SESSION 11: Paediatric Neurosurgery Emergencies | Ms Claudia Craven



This on-demand teaching session presents a case-based approach to discussing pediatric neurosurgery emergencies relevant to medical professionals. It reviews the elements for assessing patients, as well as different normal values and associated conditions. Participants are encouraged to propose solutions to the cases and discuss the priority levels of which each should be handled. This session would provide participants with the guidance for the unique aspects of caring for pediatric neurosurgery cases and enable them to gain better implementation of strategies in such instances.
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Claudia Craven is a locum consultant paediatric neurosurgeon at Cambridge University Hospitals NHS Foundation Trust

Learning objectives

Learning Objectives: 1. Recognize key physical characteristics of pediatric patients in order to assess the situation and prioritize care. 2. Identify common clinical signs of raised intracranial pressure in pediatric patients. 3. Describe the differences between assessing an adult vs a pediatric patient in a neurosurgical emergency scenario. 4. Interpret scan images to correctly diagnose hemorrhage or tumor presence in pediatric patients. 5. Compare and contrast the Glasgow Coma Scales for pediatric patients and adults.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Um You just muted. Oh, there you go. Great. So, uh my name is Claude. I'm one of the uh spinal fellows at Great Ormond Street. I'm gonna talk to you today about pediatric new surgery emergencies. Um I was given an hour but hopefully it'll be less than an hour. Uh It's a case based session. So it does require some people to volunteer some answers and it doesn't matter if you get anything wrong because this is all, not only, most of these cases are, um some of them are quite difficult. So just shout out the answers if you need them. Um I'll just start off with a little bit of an injection though. Oh, hi. Uh So the assessment of Children in pediatrics um in terms of especially in, in the context of neurosurgery and spine is slightly, it's slightly different. Of course, you'll still approach the patient in terms of airway and c spine like you do with a TLS, assessing breathing circulation, disability and exposure. But there's a few other things that you need to consider, especially in smaller Children. So for example, um toddlers and babies, um I won't name all of them but in particular, because we're talking about neurosurgery today, the size of the head is obviously bigger, the fulcrum in the neck is higher up. So they're more likely to have high cervical injuries. Um The methods of analgesia are different uh from a cardiovascular point of view, Children can compensate very well before they become shocked and then when they, they, they only start to show signs of shock, usually quite late. So that's something to consider. Um their body surface area is different. And so fluid calculations have to be calculated slightly differently. Um taking into account their weight, obviously from an airway point of view as well. Things are different because they've got a larger to wobbly teeth. Um And of course, they can have difficult IV access as well. So they might require ir access. This is just a few things to consider when you're assessing um the baby in the emergency department and these are just a few numbers um to consider as well. So depending on the age of the child, um they, they're gonna have different uh normal values. And so I actually carry a card around with me that has this information, has this information on because when you're assessing a child from a new surgery point of view, you want to know, are they bradycardia or um and are they hypertensive because these are things you look for in race intracranial pressure, but the definition of bradycardia and hypertension is different for different age groups. So it's worth knowing that. Ok. So in terms of disability, as I mentioned a little bit, so the size of the head relative to the body is obviously much bigger in smaller Children. And that's what this diagram is showing here. So normally when you have an adult who comes into a, in a trauma scenario, they're on a, they're on a spine board. But in pediatrics, you, if you put them on a spine board, then it's gonna be difficult to get airway access, first of all, because they're now flexed. And secondly, that's not gonna be very good for the cervical spine. So there's two ways around this, either the spine board can have a dip in it made for the head or the child can go onto a board. But you have to take into account that difference in the position because of the larger head when you're assessing them. Uh the common things that will come up in pediatric uh presentations in A&E may include uh obvious skull fracture or a cervical deformity. So if their head turned in abnormal position, they might have a large swelling on their scalp, suggestive of a hematoma, for example. Um So that's just on initial looking at them, then you might notice that they're very irritable and crying inconsolably or that they're vomiting. You might want to look for any features of raised intracranial pressure, which is what IC P means. And you can do this in young babies. So those, so usually there's one or less you can feel the soft spot, which is the Fontanelle and see if it's tense or not. You should be able to be ab you should be able to press down on it quite easily if it feels very full and tense, suggest raise pressure. Um, you can look in the back of the eyes and look for any Palo edema and you can also look at the eyes to see if they're showing any sunsetting. Do they have any obvious weakness in their limbs at all? And what is their consciousness level in young Children? It's difficult to assess using the G CS because GC S requires as particularly the verbal score um