Nonselective lumbosacral ventral-dorsal rhizotomy for the management of lower-limb hypertonia in nonambulatory children with cerebral palsy.

OBJECTIVE: Children with cerebral palsy (CP) often experience medically refractory hypertonia, for which there are surgical therapies including neuromodulation and rhizotomy. Traditional surgical treatment for medically refractory mixed hypertonia or dystonia includes intrathecal baclofen pumps and selective dorsal rhizotomy. A nonselective lumbosacral ventral-dorsal rhizotomy (VDR; ventral and dorsal roots lesioned by 80%-90%) has the potential to address the limitations of traditional surgical options. The authors highlighted the institutional safety and efficacy of nonselective lumbosacral VDR for palliative tone management in nonambulatory patients with more severe CP. METHODS: The authors performed a retrospective analysis of patients who had undergone lumbosacral VDR between 2022 and 2023. Demographic factors, clinical variables, and operative characteristics were collected. The primary outcomes of interest included tone control and quality of life improvement. Secondary outcome measures included, as a measure of safety, perioperative events such as paresthesias. Postoperative complications were also noted. RESULTS: Fourteen patients (7 female) were included in the study. All patients had undergone a T12-L2 osteoplastic laminoplasty and bilateral L1-S1 VDR. Nine patients had quadriplegic mixed hypertonia, 4 had quadriplegic spasticity, and 1 had generalized secondary dystonia. Following VDR, there was a significant decrease in both lower-extremity modified Ashworth Scale (mAS) scores (mean difference [MD] -2.77 ± 1.0, p < 0.001) and upper-extremity mAS scores (MD -0.71 ± 0.76, p = 0.02), with an average follow-up of 3 months. In the patient with generalized dystonia, the lower-extremity Barry-Albright Dystonia Scale score decreased from 8 to 0, and the overall score decreased from 32 to 13. All parents noted increased ease in caregiving, particularly in terms of positioning, transfers, and changing. The mean daily enteral baclofen dose decreased from 47 mg preoperatively to 24.5 mg postoperatively (p < 0.001). Three patients developed wound dehiscence, 2 of whom had concurrent infections. CONCLUSIONS: Lumbosacral VDR is safe, is effective for tone control, and can provide quality of life improvements in patients with medically refractory lower-limb mixed hypertonia. Lumbosacral VDR can be considered for palliative tone control in nonambulatory patients with more severe CP. Larger studies with longer follow-ups are necessary to further determine safety and long-term benefits in these patients.

Safety and efficacy of continuous intrathecal baclofen via cervical catheter tip: a retrospective case series.

OBJECTIVE: Intrathecal baclofen (ITB) is an effective treatment for hypertonia in children involving the implantation of a pump and catheter system. The highest concentration of ITB is at the catheter tip. The catheter tip location is most commonly within the lumbar or thoracic spine. The cervical tip location has traditionally been avoided because of concerns of hypoventilation and pneumonia; however, these complications in cervical compared with thoracic or lumbar placement have not been reliably proven. Some studies have suggested that cervical ITB location better treats upper-extremity hypertonia. There are limited data describing the safety and efficacy of cervical ITB on hypertonia. The authors present a single-institution retrospective case series highlighting the safety and efficacy of using cervical ITB location for the treatment of hypertonia. METHODS: Retrospective data analysis was performed for children who underwent continuous dosing cervical ITB between April 2022 and October 2023. Nonmodifiable risk factors, clinical variables, operative characteristics, and adverse outcomes were collected. RESULTS: This study included 25 patients (8 female). The mean age at implantation was 12.4 years, and the mean operative duration was 90 minutes. The mean Barry-Albright Dystonia Scale score decreased by 9.5 points (p = 0.01). The mean aggregated modified Ashworth scale score in the upper extremities decreased by 2.14 points (p = 0.04), and that in the lower extremities decreased by 4.98 points (p < 0.01). One patient each (4%) had infection and baclofen toxicity. Two patients (8%) had respiratory depression requiring continuous positive airway pressure. There was no incidence of pneumonia or wound dehiscence. CONCLUSIONS: The cervical catheter tip location for ITB is safe, is effective to control tone, and should be considered for the treatment of hypertonia. Larger studies with longer follow-up are necessary to further determine upper-limit dosing safety along with long-term functional benefits in these patients.

