Pediatric neurosurgical medulloblastoma outcomes in La Paz, Bolivia: How a Lower Middle-Income Country (LMIC) institution in South America compares to the United States.

BACKGROUND: How pediatric medulloblastoma patients fare in Lower Middle-Income Country (LMICs) in South America is not well understood. Correspondingly, the aim of this study was to summarize the pediatric neurosurgical experience of an institution in La Paz, and compare outcomes to that of a generalized High Income Country (HIC) United States (US) experience. METHODS: A retrospective review of all pediatric neurosurgical medulloblastoma patients at the Children's Hospital of La Paz, Bolivia (Hospital del Niño "Dr. Ovidio Aliaga Uria") between 2014 and 2023 was conducted and compared to a generalized US experience abstracted from the US National Cancer Database (NCDB) and National Inpatient Sample (NIS) databases. Categorical, continuous and survival data were statistically summarized and compared. RESULTS: A total of 24 pediatric medulloblastoma patients underwent neurosurgical treatment at the Hospital del Niño. In this La Paz cohort, there were 15 (63%) males and 9 (38%) females, with a mean age of 5.6 years old at diagnosis. The majority of patients underwent subtotal resection (STR, 79%), while the remaining patients underwent biopsy only. Ten (42%) patients expired during their hospitalization, and mean length of stay overall was 39 days. Only 8 (33%) patients received adjuvant treatment after surgery. Median overall survival from diagnosis in the La Paz cohort was 1.9 months. Compared to the US databases, the La Paz cohort experienced significantly more emergency room admissions for surgery, less gross total resection, more STR, more return to operating room for ventriculoperitoneal shunting, more bacteremia, more tracheostomy procedures, more percutaneous gastrostomy placements, longer lengths of stay, less adjuvant chemotherapy, less radiation therapy, shorter follow-up, and ultimately, significantly shorter overall survival (all P < 0.050). CONCLUSIONS: Pediatric neurosurgical medulloblastoma outcomes at the Children's Hospital of La Paz, Bolivia are significantly inferior to that of a generalized US experience. Future research is required to identify institution- and country-specific initiatives to improve discrepancies between institutions in LMICs in South America compared to HICs.

Intrathecal chemotherapy for leptomeningeal disease in high-grade gliomas: a systematic review.

BACKGROUND: Leptomeningeal disease (LMD) secondary to high grade glioma (HGG), such as glioblastoma (GBM), are characterized by the spread of tumor cells to the leptomeninges which further complicates treatment approaches. Intrathecal (IT) chemotherapy has surfaced as a potential strategy to bypass the blood-brain barrier and address the challenges posed by disseminated disease. Here, we present a review of the safety and efficacy of IT chemotherapy in the treatment of LMD secondary to HGG. METHODS: A systematic review following PRISMA guidelines was conducted searching PubMed and Embase from January 1995 to September 2022 using specified terms related to IT chemotherapy for LMD. Included articles involved patients diagnosed with LMD from HGG, treated with intrathecal chemotherapy, and provided survival data. Data, including demographics, tumor characteristics, treatment, and survival information, were collected and independently extracted. RESULTS: A total of 68 patients across 10 clinical studies were diagnosed with LMD from HGG and included in the review. Among these patients, the average age at diagnosis was 44.2 years. GBM was the most common tumor type (n = 58, 85.3%). A majority of the patients presented with recurrent disease (n = 29, 60.4%). The review encompassed various IT chemotherapy regimens, including mafosfamide, thio-TEPA, 5-fluoro-2'-deoxyuridine (FdUrd), methotrexate (MTX), and cytarabine; however, dosages and frequencies were inconsistently reported. The mean progression-free survival (PFS) and overall survival (OS) for this cohort were 7.5 months and 11.7 months, respectively. Common side effects of IT chemotherapy included headaches, nausea, and vomiting, with more severe complications such as myelotoxicity, disseminated intravascular coagulopathy, meningitis, and gastrointestinal toxicity reported in some cases. CONCLUSION: LMD continues to be an uncommon complication associated with HGG with a poor prognosis. This article provides an overview of the presently available literature on IT chemotherapy for LMD secondary to HGG, and their respective treatment protocols with overall survival attributes. Additional research is warranted to ascertain how to maximize the potential efficacy of IT chemotherapy as a treatment option.

Comparative analysis of bevacizumab and LITT for treating radiation necrosis in previously radiated CNS neoplasms: a systematic review and meta-analysis.