to actually be able to say words and if they're incomprehensible, that's the score. But in young Children, you can't do that. So they use the AU score instead, which is awake, verbal. Um Are they responsive? Are they awake and normal? Are they responsive to verbal cues? Are they responsive to pain or are they unresponsive? Ok. Um There is also a pediatric G CS for younger Children, which is exactly the same actually as the, as the adult one, except for the verbal and the eye, um responses are a tiny bit different but overall, it's pretty much pretty much the same um in verbal response for a score of two in a child. Uh these are Children aged 2 to 5. Now, they would be grunting and restless as opposed to incomprehensible sounds and a score of three would be persistent cries and screams as opposed to inappropriate words. Other than that, it's quite similar. Ok. So I just want you to bear in mind generally the the assessment um before starting the case case. So I'm gonna do a few of these cases and I'm sorry for anyone who's seen this talk before because I have, I have given this talk before. So the aim of this talk is to go through these different cases and to try and prioritize the different um the different ones as if you are seeing them in A&E. So I'm gonna go through them all. And then at the end of it, hopefully you can say who you would prioritize first or which ones are the most urgent ones to see because prioritization is probably the most important thing that you can do when you're holding your on call phone and you're seeing Children in any or in clinic. Ok. So we'll start with the first child. So you've been called to A&E and you see um this patient mom says that she's been sick a couple of times and she's got this appearance. Does anybody uh know why she might have this appearance? Is there anything that you might be worried about? So someone typed in the chat Hydrocephalus? Oh Yeah. Sun set up here if people could shout up because if I have to open the chat uh every time because if I open it on my screen it occludes the screen if that makes sense. And then I can't uh I don't know if it's possible for people to shout out or I could just go on the chat. But yes, hyper is one thing I about it will take me time to check it every time. Maybe if you could uh shout out what they're writing. Yeah, I'll do that. I'll do that. Um So yeah, people are saying increased intracranial pressure, hydrocephalus and here sunken eyes. Oh Yeah. Yeah, exactly. This is sunsetting. This is typical parents sunsetting hydrocephalus or raised intracranial pressure for some other reason. Um I would definitely be worried about um OK. What would you like to do next? Probably in the chat, probably in the chat shunting. Uh Yeah. So people are saying shunting. Yeah, before shunting. So imagine you've been called to A&E the mum's given you a history and you've examined them. Is this something that you want to do before before shunting? So, eye exam for Papilloma treatment and imaging, I saw somebody wrote imaging. So yeah. Oh You have the chat chat open now. So um yes. So I would get some imaging. Um The reason you get sunsetting because you know, adults don't get this, this is a pediatric thing and sometimes people say that it's a, it's a downward gaze, but actually what it is, it's an impaired upward gaze so that it's called paranoids. And it's due to increased pressure, that's affecting this part of where the yellow circle is. So the uh superior midbrain and in particular, it's affecting this area. So if you have tumors of the midbrain or of the pineal gland or of the thalamus, you can get this picture or if you have hydrocephalus because the third ventricle is next to the thalamus, then you can, if you have a hydro obstructive hydrocephalus, you can get this picture because it's uh a lot of pressure on this area of the brain. And the reason you get an up upgaze, um that's impaired is because the center for upgaze is in this is in this region. Um You also get a few other signs which you probably don't need to know about, but you get a near like dissociation. So um you should, you should be able to accommodate, but you lose that when they have this sign. Um They also get a type of nystagmus and a and an eyelid retraction. So the appearance of the sunsetting is exaggerated because the eyelids are also retracted back as well. You can also see this in multiple sclerosis. So not just in high pressure situations, but also if there's a lesion in this area as well. Ok. So if you get AC T scan, for example, does anybody know what this, what this shows or does anybody want to have a go present? To you. It's not an easy one to be fair. It's what, what do you think this white stuff? All this white stuff is, it could be a tumor potentially. Um It could be a tumor and calcification. So when are you looking for calcification? Um and hemorrhage. Yeah, perfect. So if you're, if you compare the bone that's obviously very dense. If you're looking for calcification, the density should be similar to the bone, I would say that this is slightly less dense. And so this is hemorrhage, this is blood in this case. And there may well be a tumor underlying this hemorrhage. There might be a vascular lesion underlying it. We don't know because it's a CT and it's not a very good quality one, but you can see that the bench cools are uh enlarged. And the reason I say that is because these at the side of the temporal horns, this uh I don't know if you can see my pointer, but there's the temporal horn is a round shape and it should look like a little bracket. It shouldn't appear around like that. And also the edges of the ventricles look a bit fuzzy and dark. And that's because there's fluid that's being pushed out of the ventricle because it's high pressure and the because the blood is blocking the normal circulation. So that's why they have acute hydrocephalus, but probably probably there was a tumor that's