Pediatric neurosurgery

The contributors to this issue of the Pediatric Clinics of North America have conceived of it as an opportunity to introduce primary pediatricians to the current scope of pediatric neurosurgical practice. The Pediatric Clinics is an exceptional vehicle for this mission in both the numbers and the focus of its readership.

The first article in this issue describes how common neurosurgical conditions sound and look when they first come to attention in the pediatrician's office. It includes suggestions for efficient initial investigations as well.

The next five articles cover what most pediatricians will view as the heart of neurosurgical practice: traumatic brain injury, hydrocephalus, brain tumors, craniosynostosis and other skull deformities, and spina bifida. Although the acute and sometimes definitive care of these conditions may be provided by the hands of surgeons, pediatricians play a large role in initial diagnosis, family counseling, and creation of a medical home for long-term care management. The intention has been to present this core material in a manner that pediatricians will find useful in fulfilling their role in the acute and chronic stages of these neurosurgical conditions.

The next three articles survey a sector of the subspecialty less familiar to pediatricians that might be called “functional” or “habilitative” pediatric neurosurgery – neurosurgical procedures that aim to improve quality of life by restoring or modulating neurophysiological function. The topics considered here are brachial plexus reconstruction for management of birth injuries, surgical interventions for medically intractable epilepsy, and surgical treatment for abnormal muscle tone in cerebral palsy and related conditions. Not all children who might benefit from such therapies currently have access to them, so hopefully the discussions in this issue will expand the reader's perception of what is possible for children with these chronic disabling conditions.

Recent advances in diagnostic imaging technology have created several challenges that are reviewed in the final three articles. The common theme is what to do about all the previously undetected and unsuspected conditions that current imaging technologies now reveal. The paradigmatic problem of this kind is Chiari malformation type 1 (CM1). Before the MRI era, CM1 could only be demonstrated by myelography, so only patients with florid symptoms or severe disability ever came to diagnosis. Experience with MRI has shown, however, that the spectrum of symptoms and signs attributable to CM1 is much broader than believed previously and that CM1 is a fairly common incidental finding in genuinely asymptomatic individuals. Thus the diagnosis is easy, but the clinical judgments are delicate. Likewise, the exquisite detail of three-dimensional ultrasonography and fast MRI sequences make the antenatal diagnosis of neurosurgical conditions commonplace now, but our knowledge of the natural history of such conditions and our understanding of what to tell parents about them have matured more slowly than the technology. The final article surveys a rogue's gallery of common incidental imaging findings that are frequent reasons for consultation in the pediatric neurosurgeon's office. Pediatricians who become familiar with the more common of these findings may still choose to request neurosurgical consultation, but they may be able more confidently to dampen the parental anxiety that an unexpectedly abnormal MRI study invariably generates.

We are grateful for our readers' attention.