PURPOSE: Radiation necrosis (RN) is a local inflammatory reaction that arises in response to radiation injury and may cause significant morbidity. This study aims to evaluate and compare the efficacy of bevacizumab and laser interstitial thermal therapy (LITT) in treating RN in patients with previously radiated central nervous system (CNS) neoplasms. METHODS: PubMed, Cochrane, Scopus, and EMBASE databases were screened. Studies of patients with radiation necrosis from primary or secondary brain tumors were included. Indirect meta-analysis with random-effect modeling was performed to compare clinical and radiological outcomes. RESULTS: Twenty-four studies were included with 210 patients in the bevacizumab group and 337 patients in the LITT group. Bevacizumab demonstrated symptomatic improvement/stability in 87.7% of cases, radiological improvement/stability in 86.2%, and steroid wean-off in 45%. LITT exhibited symptomatic improvement/stability in 71.2%, radiological improvement/stability in 64.7%, and steroid wean-off in 62.4%. Comparative analysis revealed statistically significant differences favoring bevacizumab in symptomatic improvement/stability (p = 0.02), while no significant differences were observed in radiological improvement/stability (p = 0.27) or steroid wean-off (p = 0.90). The rates of adverse reactions were 11.2% for bevacizumab and 14.9% for LITT (p = 0.66), with the majority being grade 2 or lower (72.2% for bevacizumab and 62.5% for LITT). CONCLUSION: Both bevacizumab and LITT exhibited favorable clinical and radiological outcomes in managing RN. Bevacizumab was found to be associated with better symptomatic control compared to LITT. Patient-, diagnosis- and lesion-related factors should be considered when choosing the ideal treatment modality for RN to enhance overall patient outcomes.

The epidemiologic associations of food availability with national incidence and mortality rates of pediatric central nervous system tumors.

BACKGROUND: The epidemiology of central nervous system (CNS) tumors in pediatric patients worldwide continues to be defined. To date, there has been no evaluation of how national food availability may associate with the incidence and mortality of these tumors. Correspondingly, the aim of this study was to define if such associations exist. METHODS: The most updated incidence and mortality rates of CNS tumors in pediatric patients were abstracted by country from the Global Burden of Disease database. Data regarding food availability parameters were identified and abstracted from the Food Systems Dashboard database. Associations were tested using univariate and multivariate regression analyses. RESULTS: There were sufficient data in a total of 175 countries worldwide describing the required outcomes. Median incidence and mortality rates across these countries were 1.63 per 100,000 and 0.80 per 100,000, respectively. Higher incidence rates of pediatric CNS tumors were statistically associated with lower availability of fruit and vegetables (P = 0.02), higher average protein supply (P < 0.01), lower share of dietary energy from cereal and roots (P < 0.01), lower supply of meat (P < 0.01), lower supply of nuts and seeds (P < 0.01), lower supply of vegetable oils (P < 0.01), and higher supply of vegetables (P < 0.01). Higher mortality rates due to pediatric CNS tumors were statistically associated with lower availability of fruit and vegetables (P = 0.048), lower supply of fish (P = 0.046), and lower supply of nuts and seeds (P = 0.04). When categorizing countries based on income status, there was a decrease in significant associations found more pronounced in low-middle income countries. CONCLUSIONS: There are many novel associations between national food availability and the incidence and mortality rates of pediatric CNS tumors across the world, which may be more pronounced and divergent in low-middle income countries. A greater understanding is needed to identify what specific components of the significant parameters influence these trends and how public health efforts may best address these associations to improve overall outcomes.

The osteoplastic flap for pediatric temporal lobe epilepsy treatment: step-by-step guide and technical nuances.

The osteoplastic flap is an under-utilized craniotomy approach in pediatric temporal lobe epilepsy treatment. By preserving the myofascial attachment of the temporalis muscle, the flap is allowed the remain vascularized while subdural and intracranial electrodes are in place. The process in which the flap is made and handled throughout this process can be complicated. We herein detail our surgical technique for the osteoplastic flap in the setting of pediatric temporal lobe epilepsy treatment, and highlight the surgical nuances specific to our 2-stage protocol in treating pediatric temporal lobe epilepsy.

Intramedullary pediatric low-grade glioma of the spine.