Case-based explanation of standard work tools for selective dorsal rhizotomy for cerebral palsy.

OBJECTIVE: Spasticity is a challenging feature of cerebral palsy (CP) that may be managed with selective dorsal rhizotomy (SDR). Although standard work tools (SWTs) have recently been utilized to inform a standard of care for neurosurgical procedures, no SWTs for SDR have been previously described. The authors present the multidisciplinary approach SWTs for SDR used at their institutions to promote consistency in the field and minimize complication rates. METHODS: A multidisciplinary approach was used to define all steps in the SDR pathway. Preoperative, intraoperative, and postoperative workflows were synthesized, with specific efforts to improve mobility through inpatient rehabilitation and minimize infection. RESULTS: The SWTs have been implemented at two institutions for 7 years. An illustrative case of a patient aged 3 years 10 months with a history of premature birth at 29 weeks, spastic-diplegic CP, right-sided periventricular leukomalacia, and developmental delay who underwent L2-S1 SDR is presented. CONCLUSIONS: The authors detail SWTs for SDR developed by a multidisciplinary team with specific steps at all points in the patient pathway. The illustrative case emphasizes that SWTs may help ensure the safety of SDR while maximizing its long-term efficacy for individuals with CP.

Experience in endoscope choice for neuroendoscopic lavage for intraventricular hemorrhage of prematurity: a systematic review.

OBJECTIVE: Intraventricular hemorrhage (IVH) of prematurity occurs in 20-38% of infants born < 28 weeks gestational age and 15% of infants born in 28-32 weeks gestational age. Treatment has evolved from conservative management and CSF diversion of temporizing and shunting procedures to include strategies aimed at primarily clearing intraventricular blood products. Neuroendoscopic lavage (NEL) aims to decrease the intraventricular blood burden under the same anesthetic as temporizing CSF diversion measures in cases of hydrocephalus from IVH of prematurity. Given the variety of neuroendoscopes, we sought to review the literature and practical considerations to help guide neuroendoscope selection when planning NEL. METHODS: We conducted a systematic review of the literature on neuroendoscopic lavage in IVH of prematurity to examine data on the choice of neuroendoscope and outcomes regarding shunt rate. We then collected manufacturer data on neuroendoscopic devices, including inflow and outflow mechanisms, working channel specifications, and tools compatible with the working channel. We paired this information with the advantages and disadvantages reported in the literature and observations from the experiences of pediatric neurosurgeons from several institutions to provide a pragmatic evaluation of international clinical experience with each neuroendoscope in NEL. RESULTS: Eight studies were identified; four neuroendoscopes have been used for NEL as reported in the literature. These include the Karl Storz Flexible Neuroendoscope, LOTTA® system, GAAB system, and Aesculap MINOP® system. The LOTTA® and MINOP® systems were similar in setup and instrument options. Positive neuroendoscope features for NEL include increased degrees of visualization, better visualization with the evolution of light and camera sources, the ability to sterilize with autoclave processes, balanced inflow and outflow mechanisms via separate channels, and a working channel. Neuroendoscope disadvantages for NEL may include special sterilization requirements, large outer diameter, and limitations in working channels. CONCLUSIONS: A neuroendoscope integrating continuous irrigation, characterized by measured inflow and outflow via separate channels and multiple associated instruments, appears to be the most commonly used technology in the literature. As neuroendoscopes evolve, maximizing clear visualization, adequate inflow, measured outflow, and large enough working channels for paired instrumentation while minimizing the footprint of the outer diameter will be most advantageous when applied for NEL in premature infants.

Occipital nerve stimulation in pediatric patients with refractory occipital neuralgia.

