By: Dr. Michael Burke
The most common neurosurgical conditions that occur in children generally fall into three categories: spina bifida, hydrocephalus (water in the brain) and brain tumors.
Spina bifida is a broad category that includes birth defects of the spine and spinal cord. This most commonly occurs when the spinal cord completely fails to form and is open in the skin. This is termed myelomeningocele. These are surgically closed within the first day of life, but as these children develop. They have neurological deficits of their legs and bowel and experience bladder problems based upon the level and the size of the defect. Neurosurgeons will repair the defects to prevent infection and any further damage to the child’s nervous system; however it will not lead to any improvement in leg function.
Other forms of spina bifida involve communication of the skin with the spinal cord. Very small tracks can go from the surface of the skin to the spinal cord. Most of these children are normal but are at risk for infections. These tracks can be surgically removed. One of the surgeries that I’m often called upon to correct is for spinal cord lipoma, which is when fatty tissue accumulates beneath the surface of the skin, connecting to the spinal cord. Again, these children are neurologically normal; however, as they grow the fatty connection pulls on the spinal cord and causes it to quit working. I have seen adults that were normal at birth and ultimately began losing function of their bladder, bowels- and legs to the extent that they are wheelchair-bound when they are 40 or 50 years old. This problem was not recognized many years ago, but today is commonly diagnosed and understood because of the advances of magnetic resonance imaging (MRI). Early recognition and an understanding of human development is critical to the diagnosis so that surgery can be performed to protect these children from having problems later in life.
Many children who have spina bifida also have hydrocephalus, which is commonly called water on the brain. This is the most common pediatric neurosurgical problem. Each day fluid is made and moves through the brain. If there is an obstruction to that flow then the fluid and pressure builds up on the brain and can damage it. Fluid also builds up on the brain when there is a problem with absorption, which is often seen in babies who are born prematurely. The most common treatment for this is called a ventriculoperitoneal shunt. This is a catheter that is placed within the fluid spaces of the brain and then connected to a valve under the skin with a tube that goes in-to the abdomen. This is all inside the patient and allows fluid under pressure to be diverted out of the brain and absorbed in the abdomen. The challenge with the shunt is that it can malfunction and frequently need to be repaired.
Minimally invasive and endoscopic neurosurgery can also be used to treat hydrocephalus. We can do surgery to bypass the blocks and open the channels of fluid so that the child does not need a shunt. Many patients that needed a shunt when they were born can be treated with these minimally invasive methods and have their shunt removed. Today, we place shunts as less as possible because of the reoccurring net to repair. Instead we use a small camera and endoscopically treat the problem so that the patient can live a normal life without tubing underneath the skin that can malfunction.
Brain tumors are the most common solid form of cancer that occurs in children. They are second only to leukemia (a non-solid cancer) when one considers all types of cancers that affect children. Children can be born with brain tumors and these tumors are very different than those that occur in adults and affect different parts of the brain as compared to adults.
Children can have benign brain tumors that cause seizures or other neurological problems and upon surgical removal will be cured. On the other hand there are highly malignant tumors that can be a solid mass in the brain and then have cells spreading throughout all of the fluid spaces of the brain and the spinal cord. Even in this instance surgery is critical to remove as many tumors as possible. Chemotherapy and radiation therapy are then utilized to treat the rest of the disease. Therefore, any institution caring for children with brain tumors has multiple specialists involved. The neurosurgeon removes the tumor. Oncologist, with specialty training in pediatrics, provides medical management and chemotherapy. Radiation oncologists provide the radiation therapy. This is all done in a child friendly environment with the utmost care to ensure the patient’s comfort.
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