PURPOSE: Pediatric intramedullary spinal cord low-grade gliomas (pLGGs) are rare diagnoses among central nervous system (CNS) tumors in the pediatric population. The classic presentation of the patients includes some degree of neurologic deficit, although many times the symptoms are vague which leads to delayed diagnosis. MATERIAL AND METHODS: The first step in the diagnosis includes special parameters in spinal imaging, particularly magnetic resonance imaging (MRI), and surgical resection remains the cornerstone for both diagnosis and treatment. Yet, recent years advancement in molecular and genetic understanding of CNS tumors allows for better adjustment of the treatment and follow-up regimens. Based on postoperative status, adjuvant therapy may provide additional therapeutic advantage for some types of tumors. CONCLUSION: Ultimately, patients have a very promising prognosis when treated appropriately in most of the cases of pediatric spinal cord LGG with continued advances arising. This manuscript summarizes the most contemporary evidence regarding clinical and treatment features of intramedullary pLGGs.

Postoperative pain management strategies following selective dorsal rhizotomy in pediatric cerebral palsy patients: a systematic review of published regimens.

BACKGROUND: Surgical selective dorsal rhizotomy (SDR) in appropriate pediatric cerebral palsy patients is an effective treatment for spasticity. However, there remains heterogeneity reported in postoperative pain management with and without opioid medication in this delicate cohort. The objective of this study was to aggregate pertinent metadata by means of systematic review to summarize all relevant postoperative pain regimens in the literature. METHODS: Searches of multiple electronic databases from inception to June 2024 were conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Outcomes and regimens were then summarized. RESULTS: A total of 16 cohort studies were included in this study published between 1989 and 2024. Amongst all studies, outcomes were reported for a total of 636 with median cohort age 6.3 years, and median cohort male proportion 62% was reported. Four studies reported regimens involving systemic analgesia, 8 studies reported regimens involving epidural analgesia, and the remaining 4 studies reported regimens involving intrathecal analgesia. All studies primary pain management involved opioid medication, with 8 studies having opioid medication available as indicated, 3 studies having opioid medication as a single dose, and the remaining studies having opioid medication as a continuous agent in the immediate postoperative period. Across all studies, rates of desaturations, nausea and/or vomiting, and pruritis ranged from 0 to 55%, 25 to 82%, and 15 to 70% respectively. Eleven of the 16 studies included a comparative component, demonstrating that their regimen was at least comparable to their control regimen, if not superior. CONCLUSIONS: Multiple variations of postoperative pain management in pediatric cerebral palsy patients following SDR have been reported in the literature, involving systemic, epidural, and intrathecal analgesia. Concerns for adverse effects with the utilization of opioid medication has led to the trend towards multimodal pain management relying more on non-opioid medication regimens in the more recent literature.

Pediatric shunt failure in a resource limited Lower-Middle Income Country (LMIC) institution in La Paz, Bolivia.

BACKGROUND: Shunt failure is an undesirable but common occurrence following neurosurgical shunting for pediatric hydrocephalus. Little is known about the occurrence of failure in lower-middle income country (LMIC) settings in South America. The objective of this study was to evaluate shunt failure in the sole publicly funded pediatric hospital in La Paz, Bolivia, with limited resources. METHODS: A retrospective review of all patients at the Children's Hospital of La Paz, Bolivia (Hospital del Niño "Dr. Ovidio Aliaga Uria"), was conducted to identify all patients whose index surgical shunting for hydrocephalus was performed between 2019 and 2023. Categorical, continuous, and shunt failure data were statistically summarized. RESULTS: A total of 147 unique pediatric patients underwent index ventriculoperitoneal shunting for hydrocephalus in the study period. There were 90 (61%) male and 57 (39%) female patients, with a median age of 2.2 months at index shunting procedure. The most common surgical indications were congenital hydrocephalus (n = 95, 65%), followed by hydrocephalus secondary to congenital defect (n = 25, 17%) and tumor (n = 18, 12%). A total of 18 (12%) of patients experienced inpatient failure during index admission requiring surgical revision at a median time of 12.5 days after index shunting. Postoperative imaging (OR 2.97, P = 0.037) and postoperative infection (OR 3.26, P = 0.032) during index admission both independently and statistically predicted inpatient failure. Of the 96 patients (65%) with postoperative follow-up, 16 (n = 16/96, 17%) patients experienced outpatient failure requiring readmission to hospital and surgical revision at a median time of 3.7 months after discharge. Kaplan-Meier estimations of overall inpatient and outpatient failure in this cohort were 23% (95% CI 14-37) and 28% (95% CI 15-49), respectively. CONCLUSIONS: Both inpatient and outpatient shunt failures are significant complications in the management of pediatric hydrocephalus in La Paz, Bolivia. We identify multiple avenues to improve these outcomes which are institution-specific based on the review of these failures. Lessons learnt may be applicable to other similarly resourced institutions across South American LMICs.