PURPOSE: Occipital neuralgia (ON) is a disabling problem within the pediatric population. Many of these patients fail medical therapies and continue to suffer without further surgical management. Occipital nerve stimulation (ONS) is used to treat ON in the adult population leading to a 72-89% reduction in pain; however, there are limited studies regarding its use in the pediatric population. In this study, we examined the outcomes of ONS in pediatric patients with medically refractory ON. METHODS: We performed a chart review of pediatric patients at our institution who have undergone ONS for the same indications. RESULTS: We identified 3 patients at our institution who underwent ONS trial and/or permanent implantation for ON. One patient had complete pain relief after the trial and declined permanent implantation. The other patient had fewer attacks compared to his pre-trial baseline and controlled them by adjusting his permanent implant stimulation settings. The last patient had near complete relief of her symptoms and no longer required any pain medication. CONCLUSION: Our study highlights the paucity of studies evaluating the utility of ONS in the pediatric ON population. Limited data from both the literature and our institution's experience reveal that pediatric patients may benefit from trial and/or permanent implantation of ONS for medically refractory ON pain.

Information Sharing in Neurosurgery Topics Among Pediatric Patients and Loved Ones Within the Reddit Community.

Introduction With crowd-sourced knowledge, patients arrive at their healthcare visits ready to play an active role. This exploratory study seeks to understand common concerns among patients and loved ones on Reddit, an anonymous internet forum. Ultimately, recognizing common concerns can aid providers in directing their conversations with patients. Methods Reddit posts in the "hot" tab of each subreddit were retroactively screened from September 1, 2022. Posts written within a five-year period were included. Posts by pediatric patients, loved ones, and pregnant patients experiencing the condition or whose fetus was diagnosed were included. Posts omitting the poster's age or individuals, outside of loved ones, who self-identified as over the age of 17 were excluded. Results A total of 12 subreddits and 286 posts were identified, with 37% of posts written by patients and 63% of posts written by a loved one. R/scoliosis patients (n=29) and r/epilepsy loved ones (n=28) sought the most health advice. The subreddit r/hydrocephalus comprised the most post-operative treatment symptom questions. The r/cerebralpalsy subreddit sought the most advice related to daily activities. Discussion Patients within r/scoliosis, r/hydrocephalus, and r/epilepsy are asking health-related questions. Hydrocephalus patients utilize anonymous internet responses to prepare for upcoming healthcare visits. Individuals in r/cerebralpalsy are utilizing Reddit as a method of communication; understanding how these patients interact with social media can guide software development tailored for online interactions. The anonymity of Reddit prevents us from understanding the diversity of posters. Conclusion Reddit is an avenue to disseminate correct information to pediatric patients and loved ones. Healthcare providers can use the information gathered to tailor their discussions better.

Cervicothoracic ventral-dorsal rhizotomy for bilateral upper-extremity hypertonia in cerebral palsy: illustrative case.

BACKGROUND: Management of medically refractory limb-specific hypertonia is challenging. Neurosurgical options include deep brain stimulation, intrathecal baclofen, thalamotomy, pallidotomy, or rhizotomy. Cervical dorsal rhizotomy has been successful in the treatment of upper-extremity spasticity. Cervical ventral and cervical ventral-dorsal rhizotomy (VDR) has been used in the treatment or torticollis and traumatic hypertonia; however, the use of cervicothoracic VDR for the treatment of upper-extremity mixed hypertonia is not well described. OBSERVATIONS: A 9-year-old girl with severe quadriplegic mixed hypertonia secondary to cerebral palsy (CP) underwent cervicothoracic VDR. Modified Ashworth Scale scores, provision of caregiving, and examination improved. Treatment was well tolerated. LESSONS: Cervicothoracic VDR can afford symptomatic and quality of life improvement in patients with medically refractory limb hypertonia. Intraoperative positioning and nuances in surgical techniques are particularly important based on spinal cord position as modified by scoliosis. Here, the first successful use of cervicothoracic VDR for the treatment of medically refractory upper-limb hypertonia in a pediatric patient with CP is described.

Postmortem Protocols of Implantable Neurosurgical Devices: A Cross-Sectional Survey.