underlying lying this bleed. And the reason I say that is because um she's not unconscious. This isn't like a sudden bleed, that's happened. I think this is a bleed that's been happening slowly over time because these because the symptoms are sunsetting, but she's alert and having some vomiting um is slightly more chronic than having somebody just uh drop down unconscious. So I think that this is probably going to be a treatment, which it was. So we're thinking hydrocephalus, if she had a shunt, then yes, I would, I would worry about a shunt block. Um It could be a poster poster fat tumor. Um You could also see hydrocephalus with interventricular hemorrhage in preterm as well. Ok. So this is what I would do next. So I would do an EVD, which stands for external ventricular drain. And in Children, we tend to do a long tunnel EVD. So that is a tube that well. First of all, it starts in the ventricle and it's then tunneled all the way to the skin and comes out at the abdomen. The reason for doing this is to reduce infection because in Children, the risk of infection is very high or uh ventriculitis. For example, a the reason we've gone to an EVD rather than a shunt in the first instance is because all of that blood needs to clear, the CS F is constantly being produced by the brain and it will eventually clear out the blood, but it needs time. And if you put in a shunt with this volume of blood, the shunt is quite likely to block. So they'll horribly represent with the same problems. OK. So this is just showing at the, the next step. So let's say there's a tumor there also that we want to uh remove or that we just want to evacuate the clot cause that would also be a sensible thing to do if there's a large clot at the back of the brain. First thing you have to do is make an incision in the back of the head, which is the linear incision and expose the occiput, which you can see here. And also the first ring of C one which is below that you have to go through the muscles at the back, expose the occiput, expose the C one. And then what you want to do is remove with a high speed drill ac shape of the UT and, and sometimes we also remove the back of C one if it gives you better access as well. And this is the position that you want to position the patient in theater. So it's a bit like um a little bit like a concord plane, you know, with the tips that goes down. Um So the whole body should be tilted up, but the head should be tilted down like a, like a concord taking off. And in this camp, which is called a Mayfield clamp which keeps the head still. So once the skin incision is done and you've removed the bone, you then are faced with the Jura. And the way to open the Jura here is to do a Y shaped incision. Uh that the reason we do that is because it's much easier to close. Um Because of course, once you've opened the juror, then you're going to have CS F and you want to have a really nice closure at the end. So we open it in this sort of Mercedes Benz star fashion. And then at that point, you will see this which is the cerebellum and the tonsils underneath and you can work your way through carefully opening the Arachnoid which is over the cerebellum and then working your way down to the fourth ventricle, which is underneath, which is where that clot is and possibly where a tumor might be as well. And this is called the Suboccipital approach. OK. So the next kid, so again, you're called to. So that was a, a typical presentation of a, an acute hydrocephalus if you like due to a bleed, due to a tumor or due to a block in a young child, the second case. So again, we've got a child who's attending uh A E oops, um attending Amie and apparently he got into a uh a fight with his brother and he's got this dent in his head. Does anybody know what the dentist? Any suggestions? I can't see the chat again that one. Yeah. Depressed skull fracture. Cool. Yeah. Yeah. Yeah, it is. And, and specifically in young Children, they have a soft skull. So in an adult, if you hit somebody on a, in the head with a hammer, you can have a depressed skull fracture, which would be in fragments. They probably also have a skin laceration because it'd have to be quite a high force in an adult. But in a child, the skull is softer. So it can be called a ping pong fracture because the skull can actually be pushed in and it can also pop back as well. So in young Children, you can get something called a ping pong fracture, which is more of a deformity of the skull because it's been pushed in. So whether or not you should get a CT for, you don't need to, to know this, but just know that when we're in A&E, we can't just scan every single child with a, with a head injury. Um uh immediately we have to have reason because every scan we do is exposing them to radiation. Um So there are guidelines that we're supposed to follow. If we think for some reason that this could be a nonaccidental injury. If the history was quite suspicious, we would get ac T within the hour if they had a seizure. Um if their GCS was not normal, but in this case, the child's gcs was normal. Um If we think they may have a depressed skull injury, which we do or if they've got any evidence of a basal skull fracture, like panda eyes, um which is a, a battle sign or if they've got CS F leaking or if they've got a focal neurological deficit and then there's more guidelines. So I won't go through all of these. But this is if you should, this is the caveats to that as well. So let's say we got the CT and it shows this uh which is a ping pong fracture. It's basically just like someone who's pushed the skull in um other types of skulls that you said in the group already is um uh displaced fractures. You can also get linear undisplaced fractures in Children. So basically, just a crack um in the skull. And you can also get something called growing fractures. And that's where you get a fracture, which has occurred, usually a linear one. And