Machine learning applications in craniosynostosis diagnosis and treatment prediction: a systematic review.

Craniosynostosis refers to the premature fusion of one or more of the fibrous cranial sutures connecting the bones of the skull. Machine learning (ML) is an emerging technology and its application to craniosynostosis detection and management is underexplored. This systematic review aims to evaluate the application of ML techniques in the diagnosis, severity assessment, and predictive modeling of craniosynostosis. A comprehensive search was conducted on the PubMed and Google Scholar databases using predefined keywords related to craniosynostosis and ML. Inclusion criteria encompassed peer-reviewed studies in English that investigated ML algorithms in craniosynostosis diagnosis, severity assessment, or treatment outcome prediction. Three independent reviewers screened the search results, performed full-text assessments, and extracted data from selected studies using a standardized form. Thirteen studies met the inclusion criteria and were included in the review. Of the thirteen papers examined on the application of ML to the identification and treatment of craniosynostosis, two papers were dedicated to sagittal craniosynostosis, five papers utilized several different types of craniosynostosis in the training and testing of their ML models, and six papers were dedicated to metopic craniosynostosis. ML models demonstrated high accuracy in identifying different types of craniosynostosis and objectively quantifying severity using innovative metrics such as metopic severity score and cranial morphology deviation. The findings highlight the significant strides made in utilizing ML techniques for craniosynostosis diagnosis, severity assessment, and predictive modeling. Predictive modeling of treatment outcomes following surgical interventions showed promising results, aiding in personalized treatment strategies. Despite methodological diversities among studies, the collective evidence underscores ML's transformative potential in revolutionizing craniosynostosis management.

Elevated skull fractures: an institutional experience and individual participant data meta-analysis.

Elevated skull fracture (ESF) is a rare but potentially life-threatening type of skull fracture. The literature on this topic is relatively sparse. Herein, we conducted a meta-analysis of all the patients reported in the literature with ESFs with respect to their clinical management to better inform practice. On 20th of January 2023, we conducted a systematic search of literature to find all published cases of ESF. We also conducted a retrospective review of ESF cases from our institution. The data collection and analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. After screening, 28 studies met the inclusion criteria. A total of 104 individual patients were included in the meta-analysis, with a median age of 24 years and 85.7% of whom were males. 11 patients (11.2%) had an unfavorable outcome while 37 (35.2%) had one or more complications. We found that GCS on admission is an independent predictor of poor outcome in ESF (odds ratio (95% confidence interval) = 1.605 (1.110-2.315), p value = 0.012). Regarding complications, dural injury (odds ratio (95% confidence interval) = 66.667 (7.407-500.00), p value < 0.001) and multiple bone involvement (odds ratio (95% confidence interval) = 6.849 (2.127-22.222), p value = 0.001) were independent predictors of complication. ESFs represent a rare yet consequential form of cranial injury, carrying potentially life-threatening implications if not promptly addressed. In this study, we present the meta-analysis of outcomes and complications within this patient cohort, offering a comprehensive synthesis of existing literature on this pathology. However, further investigation is imperative to provide higher-quality evidence and address lingering uncertainties in the classification and management of ESFs.

Influence of instrumentation type on outcomes after surgical management of spondylodiscitis: a systematic review and meta-analysis.