BACKGROUND: Implantable devices are increasingly more common for management of movement disorders, pain, and epilepsy. These devices are often complex and constructed of nonbiodegradable or hazardous materials. Therefore, proper postmortem handling of these devices is exceedingly important. Unfortunately, there is no consolidated resource available for postmortem neuromodulation device protocols. Thus, we surveyed and catalogued the protocols for implantable devices to summarize proper postmortem device protocols for implantable neurosurgical devices currently on the market. METHODS: We performed a cross-sectional study of companies producing commonly implanted neurosurgical devices. Using information from company websites, user manuals, and catalogs we categorized devices into 3 groups: A (formal recommendation for explantation), B (recommendation for explantation without formal company protocol), and C (explantation is not necessary). We then compiled the data into a stoplight diagram, providing a clear postmortem disposal algorithm for each device category. RESULTS: Twelve companies were queried regarding 46 devices. Postmortem protocols were available for 50% (23/46) of devices; the remaining devices did not have formal recommendations. Overall, 50% of devices were classified as category A "red light" on the stoplight diagram based on recommendations, 10.9% as category B "yellow light," and the remaining 39.1% were classified as category C "green light" indicating they are safe to bury or cremate. CONCLUSIONS: Evolution in therapies and growth in functional neurosurgery has expanded the range of implantable neurosurgical devices. We provide an educational document summarizing their postmortem protocols. This resource aims to aid health-care providers and encourage proper disposal practices during burial or cremation.

A Well-Being Well-Check for Neurosurgery: Evidence-Based Suggestions for Our Specialty Based on a Systematic Review.

BACKGROUND: The path through neurosurgery is rigorous. Many neurosurgeons may experience burnout, depression, or suicide throughout training and practice. We review the literature to help foster a culture of awareness and self-care and arm trainees with coping skills to reduce burnout and, thus, suicidality during all phases of their medical careers. METHODS: A systematic search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using 4 databases. 7 studies were included. RESULTS: Overlying themes of interventions were to increase balance, mindfulness, and physical fitness. The most common interventions included in programs were educational and physical activity. We suggest a comprehensive wellness program emphasizing interventions from 4 wellness dimensions-physical, spiritual, mental, and emotional. CONCLUSIONS: Many neurosurgeons experience burnout, leading to a lack of satisfaction and early retirement; this necessitates a discipline-wide acknowledgment of endemic burnout among neurosurgeons. Systemic changes are needed to refine the training process and prioritize physician well-being- this cannot be left to chance.

Neurosurgery trainee well-being in a pediatric neurosurgery hospital: baseline data to motivate toward implementing change.

OBJECTIVE: The aim of this study was to obtain aggregated baseline pediatric neurosurgery well-being data at a tertiary care institution. METHODS: An institutional grant funded the completion of the Maslach Burnout Inventory (MBI) by 100% (n = 13) of the trainees during a 1-year period, including 1 pediatric neurosurgery fellow and 12 residents from 4 regional neurosurgery training programs. Aggregated and anonymized group results included frequency scores ranging from 0 (never) to 6 (every day). The mean ± SD group scores were compared to the general population of > 11,000 people in the human services professions. Burnout profiles were calculated on the basis of MBI scale scores by using established comparisons to standardized normal values. Burnout profile types include engaged, ineffective, overextended, disengaged, and burnout. RESULTS: The mean ± SD score for emotional exhaustion was 2.6 ± 1.1 for trainees compared with 2.3 ± 1.2 in the comparison population. The mean ± SD score for depersonalization was 1.6 ± 1 compared with 1.7 ± 1.2 in the comparison population. The mean ± SD score for personal accomplishment was 4.9 ± 0.7 compared with 4.3 ± 0.9 in the comparison population. Profiles were classified as engaged (n = 6), ineffective (n = 3), overextended (n = 3), and burnout (n = 1). CONCLUSIONS: Problematic profiles were present for more than half (7 [53.8%]) of pediatric neurosurgery trainees who cited higher emotional exhaustion than the general population of healthcare providers. Trainees scored lower in depersonalization and higher in personal accomplishment compared with the general population, which are both protective against burnout. Targeting factors that contribute to emotional exhaustion may have an impact on improving the overall well-being of pediatric neurosurgery trainees.

