Procedures & Critical Care

Epidemiology

Incidence

Universal; every elective paediatric neurosurgical case.

Age peak

All ages.

Location

Clinic, multidisciplinary meeting, operating room planning.

Clinical Presentation

• Detailed history and examination, including developmental, growth, and family history.
• Imaging review with the radiologist: confirm anatomy, identify anatomical pitfalls, plan trajectory and craniotomy/laminoplasty size, confirm reconstructibility.
• Multidisciplinary discussion (tumour board, vascular conference, craniofacial team); formal, documented decisions.
• Anaesthetic pre-assessment, including airway, vascular access plan, and intra-operative monitoring requirements.
• Family conversation: realistic expectations, recovery trajectory, scar appearance, possible permanent deficits.

Imaging

• Diagnostic imaging (MRI, CT, angiography) must be of operative quality; repeat sub-optimal studies before booking.
• Functional imaging (fMRI, DTI tractography) and angiography selected by case.
• Navigation-quality MRI / CT acquired in advance with the navigation-system fiducial protocol when appropriate.

Pathology & Molecular

Histology. Not applicable.

Molecular. Where relevant to surgical decision-making (e.g., BRAF V600E status, NF1 confirmation), arrange pre-operatively.

Management

Surgery. Pre-operative steps include: confirm imaging quality and acquisition for navigation; confirm consent; mark site (per WHO Safe Surgery / institutional protocol); communicate antibiotic timing and choice; communicate position and head-pin choice with anaesthesia; confirm blood-product availability; confirm planned IONM modalities with the neurophysiologist; check sub-specialty backup (otolaryngology for endoscopic endonasal, plastics for complex closure).

Adjuvant therapy. WHO Surgical Safety Checklist (sign-in, time-out, sign-out) performed deliberately and in full, not as a tick-box exercise.

Considerations. Documented multidisciplinary decisions stand up better than ad-hoc surgeon-only decisions when an outcome is unexpected.

Outcomes

Adherence to a structured pre-operative process is associated with lower rates of wrong-site/wrong-side surgery, fewer unplanned intra-operative changes of plan, and improved team communication; all consistently associated with better outcomes in published surgical-safety literature.

Epidemiology

Incidence

Every operative case.

Age peak

All ages.

Location

Operating room.

Clinical Presentation

• Supine: most cranial cases (pterional, supraorbital, frontal, parasagittal); access to anterior and lateral cranial anatomy.
• Lateral or park-bench: retrosigmoid, far-lateral, certain posterior-fossa cases.
• Prone: midline suboccipital, posterior cervical, posterior spinal cases.
• Sitting (semi-sitting): some posterior-fossa cases; superior gravity-assisted drainage, balanced against venous air embolism risk and haemodynamic considerations; less commonly used in young children.
• Head fixation in young children (typically under 2-3 years): three-pin head-holders are generally avoided in favour of horseshoe or padded support, given the risk of skull penetration and fracture; institutional practice varies.

Imaging

• Pre-operative review of cervical and thoracic spine for occult instability before any extension or rotation of the head.
• Navigation registration is performed after final positioning to avoid drift error.

Pathology & Molecular

Histology. Not applicable.

Molecular. Not applicable.

Management

Surgery. Padding of all pressure points; protection of eyes (especially prone; risk of central retinal artery occlusion); neutral cervical alignment unless surgically required; avoidance of extreme rotation that may compromise venous drainage; brachial-plexus protection with arm and shoulder padding; protection of male genitalia in prone position; appropriate Trendelenburg/reverse Trendelenburg based on procedure.

Adjuvant therapy. End-tidal CO2 monitoring, precordial Doppler when sitting position is used (early detection of venous air embolism); arterial line for cases with significant blood-loss risk or those requiring tight haemodynamic control.

Considerations. A second team-member check of position before draping is not optional in paediatric cases; small errors propagate quickly in small patients.

Outcomes

Position-related complications are uncommon when discipline is maintained; when they occur they are largely preventable.

Epidemiology

Incidence

Common across paediatric neurosurgical practice.

Age peak

All ages.

Location

As per approach.