OBJECTIVE: Spondylodiscitis refers to infection of the intervertebral disk and neighboring structures. Outcomes based on instrumentation type are not well reported in the literature, but are important in establishing guidelines for surgical management of spondylodiscitis. This study aims to clarify the effect of instrumentation material selection on clinical and radiographic outcomes in patients with spondylodiscitis. METHODS: Studies that evaluated the use of polyetheretherketone (PEEK), titanium, allograft, and/or autologous bone grafts for spondylodiscitis were identified in the literature. Radiographic and clinical data were analyzed using a meta-analysis of proportions, with estimated risk and confidence intervals reported for our primary study outcomes. RESULTS: Thirty-two retrospective studies totaling 1088 patients undergoing surgical management of spondylodiscitis with PEEK, TTN, allograft, and autologous bone graft instrumentation were included. There were no differences in fusion rates (p-interaction = 0.55) with rates of fusion of 93.4% with TTN, 98.6% with allograft, 84.2% with autologous bone graft, and 93.9% with PEEK. There were no differences in screw loosening (p-interaction = 0.52) with rates of 0.33% with TTN, 0% with allograft, 1.3% with autologous bone graft, and 8.2% with PEEK. There were no differences in reoperation (p-interaction = 0.59) with rates of 2.64% with TTN, 0% with allograft, 1.69% with autologous bone graft, and 3.3% with PEEK. CONCLUSIONS: This meta-analysis demonstrates that the choice of instrumentation type in the surgical management of spondylodiscitis resulted in no significant differences in rate of radiographic fusion, screw loosening, or reoperation. Future comparative studies to optimize guidelines for the management of spondylodiscitis are needed.

The use of advanced neuroimaging modalities in the evaluation of low-grade glioma in adults: a literature review.

Low-grade gliomas encompass a subgroup of cancerous glial cell growths within the central nervous system and are distinguished by their slow growth and relatively low malignant potential. Despite their less aggressive nature, these tumors can still cause significant neurological symptoms through the compression of surrounding neural and vascular structures and, in some instances, undergo malignant transformation. For these reasons, timely and appropriate evaluation and management of low-grade gliomas is critical. Medical imaging stands as a cornerstone for evaluating patients with low-grade gliomas because of its noninvasive nature and ability to provide a vast amount of information about the underlying lesion. With the growing number of neuroimaging techniques and their capabilities, there is a lack of clear guidance on which techniques to utilize for the assessment of low-grade gliomas and what their respective core use cases should be. In this literature review, the authors discuss in significant depth the available evidence pertaining to the use of advanced neuroimaging techniques in the evaluation and management of low-grade gliomas. Specifically, they review the specificity, sensitivity, accuracy, and use cases of magnetic resonance spectroscopy (MRS), perfusion MR imaging (perfusion MRI), diffusion tensor imaging (DTI), functional MRI (fMRI), positron emission tomography (PET), single-photon emission computed tomography (SPECT), as well as other emerging imaging techniques. They conclude that most of the advanced neuroimaging techniques are reliable in differentiating low- from high-grade gliomas, whereas MRS and DTI may further support molecular subclassification of the tumor. PET has been best employed for the purpose of tumor biopsy, whereas fMRI and DTI can be particularly valuable in preoperative surgical planning, as they delineate the functionally eloquent brain regions that need to be preserved during tumor resection. MRS, PET, SPECT, and perfusion MRI are best suited to monitor tumor progression, as their respective metrics closely correlate with the underlying metabolic activity of the tumor. Together, these techniques offer a vast amount of information and serve as tools for neurologists and neurosurgeons managing patients with low-grade gliomas.

Clinical Equipoise in the Management of Patients With Femoroacetabular Impingement Syndrome and Concomitant Tönnis Grade 2 Hip Osteoarthritis or Greater: An International Expert-Panel Delphi Study.

PURPOSE: To gather global-expert opinion on the management of patients with femoroacetabular impingement syndrome (FAIS) and Tönnis grade 2 hip osteoarthritis (OA) or greater. METHODS: An internet-based modified Delphi methodology was used via an online platform (Online Surveys) using the CREDES (Conducting and Reporting Delphi Studies) guidelines. The expert panel comprised 27 members from 18 countries: 21 orthopaedic surgeons (78%), 5 physiotherapists (18%), and 1 dual orthopaedic surgeon-sport and exercise medicine physician (4%). Comments and suggestions were collected during each round, and amendments were performed for the subsequent round. Between each pair of rounds, the steering panel provided the experts with a summary of results and amendments. Consensus was set a priori as minimum agreement of 80%. RESULTS: Complete participation (100%) was achieved in all 4 rounds. A final list of 10 consensus statements was formulated. The experts agreed that there is no single superior management strategy for FAIS with Tönnis grade 2 OA and that Tönnis grade 3 OA and the presence of bilateral cartilage defects (acetabular and femoral) is a contraindication for hip preservation surgery. Nonoperative management should include activity modification and physiotherapy with hip-specific strengthening, lumbo-pelvic mobility training, and core strengthening. There was no consensus on the need for 3-dimensional imaging for initial quantification of joint degeneration. CONCLUSIONS: There is clinical equipoise in terms of the best management strategy for patients with FAIS and Tönnis grade 2 OA, and therefore, there is an urgent need to perform a randomized controlled trial for this cohort of patients to ascertian the best management strategy. LEVEL OF EVIDENCE: Level V, expert opinion.