Safety and efficacy of intrathecal baclofen trials for the treatment of hypertonia: a retrospective cohort study.

OBJECTIVE: Intrathecal baclofen (ITB) is an effective treatment for refractory hypertonia in children. ITB has long been effective for the treatment of spasticity, and indications have naturally evolved to include dystonia and mixed pediatric movement disorders (PMDs). The established uses for ITB trials are insurance prerequisite, mixed tone, and family request. Despite agreement for ITB therapy by a multidisciplinary group of subspecialists in a complex PMD program, insurance companies often require an ITB trial be performed. A longitudinal cohort was identified to determine the safety and efficacy of ITB trials and to determine the utility of test dosing in this population. METHODS: Retrospective data analysis was performed for patients with hypertonia who underwent ITB bolus trials at the authors' institution between 2021 and 2023. Nonmodifiable risk factors and clinical variables were collected. RESULTS: Thirty-one patients (11 female) underwent 32 ITB trials. Of these patients, 67.7% had a diagnosis of mixed hypertonia, 32.3% pure spasticity, and 9.1% secondary dystonia. The mean age at test dose was 12.8 years, and 58.1% of patients were born premature. The mode Gross Motor Function Classification System score was 5. The mean difference in Barry-Albright Dystonia Scale (BADS) scores was -7.33 points (p = 0.01) at 2.5 hours postoperatively. The mean difference in upper-extremity modified Ashworth Scale (mAS) scores was -5.36 points (p = 0.003), and that for lower-extremity mAS scores was -6.61 (p < 0.001). In total, 21.9% of patients developed a post-dural puncture headache. Conversion to a permanent baclofen pump was performed in 22/32 (68.8%) patients. Of those who did not pursue pump placement, 1 patient had high surgical risk, 1 had an ineffective response, 1 had a bad reaction to the test dose and cited both regression and increased discomfort, and 2 declined despite an effective trial owing to family preferences. CONCLUSIONS: ITB trials require hospitalization in some form and carry risks of procedural complications. The decision to pursue a trial should be made on a case-by-case basis by clinicians and should not be determined by insurance companies. The complication rate of ITB trials is high, and a test dose is unnecessary in this fragile population.

Machine learning models for predicting seizure outcome after MR-guided laser interstitial thermal therapy in children.

OBJECTIVE: MR-guided laser interstitial thermal therapy (MRgLITT) is associated with lower seizure-free outcome but better safety profile compared to open surgery. However, the predictors of seizure freedom following MRgLITT remain uncertain. This study aimed to use machine learning to predict seizure-free outcome following MRgLITT and to identify important predictors of seizure freedom in children with drug-resistant epilepsy. METHODS: This multicenter study included children treated with MRgLITT for drug-resistant epilepsy at 13 epilepsy centers. The authors used clinical data, diagnostic investigations, and ablation features to predict seizure-free outcome at 1 year post-MRgLITT. Patients from 12 centers formed the training cohort, and patients in the remaining center formed the testing cohort. Five machine learning algorithms were developed on the training data by using 10-fold cross-validation, and model performance was measured on the testing cohort. The models were developed and tested on the complete feature set. Subsequently, 3 feature selection methods were used to identify important predictors. The authors then assessed performance of the parsimonious models based on these important variables. RESULTS: This study included 268 patients who underwent MRgLITT, of whom 44.4% had achieved seizure freedom at 1 year post-MRgLITT. A gradient-boosting machine algorithm using the complete feature set yielded the highest area under the curve (AUC) on the testing set (AUC 0.67 [95% CI 0.50-0.82], sensitivity 0.71 [95% CI 0.47-0.88], and specificity 0.66 [95% CI 0.50-0.81]). Logistic regression, random forest, support vector machine, and neural network yielded lower AUCs (0.58-0.63) compared to the gradient-boosting machine but the findings were not statistically significant (all p > 0.05). The 3 feature selection methods identified video-EEG concordance, lesion size, preoperative seizure frequency, and number of antiseizure medications as good prognostic features for predicting seizure freedom. The parsimonious models based on important features identified by univariate feature selection slightly improved model performance compared to the complete feature set. CONCLUSIONS: Understanding the predictors of seizure freedom after MRgLITT will assist with prognostication.