as the kid grows up, the fracture at rather than healing, it becomes wider. And that's usually because there's been a tear to the Jura and underneath. And the pulsatile CS F is preventing the fracture from closing. So to treat one of these fractures, you can use one of these things, you can either leave it and as they grow up, it'll pop back or you can use one of these things which is called a Kiwi, which is a little suction cup you can put over and then you apply just a gentle amount of suction and it will pop the skull and pop back into place. Um Yeah. So usually the causes of these ping pong fractures. This is another example at the back of the skull here. Um Usually the causes are um sort of a spontaneous cause or due to birth trauma and sometimes it can be due to kids fighting with each other and they do very often pop back. But if not, you can use this Kiwi device. Another example of the skull fractures I was mentioning before is the linear skull fracture like this one here. Usually we don't have to intervene with these. Um And this is an example of a growing fracture. So you can have a linear skull fracture which as the child has grown up didn't heal. Um And that's usually because there was a dural tear associated with it and the CS f pulsating underneath the bone stopped it from healing. So in order to do that, you actually have to drill out the, the bone that's affected, repair, the dural tear underneath. And then uh usually you can, you can either put a plate or borrow some bone from the other side to repair the defect. OK? And this is an example of how you treat that. So you take this is your growing fracture. You do a craniotomy which is a, a circular craniotomy around the groin fracture, repair the defect usually with a, a dual substitute of some sort and then put AAA synthetic plate or bone from the other side. Mhm. Ok. Does anybody know what's wrong with the child in? Just seen? What would you call that? Yes. S college is excellent. Um, exactly. So this is Torticollis. Um, you'll hear some people sometimes calling it a, a cock robbing position of the head or, um, something similar to that. But the proper term is torticollis and torticollis can result from so many different causes. So, um it can be due to a cervical spine injury as I've put on the top slide here. Um So in Children, the position of the facet joints in the cervical spine is much more horizontal. I don't know if you can see in this picture, but they're, they're very horizontal. The facet joints in adult as or as we get older, the facet joints in the cervical spine become more slanted and more secure. So it's much harder for an adult to have a rotational subluxation. But in a child, the C one rotates very freely on C two and it can rotate so much that it can actually slip off. And that is called Atlanto axial rotatory. Some people call it rotatory subluxation if it's slipped and it's stuck, it's rotatory fixation. Um And this is a relatively common thing that can happen in Children and it presents initially with pain and then later they, the pain stops, but they're stuck in this position and there are some other conditions that can affect Children in the cervical spine as well. Um Osho onto is where the, the tip of the peg is floating around and usually this is due to a minor trauma that's happened. Um and it can damage the spinal cord ski aa is a term that you won't hear much anymore, but it means spinal cord injury without radiological abnormality. And this was a term used when uh before MRI scans, but it's sometimes people still use it and Children are prone to getting uh an injury, a ligamentous injury, but the bones can appear normal sometimes because they can move back into position. And then you've got pseudo subluxation, which is where the bones look like they subluxed, but they haven't. It's just cause Children are more flexible but focusing on this atlanto axial rotatory fixation. So here's some at the anatomy of this joint. So you've got your C two with the peg also known as the dens. And you've got this transverse ligament, securing it around, um securing C one around that. And you have this axis of movement and there is supposed to be some movement here. And that's how you have your right left movement in your head. But you should, you shouldn't go to the point where the facet joints actually have slipped off each other. You can grade the type this injury um into 44 types depending on how much the facet joints have slipped off each other. And also if it's an anterior slip or a posterior slip, you don't need to know that really. But it's just interesting. Um and these are just some differences again on, on differences between adults and Children and cervical spine injury. So, you know, adults, they um uh they have a small head body ratio. Children have a large head relative to the body. So they're more likely to get these high cervical injuries. Um Children have a lot more flexibility in the upper part of their neck. They also have weaker ligaments. Um they get a wedging shape of their spine. Um Whereas adults are the, the vertebral bodies are more rectangular shape and also children's facets like I mentioned earlier are more horizontal. Whereas in adults, they tend to be vertical or obliquely orientated. So the management for, for these higher vital injuries, for example, at an axial rotatory fixation. First of all requires uh moving the head back into the correct position. And this course will involve a general anesthetic for these Children and then manipulation under anesthesia. Once you've moved it back into the correct position, you need to fix them in that place. And you can do that with an external fixation like these two pictures here. And this is AAA type of what we call a Tlso brace um here, but it's just, it's uh one involving the head. And this device here is called a halo. And it's this metal ring that's actually secured to the head with screws, of