Do reconstructive techniques for osteochondritis dissecans of the skeletally mature knee work? A systematic review and meta-analysis.

PURPOSE: Osteochondritis dissecans (OCD) is a common cause of knee pain. Management for adult-onset OCD (AOCD) usually involves surgery. Surgical treatments include palliative, reparative and reconstructive techniques. The aim of this systematic review and meta-analysis is to evaluate the efficacy of reconstructive techniques for the treatment of OCD in skeletally mature knees. METHODS: A systematic search was carried out on four databases up to November 2023 (Medline, Embase, Cochrane Library, Web of Science). The study was registered on international prospective register of systematic reviews and performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Clinical studies on skeletally mature patients were included, which utilised reconstructive techniques such as autologous chondrocyte implantation (ACI), matrix-induced autologous chondrocyte implantation, osteochondral allograft transplantation surgery or bone marrow-derived cellular transplantation. Demographical data, patient-reported outcome measures and postoperative complications were recorded. Quantitative outcome measures that were comparable across studies were pooled for meta-analysis. A random effects model was used. Heterogeneity was assessed using the I2 statistic and Cochran's Q test. Statistical significance was set at p < 0.05. Risk of bias was assessed using the risk of bias in non-randomised studies - of interventions tool for nonrandomised studies. RESULTS: Sixteen studies were included with 458 OCD lesions in 432 patients. The average age was 24.9, and 62.6% were male. The mean follow-up time was 61.5 months. At 36 months follow-up, International Knee Documentation Committee (IKDC) subjective, Tegner and EuroQol-visual analogue scale (EQ-VAS) scores improved from 42.4 to 78.6 (standard mean difference [SMD]: 2.47; p < 0.001), 2.27-4.99 (SMD: 2.363; p = 0.002) and 30.4-57.5 (SMD: 2.390; p < 0.001), respectively. Overall complication rate was 8.9%. Smaller OCD lesion sizes resulted in a greater improvement in IKDC subjective (SMD: 2.64 vs. 2.01; p = 0.038), EQ-VAS (SMD: 3.16 vs. 0.95; p = 0.046) and Tegner scores (SMD: 3.13 vs. 1.05; p = 0.007) and had a lower complication rate (p = 0.008). Males showed a larger improvement in IKDC subjective scores than females (SMD: 2.56 vs. 1.56; p = 0.029), while younger patients had a larger improvement in IKDC subjective scores (SMD: 2.71 vs. 2.12; p = 0.045) and fewer complications than older patients (p = 0.003). There were no significant differences between cohorts treated with ACI and those treated with non-ACI reconstructive techniques. Publication bias was not detected (n.s.). CONCLUSION: Reconstructive techniques used to treat OCD in the skeletally mature knee resulted in significant improvements in clinical and functional outcomes, with a low overall complication rate. Since a younger age leads to a greater improvement in IKDC subjective score and a lower complication rate, surgical intervention should not be delayed, especially in AOCD lesions which are more likely to follow a progressive and unremitting clinical course. LEVEL OF EVIDENCE: Level III.

What are the Outcomes of Secondary Patella Resurfacing for Dissatisfaction Following Primary Knee Arthroplasty? A Systematic Review and Meta-Analysis of 604 Knees.

BACKGROUND: Secondary patella resurfacing is often performed for dissatisfaction following primary knee arthroplasty where the native patella was retained. The purpose of this meta-analysis was to evaluate outcomes of secondary patella resurfacing. METHODS: The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting on patients who underwent secondary patella resurfacing after previous primary knee arthroplasty with retention of the native patella were considered eligible. The risk of bias was assessed using the Methodological Index for Non-Randomized studies tool. A random-effects model and the inverse-variance weighting method was used for meta-analysis. There were sixteen retrospective studies including 604 knees (594 patients) with a mean follow up of 42 months (range, 2 to 197). RESULTS: An overall improvement in patient-reported outcomes (PROMs) was achieved in 53% of cases from pooled data available for 293 knees [95% Confidence Interval (CI) (0.44, 0.62), I2=68% - moderate heterogeneity]. The pooled proportion of patients satisfied with the procedure was 59% [95% CI (48, 68), I2 = 70% - moderate heterogeneity] in a sample size of 415. There was a minimal rate (2%) of complication incidence when performing secondary patella resurfacing and a pooled rate of revision surgery of 10%. CONCLUSIONS: An improvement in pain, satisfaction, and PROMs was achieved in slightly more than half of the patients following secondary patella resurfacing. However, studies lacked standardized objective selection criteria for the procedure and the available data was predominantly retrospective, with high heterogeneity and variation in outcome reporting.