Clinical Presentation

• Pterional (frontotemporal): anterior circulation, sellar/suprasellar, anterior temporal, sylvian fissure pathology.
• Supraorbital (eyebrow): selected midline anterior fossa and suprasellar lesions; minimally invasive cosmetic alternative to pterional.
• Bifrontal: subfrontal access to bilateral anterior fossa pathology and large midline anterior cranial lesions.
• Retrosigmoid: cerebellopontine-angle pathology (vestibular schwannoma, meningioma, cerebellar lesions).
• Midline suboccipital: posterior fossa midline pathology (vermian tumours, fourth-ventricular lesions, foramen magnum), with telovelar opening of the fourth ventricle increasingly preferred over splitting the vermis.
• Far lateral (extreme lateral): lower clivus, foramen magnum, anterior brainstem, vertebral artery.
• Interhemispheric: parasagittal and corpus callosum lesions, including callosotomy.

Imaging

• Each approach is planned from the diagnostic MRI / CT, with navigation registration used to optimise craniotomy placement and trajectory.
• Consider vascular imaging where the approach risks parent-vessel injury.

Pathology & Molecular

Histology. Not applicable.

Molecular. Not applicable.

Management

Surgery. Approach steps follow the standard textbook descriptions; key paediatric considerations include limited bone for autograft cranioplasty in infants, immature mastoid pneumatisation simplifying retrosigmoid drilling (with care to identify the sigmoid sinus early), and the need for meticulous closure to prevent CSF leak, particularly important in posterior fossa and skull base approaches.

Adjuvant therapy. Bone-flap fixation in growing children avoids rigid wires that can erode; resorbable plates or wire-only fixation are commonly used.

Considerations. Plan the closure before you open; incision design and bony exposure determine whether watertight reconstruction is possible at the end.

Outcomes

Approach-related complications (CSF leak, pseudomeningocele, infection, cosmetic defect, post-operative haemorrhage) are largely preventable through disciplined technique and closure.

Epidemiology

Incidence

Common in modern paediatric centres for hydrocephalus and intraventricular pathology; increasing for sellar/skull-base disease.

Age peak

Intraventricular endoscopy: any age. Endonasal: limited in very young children by sphenoid pneumatisation and intercarotid distance.

Location

Ventricular system; sellar / suprasellar / clival skull base.

Clinical Presentation

• Intraventricular: ETV, ETV+CPC, biopsy of intraventricular tumours, cyst fenestration (arachnoid, suprasellar, septum pellucidum), septostomy.
• Endonasal: transsphenoidal access for craniopharyngioma, Rathke's cleft cyst, pituitary lesions (uncommon in childhood), extended approaches for selected suprasellar and midline clival lesions.
• Combined transcranial-endonasal: occasional in complex skull-base cases.

Imaging

• MRI is the standard for planning, with attention to ventricular anatomy (foramen of Monro size, septum pellucidum), third-ventricle floor (for ETV), and skull-base pneumatisation (for endonasal).
• CT for bony anatomy when endonasal approach is planned.

Pathology & Molecular

Histology. Not applicable.

Molecular. Not applicable.

Management

Surgery. Intraventricular technique: pre-coronal burr hole (frontal point of entry); careful trajectory through the lateral ventricle and foramen of Monro; identification of landmarks (mammillary bodies, infundibular recess, basilar artery) before any fenestration. Endonasal technique: bi-narial four-handed approach with otolaryngology; sphenoidotomy, identification of the sella floor, opening of the dura, microscopic or endoscopic tumour resection, and skull-base reconstruction (nasoseptal flap, multilayer closure) to prevent post-operative CSF leak, the major complication.

Adjuvant therapy. CSF diversion is a separate decision for hydrocephalus cases. Hormonal replacement and DI management are integral to peri-operative care for sellar/suprasellar surgery.

Considerations. Endonasal surgery in children under approximately 6 years is constrained by skull-base anatomy; case selection by an experienced team is essential.

Outcomes

Outcomes in experienced hands are favourable; centre and surgeon volume strongly predict CSF-leak and complication rates for endonasal cases.

Epidemiology

Incidence

Common across paediatric neurosurgical practice.

Age peak

All ages; instrumented fusion proportionally more common in adolescents.

Location

Cervical, thoracic, lumbar, sacral as required.

Clinical Presentation

• Posterior laminoplasty preserves the posterior tension band and reduces (but does not eliminate) the risk of post-operative kyphosis compared with laminectomy.
• Multilevel cervical posterior approach in children has a meaningful long-term deformity risk; pre-operative counselling and post-operative surveillance are essential.
• Anterior cervical surgery is uncommon in children outside of trauma and selected pathology.
• Sacral and lumbosacral approaches for tethered cord and lipoma require attention to closure and bony reconstruction.