course, under general anesthetic. And then that is connected to this chest brace, which they have to wear for six weeks and this completely immobilizes them and they have to move in this sort of position. Um They get used to it very quickly though and these devices are used in adults as well. However, even using this uh after six weeks, something like 60% of Children will slip back. Because once you get a dislocation of a joint, the risk of it happening again is very high. You probably know people who have dislocated their shoulder or their toes or something. It's the same in the neck. Once you have a joint that has uh subluxed, the risk of it happening again, is really high. So if it happens again, we have to offer an occipital spal fixation and this involves doing it the same approach as before you open the skin, expose the occiput. But this time you secure a plate to the back of the skull and connected to that plate is a rod. And again, you put screws into the um into the spine that these are usually going into the pedicles. You don't always have to go as low as this. Usually, it's just occiput to C two, but sometimes people will do occiput to C three if there's injuries that have play sports. Ok. So that's the vial spine. So then this next child. He is really irritable and upset, uh, unconsoled in a knee. Um, and on examination he has some retinal hemorrhages. What does anybody, what does somebody think about that? Mum's, the mum has brought him in? She's quite quiet. Mm. Oh, good. That means something that means. Uh, so you said the right thing? Um, shaken baby syndrome, which has, do, what was it, what was it that I said that gave it away because it's quite minimal information. Yeah, exactly. So retinal hemorrhage was the key thing. In fact, retinal hemorrhage, hemorrhage. If you see it, it's almost, it's almost pathognomonic. I think they say it's like more than 90% able to predict um uh non accidental injury. Um So we if you see a child who's inconsolable um or sometimes worryingly consolable and not crying at all and they've been brought in perhaps by an anxious relative, but they don't want to tell you everything. Um The CT shows these large areas of subdural hematoma. So, chronic blood on a scan doesn't appear bright white. The previous scan I showed you with that hemorrhage and hydrocephalus that was, that was white, almost like calcification, white, but not quite as here. You've got chronic blood and that's, that's darker in appearance. Um But these are subdurals and you can tell they are because you can see how far the brain is away from the skull. If a child should not have such a large gap between the brain and the skull. And also you can see above the brain, you can see a little darker area and that's actually the subarachnoid space. So you can see the subarachnoid space and then there's this extra space here. So this isn't some Children just have large subarachnoid spaces, but this isn't a large subarachnoid space. This is definitely subdural collections and the fact that it's so chronic suggests that it's been something that's been ongoing and retinal hemorrhages as well as the big giveaway also. No, this is a subdural hemorrhage. If you see this, you have to consider nonaccidental injury. It happens cause the child has been shaken and the the small vessels that bridge between the surface of the brain and the skull have been torn. Um Other types of hemorrhage you might see is an extra dual, but in Children, that's much rarer that's more common in teenagers and young adults in trauma scenarios. Um And if you see an intraparenchymal hemorrhage, so if you see a bleed in the brain, that's less likely to be a trauma thing, it can be but more likely to be something like a tumor or an A BM. Ok. So the things to look out for or suspected in A I and it always has to be suspected. Um initially uh is bruising inside the mouth, we call buccal bruising retinal hemorrhage, uh subdural and then if they have fractures of other bones like long bones. Um and if they have any other concerning signs like bruising or bones. Um We have to do a full investigation. So a body map uh x-rays of the um well, a whole body x-ray essentially um and also test for false uh pulse nis. So, for example, some Children have metabolic disorders um which can cause them to have more frequent subdural hemorrhages. They could have uh clotting diseases like hemophilia and they can also have fractures due to something called osteogenesis, imperfecta, um which is uh to do with uh collagen. So you need to rule out all of those conditions also because consequently, if, if, if they found out to have an A I, then of course, that could result in a legal case or some parents getting arrested. This is an example of an extradural. So in young Children with an extradural, it's not like it when I say young Children, I mean, under the age of two, it's usually not as severe as it is. So I know in adults and in teenagers who are taught the extradural is the one to look out for subdurals can wait. And actually, in young Children, it's very rare that extradural is an emergency because the sutures in their skull hasn't closed. So what an extra dual will do, it will just expand the skull. And I in this picture here, yes, if there is a very large one sort of, let's say it's not, you're finding, you know, half of the hemisphere or something, a quarter of the hemisphere, then yes, you may need to admit them and observe. But even then you may not operate um only operate if, if there's actual clinical signs of deterioration. What you do have to be careful about though is the hemoglobin level because Children only have a certain amount of circulating volume and they can actually lose a large volume into this space and they might need a blood transfusion for example. And again, this is a subgaleal hematoma. The same problem this is from a, um, uh, being born with the suction, uh bontu type of suction. It