Infant Hydrocephalus.

Hydrocephalus is a neurosurgical condition that is highly prevalent in pediatric medicine. In the infant population, there is a distinct set of features that all primary pediatricians would benefit from understanding. Infant hydrocephalus can present prenatally on imaging and postnatally with symptomatic enlargement of the head and associated skull features and raised intracranial pressures. The 2 major pathophysiology models of infant hydrocephalus are the bulk flow and the intracranial pulsatility models. The most common acquired forms of hydrocephalus include posthemorrhagic hydrocephalus, postinfectious hydrocephalus, and brain tumor. The most common congenital forms of hydrocephalus include those due to myelomeningocele, aqueductal stenosis, and posterior fossa malformations. There are various evaluation and treatment algorithms for these different types of hydrocephalus, including cerebrospinal fluid shunting and endoscopic third ventriculostomy. The aim of this review was to elaborate on those features of hydrocephalus to best equip primary pediatricians to diagnose and manage hydrocephalus in infants.

Postoperative course of cerebrospinal fluid diversion in the setting of leptomeningeal disease: a systematic review, meta-analysis, and meta-regression with an illustrative case.

BACKGROUND: Management of hydrocephalus symptoms in the setting of leptomeningeal disease (LMD) includes cerebrospinal fluid (CSF) diversion, which can in the form of ventriculoperitoneal shunting (VPS) and lumboperitoneal shunting (LPS). However, the quantifiable postoperative course following this intervention is poorly defined. Correspondingly the aim of our study was to quantitatively define and analyze the pooled metadata regarding this topic. METHODS: Multiple electronic databases from inception to March 2023 were searched following PRISMA guidelines. Respective cohort-level outcomes were then abstracted and pooled by means of meta-analyses and analyzed by means meta-regression, both utilizing random-effects modeling. Post-hoc bias evaluation was then performed for all outcomes. RESULTS: A total of 12 studies were identified for inclusion, describing 503 LMD patients managed by CSF diversion - 442 (88%) by VPS and 61 (12%) by LPS. Median male percentage and age at diversion were 32% and 58 years respectively, with lung and breast cancer the most common primary diagnoses. Meta-analysis demonstrated pooled incidence of symptom resolution in 79% (95% CI 68-88%) of patients after index shunt surgery, and shunt revision required in 10% (95% CI 6-15%) of cases. Pooled overall survival from index shunt surgery was 3.8 mo (95% CI 2.9-4.6 mo) across all studies. Meta-regression demonstrated that studies published later trended towards significantly shorter overall survival from index shunt surgery (co-efficient=-0.38, P = 0.023), whereas the proportion of VPS to LPS in each study did not impact survival (P = 0.89). When accounting for these biases, overall survival from index shunt surgery was re-estimated to be shorter 3.1 mo (95% CI 1.7-4.4 mo). We present an illustrative case demonstrating the course of symptom improvement, shunt revision and an overall survival of 2 weeks from index CSF diversion. CONCLUSION: Although CSF diversion in the setting of LMD can improve hydrocephalus symptoms in the majority of patients, there is a non-negligible proportion that will require shunt revision. Postoperatively, the prognosis of LMD remains poor irrespective of shunt type, and despite possible biases within the current literature, the expected median overall survival after index surgery is a matter of months. These findings support CSF diversion as an effective palliative procedure when considering symptoms and quality of life. Further research is required to understand how postoperative expectations can be managed to respect the best wishes of patients, their family, and the treating clinical team.

Clinical course of ventriculoperitoneal shunting for hydrocephalus following glioblastoma surgery: a systematic review and meta-analysis.