Imaging

• Whole-spine MRI for intradural pathology; CT for bony anatomy when instrumentation is planned.
• Standing scoliosis radiographs for deformity cases.
• Pre-operative neurophysiological baseline if IONM is planned.

Pathology & Molecular

Histology. Not applicable.

Molecular. Not applicable.

Management

Surgery. Laminoplasty: en-bloc removal of laminae as a single unit, with replacement and fixation (mini-plates or sutures) at closure. Laminectomy: removal of laminae without replacement; appropriate where access is needed and replacement not feasible. Instrumented fusion: paediatric pedicle screws are technically demanding (small pedicle diameter, growth implications); intra-operative imaging and navigation increasingly used.

Adjuvant therapy. IONM is the standard for intramedullary tumour resection; bracing post-operatively where deformity risk is high.

Considerations. Counselling families on the risk of late kyphosis after multilevel posterior cervical or thoracic surgery is appropriate; surveillance imaging for deformity should be part of long-term follow-up.

Outcomes

Surgical outcomes depend on the underlying pathology; the rate of post-operative deformity correlates with age (younger children at higher risk), level (cervical and high-thoracic at higher risk), and number of levels operated.

Epidemiology

Incidence

Standard adjunct for many paediatric neurosurgical procedures.

Age peak

All ages; technically more challenging in young infants.

Location

Eloquent cortical, sub-cortical white matter, brainstem and cranial-nerve nuclei, spinal cord, spinal nerve roots.

Clinical Presentation

• MEP: motor pathway integrity; transcranial electrical stimulation evoking responses in distal muscles. Useful for intramedullary spinal, eloquent-cortex, and brainstem surgery.
• SSEP: dorsal-column sensory pathway integrity; peripheral stimulation, cortical recording.
• D-wave: direct recording from spinal cord epidural electrode, particularly useful in intramedullary spinal cord tumour resection; robust to anaesthetic confounders, with characteristic amplitude changes signalling injury.
• BAEP: auditory pathway integrity for cerebellopontine-angle and brainstem surgery.
• EMG (free-running): continuous monitoring of motor cranial nerves or spinal nerve roots; spontaneous bursts of activity flag mechanical irritation.
• Stimulated EMG: triggered identification of motor cranial nerves intra-operatively during dissection.

Imaging

• Not applicable as an intra-operative imaging modality, but pre-operative imaging informs which modalities are most useful for the planned case.

Pathology & Molecular

Histology. Not applicable.

Molecular. Not applicable.

Management

Surgery. Standard alarm criteria vary by modality and centre: significant amplitude loss (e.g., MEP > 50%, SSEP > 50%), latency prolongation, or loss of response should prompt review of operative manoeuvre, retraction, blood pressure, and depth of anaesthesia.

Adjuvant therapy. Anaesthetic regime: total intravenous anaesthesia (TIVA) is generally preferred over volatile agents when MEP/SSEP are to be monitored; neuromuscular blockade should be avoided after intubation if MEP is required.

Considerations. Establish baseline traces with the patient positioned but before incision; communicate with anaesthesia about the planned monitoring requirements at the start of the case, not midway through.

Outcomes

Use of IONM during intramedullary spinal cord tumour surgery is associated with improved neurological outcomes in published series; D-wave changes in particular have well-defined operative thresholds. IONM does not eliminate risk but provides earlier warning.

Epidemiology

Incidence

Frameless neuro-navigation is now standard for many paediatric cranial cases; iMRI is centre-dependent.

Age peak

All ages.

Location

Operating room.

Clinical Presentation

• Frameless neuro-navigation: pre-operative MRI / CT acquired with surface or skin-mounted fiducials; registered intra-operatively after head fixation; provides real-time position information to within typically 1-3 mm of accuracy, drift permitting.
• Intra-operative ultrasound: real-time, intra-operative imaging without re-positioning; useful for tumour delineation, residual disease, and confirmation of catheter or shunt placement.
• Intra-operative MRI (iMRI): low-field (0.15-0.5 T) or high-field (1.5-3 T) magnets in the operating room; allows mid-resection imaging to identify residual tumour. Significant infrastructure required.
• Tubular retractor systems: small-corridor access to deep lesions with image-guided placement.

Imaging

• Pre-operative MRI / CT to navigation-system protocol.
• Intra-operative imaging modality as appropriate.

Pathology & Molecular

Histology. Not applicable.

Molecular. Not applicable.

Management

Surgery. Plan trajectory and exposure using navigation; remember that brain shift (after dural opening, CSF release, or tumour resection) will degrade navigation accuracy and warrants re-registration or re-imaging.