Navigated Radiofrequency Ablation Peripheral Rhizotomy for Lumbosacral Hypertonia in a Nonambulatory Patient With Spinal Fusion: Indications, Surgical Techniques, and Lessons Learned.

BACKGROUND AND OBJECTIVES: Radiofrequency ablation (RFA) is a destructive therapy which causes target tissue destruction by application of a thermal dose. Neurosurgical applications of RFA are well-described for myriad chronic pain and movement disorder diagnoses. In fact, RFA pallidotomy and thalamotomy are the initial procedures from which the field of neurosurgical management for movement disorders emerged. RFA rhizotomy for post-traumatic spasms was popular in the 1970s and 1980s, although it was largely abandoned after the invention and Food and Drug Administration approval of intrathecal baclofen therapy. RFA has not been described as a primary treatment of hypertonia in nonambulatory children. METHODS: We report a case of computer-navigated, nonselective RFA peripheral rhizotomy for a nonambulatory child with a history of severe scoliosis and spinal fusion, where an open rhizotomy was technically impractical. RESULTS: Navigation to and ablation of the bilateral L1-L5 peripheral nerves with this approach was successful, and the patient experienced bilateral lower extremity tone improvement. CONCLUSION: We use this case to highlight considerations in indications, our applied operative technique, and lessons learned from this novel application of RFA peripheral rhizotomy in children.

Showing Some Spine on Reddit: Neurosurgical Spinal Cord Conditions in Adults.

BACKGROUND: A crowdsourcing resource used by patients with spinal disease has yet to be thoroughly investigated: the Internet. One such platform is Reddit, a virtual, anonymous meeting place. Analyzing how patients use spinal condition "subreddits" may enable a greater understanding of the questions that patients do not ask their doctors. METHODS: Up to 50 posts in each subreddit's "hot" tab were retroactively screened from June 1, 2022. Posts written by those who had the condition or those interested in knowing more were included. Redditors self-identifying as younger than 18 years were excluded. Posts were subcategorized into questions related to social advice, health advice, providing health education or suggesting equipment, detailing their personal experience, or researchers recruiting patients for research. RESULTS: Eight subreddits with 398 posts were identified related to spinal conditions, including scoliosis, herniated disks, spondylolisthesis, kyphosis, spina bifida, and degenerative disk disease, and 2 subreddits for spinal cord injury. Most patients sought out health advice (59.8%), specifically related to questions regarding their treatments (33.6%), followed by social advice (14.1%) relating to activities in their daily lives. Six posts from the spinal cord injury subreddits discussed the inability to achieve or maintain an erection. DISCUSSION: Patients with spinal conditions congregate on Reddit. Analysis of subreddits allows for a more robust fund of knowledge, granting providers an opportunity to address the main health concerns of patients and caregivers.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Surgical Interventions.