BACKGROUND: Surgical resection of glioblastoma (GBM) remains a cornerstone in the current treatment paradigm. The postoperative evolution of hydrocephalus necessitating ventriculoperitoneal shunting (VPS) continues to be defined. Correspondingly the objective of this study was to aggregate pertinent metadata to better define the clinical course of VPS for hydrocephalus following glioblastoma surgery in light of contemporary management. METHODS: Searches of multiple electronic databases from inception to November 2023 were conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Outcomes were pooled by random-effects meta-analyses where possible. RESULTS: A total of 12 cohort studies satisfied all selection criteria, describing a total of 6,098 glioblastoma patients after surgery with a total of 261 (4%) of patients requiring postoperative VPS for hydrocephalus. Meta-analysis demonstrated the estimated pooled rate of symptomatic improvement following VPS was 78% (95% CI 66-88), and the estimated pooled rate of VPS revision was 24% (95% CI 16-33). Pooled time from index glioblastoma surgery to VPS surgery was 4.1 months (95% CI 2.8-5.3), and pooled survival time for index VPS surgery was 7.3 months (95% CI 5.4-9.4). Certainty of these outcomes were limited by the heterogenous and palliative nature of postoperative glioblastoma management. CONCLUSIONS: Of the limited proportion of glioblastoma patients requiring VPS surgery for hydrocephalus after index surgery, 78% patients are expected to show symptom improvement, and 24% can expect to undergo revision surgery. An individualized approach to each patient is required to optimize both index glioblastoma and VPS surgeries to account for anatomy and goals of care given the poor prognosis of this tumor overall.

Global, regional, and national epidemiological trends in neural tube defects between 1990 and 2019: a summary.

BACKGROUND: Neural tube defects (NTD), such as spina bifida, are surgically treatable and primarily preventable non-communicable diseases. How incidence, mortality and disability-adjusted life year (DALYs) rates of NTD have modulated over time is not well defined. Correspondingly, the aim of this study was to quantitively define the global, regional, and national epidemiological trends in these. METHODS: A retrospective review of data from the Global Burden of Disease Study 2019 Database was performed. Global, regional, and national outcomes for NTD were collected for incidence, mortality, and DALY rates and their age-standardized metrics analyzed. There were 7 regions at a regional level, and 204 countries and territories at a national level. RESULTS: Globally, the latest age-standardized rates of incidence, mortality, and DALYs of NTD were 2.1 per 100,000 population, 1.3 per 1000,000, and 117 per 100,000 respectively. All rates demonstrated decreases in the last two decades to now. Regionally, sub-Saharan Africa and North America demonstrated the highest and lowest age-standardized rates of incidence (4.0 vs 0.5 per 100,000), mortality (3.0 vs 0.4 per 100,000), and DALYs (266 vs 33 per 100,000), respectively. Similar to global trends, all regions demonstrated decrease in these rates over the last two decades. Nationally, the highest age-standardized rates were reported in African countries, Central African Republic, with highest incidence rate (7.6 per 100,000), and Burkina Faso with highest mortality rate (5.8 per 100,000) and DALY rate (518 per 100,000). India was the country with the highest number of new NTD cases (22,000 per country) in the most recent year of study. Between 1990 and 2019, 182/204 (89%), 188/204 (92%), and 188/204 (92%) countries and territories demonstrated a decrease in age-standardized incidence, mortality, and DALY rates respectively, with the greatest decreases seen in Saudi Arabia for all statistics. CONCLUSIONS: Between 1990 and 2019, overall trends in incidence, mortality, and DALY rates of NTD have been favorably downtrending globally. Regionally, these rates in the highest sub-Saharan Africa were 8 times greater compared to the lowest North America. Nationally, although the majority of countries showed decreases in these rates, a small number of countries demonstrated uptrending rates of NTD. Understanding the mechanics behind these trends will allow future public health endeavors for both prevention and neurosurgical treatment to be targeted appropriately.

Surgical considerations for spinal epidural hematoma evacuation in the setting of blue rubber bleb nevus syndrome in a child.

Blue rubber bleb nevus syndrome (BRBNS) is a rare condition that presents with venous malformation blebs throughout the body, most commonly on the skin and gastrointestinal tract. There have only been a limited number of reports of benign BRBNS lesions involving the spine in children, which were detected after chronic symptomatology. We herein present a unique case of a ruptured BRBNS venous malformation into the epidural space of the lumbar spine in a child presenting with acute neurologic deficit and discuss the relevant surgical considerations for operating in the setting of BRBNS.