Adjuvant therapy. Intra-operative ultrasound is a cost-effective adjunct in centres without iMRI; intra-operative MRI substantially improves resection extent in selected paediatric tumours.

Considerations. Image guidance is a tool, not a substitute for anatomical knowledge; confirm landmarks at every key step.

Outcomes

Intra-operative imaging improves resection extent in paediatric brain tumour surgery in published series, particularly for low-grade glioma and craniopharyngioma; whether this translates to improved long-term outcomes depends on the tumour biology.

Epidemiology

Incidence

Every paediatric neurosurgical case.

Age peak

All ages; physiological challenges greatest in neonates and infants.

Location

Operating room.

Clinical Presentation

• Airway: small infants are more difficult to intubate and ventilate; positioning for cranial surgery may compromise access; clear plan for difficult-airway scenarios.
• Vascular access: at least two large-bore lines for cases at risk of significant blood loss; arterial line for continuous blood pressure and gas sampling in major cases; central venous access for selected cases (sitting position, vasoactive infusions).
• Maintenance: total intravenous anaesthesia (TIVA) is generally preferred when MEP/SSEP monitoring is planned; volatile anaesthesia is acceptable for cases without MEP.
• Fluid management: isotonic crystalloid; avoid hypotonic fluids (risk of hyponatraemia and cerebral oedema); maintain normoglycaemia.
• Blood management: cross-matched blood available for all major cases; transfusion thresholds typically Hb 70 g/L for stable patients but higher (e.g., 80-100 g/L) for ongoing haemorrhage, ICU patients, or known cardiac disease.

Imaging

• Not applicable.

Pathology & Molecular

Histology. Not applicable.

Molecular. Not applicable.

Management

Surgery. Anaesthetic role at the start of the case: induction, intubation, vascular access, positioning, antibiotic timing, anti-fibrinolytic decision. During the case: maintenance of cerebral perfusion, blood-loss management, communication with surgical team. At the end: smooth emergence, controlled blood pressure, transfer plan to ICU or recovery.

Adjuvant therapy. Tranexamic acid (TXA) is widely used in cases at risk of significant blood loss (e.g., open craniosynostosis repair, scoliosis surgery, large tumour resections), with evidence of meaningful reduction in transfusion requirement in paediatric craniofacial and spinal surgery in multiple trials and meta-analyses.

Considerations. Hypoglycaemia and hyperglycaemia both worsen outcomes; aim for normoglycaemia and check intra-operatively.

Outcomes

Anaesthetic care directly affects outcome; avoidance of hypoxia, hypotension, hypoglycaemia, and hyponatraemia are the foundations of any paediatric neuroanaesthetic plan.

Epidemiology

Incidence

Selected severe TBI, selected post-operative cases, acute hydrocephalus.

Age peak

Any age.

Location

Lateral ventricle (EVD), brain parenchyma (microsensor).

Clinical Presentation

• Indications in paediatric severe TBI per BTF guidelines: severe TBI (GCS ≤8) with abnormal admission CT (haematoma, contusion, oedema, compressed basal cisterns) or normal CT but additional features (age <2 y, GCS deteriorating); other selected cases informed by clinical judgement.
• ICP thresholds for paediatric intervention are commonly cited as approximately 20 mm Hg sustained (with management generally triggered at lower values in young children); CPP targets are age-dependent (commonly cited as ≥40 mm Hg in infants, ≥50 mm Hg in older children).
• EVD additionally permits therapeutic CSF drainage as a tier-1 ICP-lowering intervention.

Imaging

• CT to confirm ICP-monitor position after insertion (EVD location in frontal horn of lateral ventricle; intraparenchymal sensor depth).

Pathology & Molecular

Histology. Not applicable.

Molecular. Not applicable.

Management

Surgery. EVD insertion via a frontal pre-coronal burr hole; Kocher's point (typically 11 cm posterior to nasion, 3 cm lateral to midline) is the classical landmark; targeting the foramen of Monro guides catheter trajectory. Intraparenchymal microsensor insertion via a small burr hole and standardised bolt.

Adjuvant therapy. Tiered ICP management per BTF 3rd Edition as covered in the Trauma & Vascular module: head-of-bed elevation, normothermia, normocapnia, sedation/analgesia, osmotherapy (hypertonic saline preferred), CSF drainage via EVD, neuromuscular blockade, controlled mild hypocapnia, barbiturate trial, and decompressive craniectomy or controlled hypothermia as tier-3 measures.