can cause a hemorrhage into the scalp. And if this will eventually heal, sometimes you can stick a needle and aspirate. But the main thing that can be life-threatening is the fact that, um, they have a low, they, they'll have a low hemoglobin and they may need a transfusion. They probably won't need surgery. OK? How much? My dinner time? Ok. Not doing too badly. Mm. So let's say you've got a, you get a phone call and you're on call for pediatric neurosurgery and this, a child has been born with disappearance on their back and they're crawling you, they've taken a photo and they've sent you this photo and they're asking you what it is. Does anybody know what the technical term for this is? Hi. Yes. Yeah. Yeah. It's um, it's a myelomeningocele. Um, the reason you say myelomeningocele is because it's in it, it includes meninges and the nerves. Also. If it was just the meninges, it would be a meningocele. Admittedly, you can't tell from this picture because you can't uh it, it's, it's a bit of a fuzzy picture, but it, if it was a better quality picture, you would see the thin membrane and you can even see the little nerves underneath. So if there's nerves in it, it's a mylo meningocele. If it's just a sac of fluid, it's a meningocele, the term spina bifida. Um basically just means that there's a defect in the bone at the back of the spine. And as you say, um uh Oculus mentioned that uh this is the most severe type, which is, which is right. You can, you neither get patients with just a defect in the bone and they may not appear like this. In fact, they may appear completely normal. But um this is on the more extreme end of the spectrum. So I usually uh use the term myelin and rather than spina bid to just to be more accurate with the terminology, Okie Doke. So this child has um now been transferred. This is just a picture showing me the different types. So of dysraphism, dysraphism, meaning um uh something that's occurred because of development. So you can get open dysraphism and close, which is what I was just all lead to. And in open, for example, you've got this picture in a which is a myelomeningocele, which is the uh the, you can see this fecal sac has gone through the bony defect and the nerves are in there also. And you can also get a meningocele where it's just the meningeal sac, but the nerves are still in place. And you can also just get simple spina bifida, which is just the missing bone. Sometimes you get a little tuft of hair. There. Also, there are other forms that you probably don't need to know about but um like split cord malformations and things also. Um but that's for another lecture. Sorry, the management for this needs to be quite rapid. They need to have surgery within 48 hours because the concern is that yeah, this membrane is very, very thin and they could get meningitis if CSF leaks out of this. So they need to cover the wound usually with some sort of clin bone, give them antibiotics to cover them anyway, for meningitis. And then we operate within 48 hours. The reason this happens is because there's a failure of new relation. So you will probably remember that new relation involves um um uh primary ation is basically the Conus upwards, the formation of the Conus upwards. And that's where you have a holding you, you've completed gastrulation, um which is a bi laminar disc, becoming the tri laminar disc. And then at that stage, you start to get folding and once all the tissues are folded it zips up. But if it doesn't zip up properly, you'll get a defect up back and that's why it occurs. So it's a deep a problem of primary ne relation. So, in order to treat it, we essentially neate, but surgically by neate, I mean, we close the spinal cord. So we got this open, these, uh, these open nerves and we close the tissues over the top of them layer by layer. It's quite fiddly surgery. And nowadays actually, um, you can prenatally check for my meningocele. And, uh, if you, if it's found we can also do in utero surgery. And, uh, I joined for a couple of those, but it's usually consultant led and the repair is done in uter. So you operate, uh, the gynecologist will open the uterus and then we will close the defect in the fetus and then the gynecologist comes back and they close the uterus again. Um, and then the child's born and they have much better outcomes if you do that rather than if you wait for them to be born. Um, something on the chat. No. Ok. Ok. So this next child, um, so she has had a, a temperature and is feeling very lethargic and has this swelling on the front of her forehead. Um, she's had a, uh, runny nose for about, um, you know, three weeks or so, does anyone have an idea of what that could be? He has a temperature? That's the clue. And she's had a cold for weeks. Mhm. Yes. Sinusitis. I can see someone's written sinus. Oh, sorry, I just saw a question, somebody said, is fetal surgery better than neonatal surgery. Oh, yes. Absolutely. So, to answer that question about fetal surgery, it will increase, um, their power in their lower limbs. On the MRC scale, it increases their power by two. If you do fetal surgery. In other words, they will be able to walk versus a child who doesn't have fetal fetal surgery, they may not be able to walk. So it's a huge difference and also the rates of needing chance in the future is also reduced. So, if we can do fetal surgery, we'll do it. Um There's a trial if you're interested called the mums trial, mo MS uh which showed that and it's um that's why it's not. Yes. So the answer is uh sinusitis. Technically, somebody wrote a frontal bone fracture. That's not wrong. It is a type of fracture of pathological fracture. Um because the, the sinusitis has affected the bone. So yes, it's sinusitis. Um Some sinusitis can actually be really bad. It can erode through the frontal bone and then can become a, an abscess or an uh an empyema. The difference between an abscess and an empyema of course, is an