Faculty Bibliography

INTRODUCTION:Surgical specialization is critical in medical training, with fellowships as key pathways for career advancement and shaping the pediatric surgical workforce. Given the surgical condition and procedural overlap between subspecialties, skills often complement each other to enhance comprehensive pediatric care. This study examines the balance of supply and demand across pediatric surgical fellowship positions, evaluating trends in individual fields and their collective impact on pediatric surgical care. METHODS:We analyzed available fellowship match data from 2004 to 2024 across nine pediatric subspecialties: anesthesiology, cardiac surgery, general surgery, gynecology, neurosurgery, orthopedics, otolaryngology, plastic surgery, and urology. Data were obtained from the National Resident Matching Program, San Francisco Match, and the Pediatric Orthopedic Society of North America. Applicant-to-position ratios were calculated, with 1 indicating balance, >1 reflecting higher demand, and <1 indicating lower demand. Statistical analysis was performed using least squares regression and ANOVA in SPSS (IBM SPSS Statistics, Version 29.0.2.0 (IBM Corp, Armonk, NY)). Data are expressed as mean ± standard deviation, where applicable. RESULTS:Nine subspecialties were assessed. Higher demand was found for available positions in pediatric general surgery (1.80 ± 0.23), gynecology (1.35 ± 0.21), and cardiac surgery (1.21 ± 0.46). Specialties with lower demand included urology (0.81 ± 0.08), plastic surgery (0.88 ± 0.13), anesthesiology (0.92 ± 0.20), otolaryngology (0.95 ± 0.14), and neurosurgery (0.96 ± 0.20). An analysis of trends revealed that all specialties experienced a decline in the ratio of applicants to available positions, except for orthopedics, which saw significant decreases in the ratios for anesthesiology, general surgery, and plastic surgery. The average number of unfilled fellowship positions was most notable for anesthesiology (35.2 ± 19.5), orthopedics (16.4 ± 5.5), and otolaryngology (11.2 ± 4.7). The percentage of unfilled positions was notably high for urology (31.9% ± 8.8%), plastic surgery (27.6% ± 11.6%), and otolaryngology (24.0% ± 9.4%). CONCLUSIONS:The findings suggest that pediatric general surgery, gynecology, and cardiac surgery continue to attract strong interest, while anesthesiology, orthopedics, otolaryngology, plastic surgery, and urology are seeing fewer applicants than available positions. What is most concerning, however, is that almost all fields have witnessed a decline in interest over time. If it continues, this trend portends poorly for the future of pediatric surgical care, as an imbalance between the decreasing supply of specialists and the growing demand for specialized care could lead to gaps in patient services. Addressing these imbalances is crucial to sustaining a well-rounded, highly qualified pediatric surgical workforce.

BACKGROUND:Supratentorial ependymoma, ZFTA fusion-positive, CNS WHO grade 3, is a rare pediatric brain tumor characterized by brisk mitotic activity and sometimes microvascular proliferation and/or necrosis. Typical treatment includes a combination of resection, chemotherapy, and radiation therapy. These tumors often present at age 3 or 4 years and have a poor prognosis. OBSERVATIONS/METHODS:The authors present the case of a 4-year-old girl who presented asymptomatically with recurrence of a supratentorial ependymoma, ZFTA fusion-positive, CNS WHO grade 3, of the right parietal lobe with a homozygous CDKN2A deletion through chemotherapy after an initial gross-total resection. Tumor recurrence presented with a traditional intraparenchymal cystic component that initially appeared to invade through the dura mater, diploë, and outer table of the skull. On closer examination of the calvaria and dura in the operating room, a trabeculated and soft tissue mixed with invasion into the outer table contiguous with calcifications on the native dura was observed. Histopathological analysis confirmed that the recurrent tumor was confined intradurally with treatment effect, and the dural and calvarial findings represented a reactive inflammatory process likely related to prior surgery, chemotherapy, and possibly the neoplasm itself. LESSONS/CONCLUSIONS:This case illustrates an atypical presentation of a recurrent supratentorial ependymoma, ZFTA fusion-positive, CNS WHO grade 3, where reactive inflammatory changes of the dura and calvaria mimicked dural and calvarial invasion. These findings demonstrate the importance of histopathological evaluation in distinguishing true tumor recurrence from atypical inflammatory responses to prior surgery, chemotherapy, or the neoplasm itself and close postoperative follow-up. https://thejns.org/doi/10.3171/CASE25146.