Considerations. Infection risk of EVD increases with duration of monitoring; most series report rising infection rates after 5-10 days; tunnelled insertion, strict aseptic technique, closed-system maintenance, and antibiotic-impregnated catheters reduce risk.

Outcomes

ICP monitoring informs management but does not by itself improve outcome; guideline-adherent ICP-directed management is associated with better outcomes in published paediatric severe TBI series.

Epidemiology

Incidence

Routine for major paediatric neurosurgical cases.

Age peak

All ages.

Location

Paediatric intensive care unit.

Clinical Presentation

• Neurological observation: GCS, pupils, focal deficit; at intervals appropriate to severity.
• Haemodynamic: maintain age-appropriate MAP and CPP targets; avoid hypotension; treat hypertension carefully if present.
• Respiratory: maintain oxygenation (avoid SpO2 <90%) and normocapnia (PaCO2 35-38 mm Hg); brief hyperventilation only for impending herniation.
• Fluid and electrolyte: isotonic maintenance; treat hyponatraemia and hypernatraemia (each carries risk in different scenarios); manage syndrome of inappropriate antidiuretic hormone (SIADH), cerebral salt wasting, and diabetes insipidus; distinguishing these is essential and not always trivial.
• Endocrine: monitor for DI after sellar/suprasellar surgery; cortisol replacement after pituitary or sellar surgery as indicated.
• Glycaemic: normoglycaemia; treat hypoglycaemia immediately; avoid hyperglycaemia.
• Seizure prophylaxis: not routine; treat documented seizures.
• Infection surveillance: temperature, WCC, CRP, line review; CSF cultures via EVD as clinically indicated.
• Pain and sedation: protocolised, age-appropriate, monitored.

Imaging

• Post-operative imaging per institutional protocol, typically CT in the first 24 hours (or earlier for clinical change) and MRI in the sub-acute period for tumour cases.

Pathology & Molecular

Histology. Not applicable.

Molecular. Not applicable.

Management

Surgery. ICU-based management is non-surgical in principle but with frequent surgical re-look decisions: re-operation for haemorrhage; EVD insertion for new hydrocephalus; decompressive craniectomy for refractory raised ICP; revision surgery for CSF leak or wound complication.

Adjuvant therapy. Multidisciplinary team; intensive care, neurology, neurosurgery, endocrinology, infectious diseases, rehabilitation.

Considerations. Distinguishing SIADH, cerebral salt wasting, and central DI requires careful interpretation of paired serum and urine osmolality, sodium, fluid balance, and clinical state; protocolise the work-up so that the wrong fluid is never given to the wrong patient.

Outcomes

Quality of neurocritical care correlates with long-term outcome across paediatric neurosurgical conditions.

Epidemiology

Incidence

Reported paediatric shunt infection rates have fallen substantially with adherence to standardised protocols; cranial and spinal SSI rates also fall with bundled interventions.

Age peak

All ages; higher risk in young infants, immunocompromised patients, and revision surgery.

Location

Cranial, spinal, or implant-related.

Clinical Presentation

• SSI presents as wound erythema, discharge, dehiscence, fever, or (for implanted devices) systemic infection or shunt malfunction.
• Time to presentation is bimodal: early (within 30 days, often staphylococcal) and late (months later, often skin-flora or low-virulence organisms).
• Implant-related infection often necessitates removal of the foreign material.

Imaging

• Imaging guided by clinical suspicion; wound or shunt-tract imaging, CSF sampling via EVD or implant when appropriate.

Pathology & Molecular

Histology. Not applicable.

Molecular. Not applicable.

Management

Surgery. Established infection: source control; debride wounds, externalise infected shunts, remove fixation hardware, drain collections; staged re-implantation after culture-confirmed clearance.

Adjuvant therapy. Prophylactic antibiotics: timing matters; completed before incision, choice institution-protocol-based (typically cefazolin for clean cranial / spinal cases, adjusted for local epidemiology and patient allergy). Antibiotic-impregnated shunt catheters and intra-ventricular antibiotic prophylaxis are used in some centres.

Considerations. A 'shunt protocol' bundle, hair clipping (not shaving), chlorhexidine skin preparation, gloved skin-handling, minimal hardware handling, dual-glove technique, timely antibiotic prophylaxis, is associated with substantial reductions in shunt infection rate in published multi-centre series.

Outcomes

Adherence to a bundled prevention protocol consistently reduces SSI rates in paediatric neurosurgery; centre and surgeon discipline are the main modifiable variables.