abscess has a capsule around, it was an empyema is an infected collection of fluid but not without a, without a capsule. So here is an example, the sinusitis is tracked up. Um and it's affecting the, the swelling and subcutaneous tissues are affected. But also it has gotten in Trica me and you can see it almost looks like a subdural. And actually, when you see a subdural, you have to think, could that be an infection? Um this is ac T scan with contrast and you can tell because you can see the vessels are lighting up and the contrast here is going around the edge of the jura there. So the jura is enhancing, which also can suggest an infection. Ok. So yes. So infections usually they have a pretty good history of infection and you take their blood. So have a very high CRP. It will be, you know, 300 or something. Um raised white cell counts, consider abscesses. Of course, these are us, abscesses tend to be within the parenchyma and encapsulated. Whereas empyema are usually this sort of appearance looking like a subdural. Also you can get kids with shunt infections sometimes if they have a shunt. So yeah, here's another example of a subdural pain and like I said, it looks a lot like a subdural but with the clinical history of infection, commonly it'll be on the front of the head used to. Um they can also get a lot um they can get it from, they can get um which is due to ear infections. For example, they do need this draining within 24 hours because this is at the moment in the subdural space. If this breaches the jura, if this breach of the draw and goes into the brain, the whole brain will swell up very quickly cause it'll be a lot of organisms, bacteria probably um the brain will swell and they can, they can die from this. So it is a very urgent presentation. OK. Right. So um this is the, let's imagine we got a preterm and we're almost done, by the way. Um So we've got a preterm, preterm infant now and stay there. They're 28 weeks and they're irritable and they've got a full fontanelle, we've sort of covered this one already. But something that we see quite common is hydrocephalus, but due to interventricular hemorrhage, the other hera surgery in the first child was different because um they had a very high blood volume on that CT, but also the, they were an older child, little preterm babies. They don't have a reason for bleeding into their ventricles. The only reason they have is just because so they don't need to have a tumor or a vascular malformation, they just bleed because they're preterm. And that's because their germinal matrix is immature and is more friable and prone to bleeding and we grade the amount of blood based on the distribution. So this is uh called the PAP grading. So in picture one, you can, this is uh an ultrasound picture looking at the brain as if you're looking straight through the face. So this is a Coronal view and you can see there's a tiny bit of blood, which is the whitest stuff in ventricles. On, on the second picture, you can see there's more blood filling the ventricles. And then on the third picture, there's more blood and the ventricles are enlarged. Then in the last picture, the blood not only affects the ventricle but also is going a bit into the brain as well. So that's the grading system that we use. And so these two, this is the, yeah, grading. So for these Children, we don't shunt all of them, we see how much hydrocephalus they have by measuring ventricles and we look at their gestational age and you can plot the width against the gestational age. And if they are over the 97th percentile, that's when we start to treat and you can treat them either by tapping the ventricle, by putting a little uh tube in the ventricle and then with a reservoir. So you can tap it or the local hospital can do lumbar punctures if they're feeling um competent, which usually they are. So they would do a little, little lumbar puncture and let us some CS there. If they have to have multiple lumbar punctures, then we do this procedure which is either fitting in, yeah, a tube into the ventricle with the reservoir. So it's almost like a shunt. But without the rest of it and we would tap the reservoir to take off the fluid until the brain clears the blood and then the ven, then the brain matures and they stop bleeding. The other option is to do this thing which is called a subgaleal shunt. And rather than having that little reservoir, the CS F collects underneath the scalp and that's an alternative. There's no difference really between the two. It's just depends on the surgeon, what their preference is soon you need to care. Bye. Um Oh, did I I did? Hm I've got another case here, which um does anybody remember what the term for this eye position is? Oh, right. Yeah. Begins to pee there's Perones. So para nos is this high position is some section, some setting is a not a technical term. So Parana um ok. So, so this is an example again of another child with some setting or, or para um syndrome. And in this case, there's a, this is an example of a kid with large ventricles clearly as in, as in the here. Um And you can see that the third ventricle is much bigger than it should be as well. And that's why they got this experience, this sunset appearance again. But in this case, it's because the aqueduct, so the aqueduct connects the third ventricle to the fourth ventricle and they've got stenosis of the aqueduct and this is very common in Children as well. Sometimes it's due to your previous intraventricular hemorrhage, like in that neon age that we just saw and it can cause scarring and it can get to stenosis or it can just be a congenital um abnormality. So, the treatment for this is to do an ETB which stands for an endoscopic third ventriculostomy. And what that does is it bypasses. So you've got a, the aqueducts here, but you want your normal circulation CS F. So you're making an alternative route. So you put the scope in and you go through the