Tectal gliomas are rare brainstem tumors. These tumors typically cause obstructive hydrocephalus due to mass effect on the cerebral aqueduct; however, intratumoral hemorrhage is exceedingly rare, with only one previously documented case to our knowledge. Patients typically present with symptoms of hydrocephalus, including headaches, nausea, and visual disturbances. We report the case of a 43-year-old man with a known tectal plate glioma who presented with acute obstructive hydrocephalus secondary to intratumoral hemorrhage. Following the patient's rapid neurological decline, computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the diagnosis. The patient underwent an endoscopic third ventriculocisternostomy (ETV) for cerebrospinal fluid diversion, along with an endoscopic biopsy of the tectal mass. The patient's postoperative course was favorable, with gradual resolution of symptoms, including diplopia and headaches. A follow-up MRI revealed reduced tumor size and stable ventriculomegaly. Histopathological analysis suggested the tumor to be of glial origin and low-grade in nature, based on its contrast enhancement on MRI and the patient's clinical trajectory. This case illustrates a rare presentation of intratumoral hemorrhage in tectal gliomas, emphasizing the need for heightened clinical suspicion in such cases. ETV remains an effective treatment for obstructive hydrocephalus, though the potential for hemorrhagic complications warrants close monitoring.

BACKGROUND:Chiari malformations type I are commonly encountered in pediatric patients. Posterior fossa decompression with or without duraplasty is recommended for patients with intractable symptoms, as well as those showing evidence of brainstem dysfunction. OBSERVATIONS/METHODS:In this report, the authors describe the case of a 19-year-old female who presented to the neurosurgery clinic with delayed synthetic dural graft breakdown as well as associated pseudomeningocele and intracranial hypotension. She underwent exploration and revision of her duraplasty, where a dural defect measuring 1.5 cm in diameter was observed. The defect was not contiguous with peripheral sutures. The defect was repaired with a pericranium autograft and reinforced with dural sealants. Her postoperative course was complicated by scalp dysesthesia. LESSONS/CONCLUSIONS:To the authors' knowledge, this is the first reported case of a synthetic dural graft breakdown following posterior fossa decompression with duraplasty. https://thejns.org/doi/10.3171/CASE24715.

PURPOSE/OBJECTIVE:Traumatic brain injury (TBI) is a leading cause of pediatric death and disability. Abusive head trauma confers greater morbidity and mortality compared with accidental TBI. National trends reveal disproportionate involvement of minority children in the child welfare system. The study investigates socioeconomic disparities in child protective services (CPS) involvement in pediatric TBI. METHODS:Retrospective chart review was conducted for TBI patients (n = 596) admitted to an academic pediatric level I trauma center from 2015 to 2022, where institutional policy dictates automatic CPS referral for TBI patients ≤ 2 years. Analysis of variance, chi-squared, and logistic regressions compared racial and ethnic groups and calculated adjusted odds of CPS case acceptance. RESULTS:Rates of non-accidental trauma, CPS involvement, insurance, and marital status differed across racial and ethnic backgrounds (p < 0.05). Of patients ≤ 2 years, Hispanic patients (OR: 0.38, 95%CI [0.16,0.91]) had decreased odds of CPS involvement compared to non-Hispanic White patients when adjusting for confounders including injury severity, injury type, and socioeconomic status. CONCLUSIONS:We highlight racial and ethnic differences in incidence of pediatric TBI and CPS involvement, even in the setting of an automatic CPS referral policy for pediatric TBI patients ≤ 2 years.

BACKGROUND:To study the impact of the COVID-19 pandemic on traumatic brain injury (TBI) patient demographic, clinical and trauma related characteristics, and outcomes. METHODS:Retrospective chart review was conducted on pediatric TBI patients admitted to a Level I Pediatric Trauma Center between January 2015 and June 2022. The pre-COVID era was defined as January 1, 2015, through March 12, 2020. The COVID-19 era was defined as March 13, 2020, through June 30, 2022. Bivariate analysis and logistic regression were performed. RESULTS:Four hundred-thirty patients were treated for pediatric TBI in the pre-COVID-19 period, and 166 patients during COVID-19. In bivariate analyses, the racial/ethnic makeup, age, and sex varied significantly across the two time periods (p < 0.05). Unwitnessed TBI events increased during the COVID-19 era. Logistic regression analyses also demonstrated significantly increased odds of death, severe disability, or vegetative state during COVID-19 (AOR 7.23; 95 % CI 1.43, 36.41). CONCLUSION/CONCLUSIONS:During the COVID-19 pandemic, patients admitted with pediatric TBI had significantly different demographics with regards to age, sex, and race/ethnicity when compared to patients prior to the pandemic. There was an increase in unwitnessed events. In the COVID period, patients had a higher odds ratio of severe morbidity and mortality despite adjustment for confounding factors. LEVEL OF EVIDENCE AND STUDY TYPE/METHODS:Level II, Prognosis.