BACKGROUND: Chiari malformation type I (CIM) diagnoses have increased in recent years. Controversy regarding the best operative management prompted a review of the literature to offer guidance on surgical interventions. OBJECTIVE: To assess the literature to determine (1) whether posterior fossa decompression or posterior fossa decompression with duraplasty is more effective in preoperative symptom resolution; (2) whether there is benefit from cerebellar tonsillar resection/reduction; (3) the role of intraoperative neuromonitoring; (4) in patients with a syrinx, how long should a syrinx be observed for improvement before additional surgery is performed; and 5) what is the optimal duration of follow-up care after preoperative symptom resolution. METHODS: A systematic review was performed using the National Library of Medicine/PubMed and Embase databases for studies on CIM in children and adults. The most appropriate surgical interventions, the use of neuromonitoring, and clinical improvement during follow-up were reviewed for studies published between 1946 and January 23, 2021. RESULTS: A total of 80 studies met inclusion criteria. Posterior fossa decompression with or without duraplasty or cerebellar tonsil reduction all appeared to show some benefit for symptom relief and syrinx reduction. There was insufficient evidence to determine whether duraplasty or cerebellar tonsil reduction was needed for specific patient groups. There was no strong correlation between symptom relief and syringomyelia resolution. Many surgeons follow patients for 6-12 months before considering reoperation for persistent syringomyelia. No benefit or harm was seen with the use of neuromonitoring. CONCLUSION: This evidence-based clinical guidelines for the treatment of CIM provide 1 Class II and 4 Class III recommendations. In patients with CIM with or without syringomyelia, treatment options include bone decompression with or without duraplasty or cerebellar tonsil reduction. Improved syrinx resolution may potentially be seen with dural patch grafting. Symptom resolution and syrinx resolution did not correlate directly. Reoperation for a persistent syrinx was potentially beneficial if the syrinx had not improved 6 to 12 months after the initial operation. The full guidelines can be seen online at https://www.cns.org/guidelines/browse-guidelines-detail/3-surgical-interventions .

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Diagnosis.

BACKGROUND: Chiari I malformation (CIM) is characterized by descent of the cerebellar tonsils through the foramen magnum, potentially causing symptoms from compression or obstruction of the flow of cerebrospinal fluid. Diagnosis and treatment of CIM is varied, and guidelines produced through systematic review may be helpful for clinicians. OBJECTIVE: To perform a systematic review of the medical literature to answer specific questions on the diagnosis and treatment of CIM. METHODS: PubMed and Embase were queried between 1946 and January 23, 2021, using the search strategies provided in Appendix I of the full guidelines. RESULTS: The literature search yielded 567 abstracts, of which 151 were selected for full-text review, 109 were then rejected for not meeting the inclusion criteria or for being off-topic, and 42 were included in this systematic review. CONCLUSION: Three Grade C recommendations were made based on Level III evidence. The full guidelines can be seen online at https://www.cns.org/guidelines/browse-guidelines-detail/1-imaging .

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Symptoms.

BACKGROUND: Chiari I malformation (CIM) is characterized by descent of the cerebellar tonsils through the foramen magnum, potentially causing symptoms from compression or obstruction of the flow of cerebrospinal fluid. Diagnosis and treatment of CIM is varied, and guidelines produced through systematic review may be helpful for clinicians. OBJECTIVE: To perform a systematic review of the medical literature to answer specific questions on the diagnosis and treatment of CIM. METHODS: PubMed and Embase were queried between 1946 and January 23, 2021, using the search strategies provided in Appendix I of the full guidelines. RESULTS: The literature search yielded 430 abstracts, of which 79 were selected for full-text review, 44 were then rejected for not meeting the inclusion criteria or for being off-topic, and 35 were included in this systematic review. CONCLUSION: Four Grade C recommendations were made based on Class III evidence, and 1 question had insufficient evidence. The full guidelines can be seen online at https://www.cns.org/guidelines/browse-guidelines-detail/2-symptoms .

Pediatric intraspinal arachnoid cyst: successful endoscopic fenestration. Illustrative case.

BACKGROUND: Intradural spinal arachnoid cysts (SACs) are a rare cause of spinal cord compression. Treatment is centered on decompression of the spinal cord via laminectomy or laminoplasty followed by resection or fenestration of the cyst. Although laminectomy or laminoplasty access may be needed to achieve the desired result, either procedure can be associated with more extensive surgical dissections and long-term spinal stability concerns, including postsurgical kyphosis. OBSERVATIONS: The authors present a case of a cervical intradural SAC in a 4-month-old girl presenting with symptomatic compression. The patient was treated by laminotomy and endoscopic fenestration of the SAC with resolution of symptoms and no disease progression 10 months postoperatively, when the patient was 14 months old. LESSONS: Microsurgical endoscopic fenestration of an intradural SAC can provide a less invasive means of treatment while avoiding the risks associated with more invasive approaches.