the study. Twenty-nine patients (60%) had not received prior surgery. Twenty-six patients (54%) were diagnosed with WHO grade II/III tumors, and 22 patients (46%) were diagnosed with glioblastoma. Twenty-five cases (52%) were performed awake. At least 90% of the tumor was resected in 35 cases (73%). Three of 43 patients with clinical follow-up experienced permanent deficits.

CONCLUSION

We provide our experience in using keyhole craniotomies for resecting frontal gliomas. Our data demonstrate the feasibility of using minimally invasive techniques to safely and aggressively treat these tumors.