CNS injury following a traumatic intraoral injury is a rare but potentially catastrophic occurrence in pediatrics. For example, intraoral trauma resulting in acute ischemic stroke (AIS) secondary to carotid artery dissection has only been described by a limited number of case reports [1]. We report the case of a 4-year-old boy who suffered a penetrating right internal carotid injury after a fall resulting in a metal straw perforating the neck and oropharynx. The patient presented in hemorrhagic shock with altered consciousness. CT Angiography revealed a right internal carotid traumatic rupture with flow occlusion and right cerebral hemispheric hypoperfusion. The patient underwent emergent neuroradiologic intervention under general anesthesia with successful reconstruction of the right carotid artery through the use of five flow diverting pipeline stents. The patient was extubated one week later with the only neurologic sequala being slight left upper extremity weakness. Anesthetic management played a vital part in this outstanding outcome. Thoughtful management is required to ensure both survival and the best possible neurologic recovery. Despite the rarity of these events, there is sufficient evidence from similar interventions and neurophysiology to guide sound management. This case report highlights these principles and areas for further investigation. Our experience may be instructive in the support of safe care under similarly rare but challenging circumstances.

BACKGROUND:Colloid cysts arise from the roof of the third ventricle and are at risk for obstructing the flow of cerebrospinal fluid (CSF) and causing increased intracranial pressure. With advancements and increased frequency of imaging, colloid cysts are sometimes discovered incidentally. In these cases, the neurosurgeon is faced with the decision of whether to intervene or manage conservatively. CASE DESCRIPTION/METHODS:A 67-year-old man was discovered to have a colloid cyst when imaging was performed for transient neurologic deficits. CT and MRI brain revealed a 5mm lesion in the third ventricle with characteristics suggestive of the colloid cyst. Except for his initial presentation, the patient did not exhibit any symptoms and was followed with serial imaging. Four years after discovery, the colloid cyst regressed in size. CONCLUSION/CONCLUSIONS:The evolution and resolution of colloid cysts remain elusive; however, the discovery of incidental colloid cysts due to more frequent and more advanced neuroimaging emphasize the importance of this topic. The fear of conservative management is acute decompensation due to obstruction of CSF. However, surgical risks may be avoided if these asymptomatic lesions regress and resolve without intervention. Conservative management is a viable option for patients with colloid cysts, who may not only avoid surgery but who might also rarely experience cyst resolution.

INTRODUCTION:Craniosynostosis is the premature fusion of one or more cranial sutures. The cause of non-syndromic craniosynostosis has been attributed to a complex interaction among genetic, epigenetic, and environmental factors. Increased concordance rates in monozygotic twins support a genetic etiology while a concordance rate less than 100% suggests environmental and/or epigenetic influences. Here, we describe the first reported occurrence of all three children in a triplet set with non-syndromic single-suture craniosynostosis. CASE REPORT:The dichorionic triamniotic triplets were the product of a non-consanguineous marriage delivered at 35 weeks' gestation by a 38-year-old mother and consisted of a monochorionic-diamniotic pair (A and B) and a fraternal triplet (C). Three-dimensional computed tomography scans confirmed sagittal synostosis in A and B and metopic synostosis in C. All patients underwent endoscopic strip craniectomy and were discharged on the second postoperative day with helmet orthoses. Comparative genetic hybridization (CGH) and whole-exome sequencing (WES) failed to identify pathogenic copy number variants or gene mutations, respectively. DISCUSSION AND CONCLUSION:The results of the genetic testing suggest the possibility of a rare variant contributing to the risk of midline craniosynostosis shared among the triplets, with potential modifiers at other genetic loci affecting the phenotype. We speculate mutations at loci within non-coding regions not captured by our genetic analysis may have been involved. Moreover, epigenetic factors as well as environmental factors including, but not limited to, in utero head constraint could have contributed to the observed phenotype.

Advances in stereotactic navigation technology have helped to improve the ease, reliability, and workflow of neurosurgical intraoperative navigation. These advances have also allowed novel, minimally invasive neurosurgical techniques to emerge. Minimally invasive techniques for intracerebral hemorrhage (ICH) evacuation, including endoscopic evacuation and passive catheter drainage, are notable examples, and as these gain support in the literature and their use expands, stereotactic navigation will take on an increasingly important and central role. Each neurosurgical navigation system has unique characteristics. Operators may find that certain aspects are more important than others, depending on the environment in which the evacuation is performed and operator preferences. This review will describe the characteristics of three popular stereotactic neuronavigation systems and compare their advantages and disadvantages as they relate to minimally invasive ICH evacuation.