lateral ventricle um and uh through the foreman of Monroe and you can, you can um make sure you're in the right place by looking for the choroid plexus and following it. And you should see on one side, the thalamus striate vein and on the other side, the anterior ate vein and you'll see the forin of Monroe. If you go through the foramen of Monroe with your endoscope, you will then see the floor of the third ventricle, which um is quite easy to spot cause you'll see the two mammillary bodies and the infundibular reces, which is this red area, which actually in this case, the person has done a hole in it. I would have done the hole a tiny bit further back because you make the hole between the infundibular recess, which is um anterior and the mali bodies. And by making that hole which you, you make with a balloon, you create a new uh pathway for the ES A, Okie Dokie, um and ETB S uh used very commonly in pediatric um neurosurgery and they're more likely to succeed. Um So this is a best success for, for E TV S, they're more likely to succeed in Children who have got aqueduct stenosis or tumors and who are older and who have not had a shunt before, if they have had a lot of infections or they're very young or they've had a shunt, these things are more likely to be associated with scarring. So if you make a hole in the floor of the third, it will scar back over. But if they're older and they don't have infection, then it's more likely to succeed. Ok. So basically that's the, the, the cases, if you had to triage these cases, which let's say you had to pick three, that you need to treat that day. Which three would you treat? What are your top three? Mhm. Ok. One person says first, which are the two. I, I think Empire was definitely in the top three. Yeah. Mhm. So, I've got dysraphism and Empyema. Any other? Somebody said subdural M MC? I mean, to be honest, they're all pretty, they're all pretty urgent, aren't they? I think the ones, the ones that could die. Um Which is how, when you, when you're triaging, you have to think like that. Actually the ones that could die um within, within hours would be the Empyema and the Hydrocephalus one, even though the hydrocephalus, one took a long time or they can take a long time to build up and present, you probably are aware of the IC P curve with raised IC P. It can take a long time to build up. But once you start to get symptoms and you start to go up, that cure you decompensate very quickly. It's an exponential curve. So uh a blocked shunt or acute hydrocephalus needs treating this within as soon as you can. The empyema. Definitely also, if I had a hydrocephalus case and an empyema, I'd take them both to theater that night. The dysraphism case needs to be treated ideally within 24 hours. But I would wait if I got referred into the night, I would wait till the morning. Whereas an empyema hydrocephalus, I wouldn't wait till the morning if that helps in the management. The exception to the hydrocephalus, one is the preterm IVH. Usually those can wait because first of all, their skull isn't closed. Um They're very young and secondly, the local unit is usually happy to do a lumbar puncture and it's uh normally a communicating type of hydrocephalus. So the preterm IVHS are less urgent usually, but they can become urgent later. The cervical spine case is, is something that needs addressing because if you leave it, they can get stuck like that, the bones can actually fuse. So they need, they need management usually within um they need surgery usually within weeks, if it's a rotator, rotatory fixation, obviously, if it's a different type of cervical injury, they might need surgery after. Mhm. And the skull fracture that's not very urgent at all, it'll probably pop back itself. Um And then the subdural is not urgent from a clinical point of view as in it will probably get better, but it's urgent from a safeguarding point of view. So he does need urgent admission into the hospital and investigation but is unlikely to need urgent or, or any treatment. It's mainly a safeguarding issue. Um So actually I said I wouldn't be an hour, but I think I have been an hour exactly an hour. I'm sorry if I've been talking at you too much. Um But yeah, I hope some of that was useful. Welcome to have the um use the slides. And um yes, if you need any more information, do you have any questions? Sorry, there's a lot of information and I'm not entirely sure what level you are. So apologies if I got the level wrong or, or if it's too simple, I'm never sure. No, it was, it was perfect. Thank you so much. That was very interesting. Uh cause we don't get told much about pediatric neurosurgery. No, and actually I think it's, it's quite relevant to the curriculum, especially, for example, Dysraphism is very nice to go with the curriculum in terms of development and um primary new relations it fits in quite nicely. Probably with the, I, I guess that's probably in your, in your curriculum and I remember we had to learn about New Relation Gast Relation, New Relation and, um, that fits in quite nicely. Um, but, yeah. Good. Yeah. No, I agree. Thank you so much. Um, I'll just quickly share my slide if that's fine just for the feedback call. Do you want me to stop sharing? Um, uh, sorry, I just took over. Oh, for Hydrocephalus. There's a question. Are there any early signs we can look for? Um, well, probably before the large head sunsetting. Yeah. Uh it uh agitation. Um You're welcome uh AGI agitation, uh vomiting, headaches, uh signs that can the early signs of raised intracranial pressure. It's always difficult in young Children because they don't tell you of course. But agitation or inconsolable crying and vomiting that isn't um attributed to other symptoms can be an early sign. Yes. Hm. Ok. So I think um I might head off then if that's the end of. But yeah. No, it's perfect. Thank you so much for taking the time. You're welcome. Thanks for having me. Bye.