OBJECTIVE The role of duraplasty in posterior fossa decompression for pediatric Chiari malformation type I (CM-I) remains controversial. Proponents of posterior fossa decompression with duraplasty (PFDD) argue that it improves CSF flow and syrinx regression, while posterior fossa decompression only (PFDO) is thought to offer a less invasive alternative with fewer complications. The authors investigated whether adding duraplasty provides patient-relevant clinical benefit in children with CM-I. METHODS A systematic review and meta-analysis of comparative pediatric studies (PFDD vs PFDO) was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcomes were overall clinical improvement, syrinx regression, Chicago Chiari Outcome Scale (CCOS) score, complications, and reoperation. Random-effects models, study-level meta-regression, graft-type subgroup analyses, and prespecified sensitivity analyzes were performed, including restriction to rigorously defined congenital CM-I cohorts and studies routinely using intraoperative ultrasound. Formal assessments of risk of bias, publication bias, and certainty of evidence were also conducted. RESULTS Twenty-six studies consisting of 5977 pediatric patients (2641 PFDO, 3336 PFDD) were included. Clinical improvement (70.8% PFDO, 80.0% PFDD; p = 0.13), syrinx improvement (55.4% PFDO, 63.5% PFDD; p = 0.11), CCOS scores (p = 0.39), and reoperation (risk ratio [RR] 1.54, 95% CI 0.93–2.54; p = 0.09) showed no significant intergroup difference. PFDD was associated with substantially higher CSF-related morbidity (RR 0.47, 95% CI 0.28–0.78; p < 0.01) and longer operative time (mean difference [MD] 63.9 minutes) and hospital stay (MD 1.22 days). No consistent differences emerged by graft type. Meta-regression showed that higher cohort-level syrinx prevalence correlated with greater clinical improvement after PFDD (p < 0.05) but not PFDO. Sensitivity analyses restricted to rigorously defined congenital CM-I cohorts and studies routinely performing intraoperative ultrasound reproduced all primary findings. Most studies were retrospective with moderate to serious risk of bias and overall certainty of evidence graded as moderate. No significant publication bias was detected (p = 0.36). CONCLUSIONS PFDD and PFDO yielded broadly comparable clinical and radiographic outcomes in pediatric CM-I, although PFDD was associated with higher CSF-related morbidity and greater operative burden. Current evidence does not clearly define patient subgroups that derive additional benefit from duraplasty, and observed differences are likely influenced by underlying cohort heterogeneity. Prospective trials incorporating standardized phenotyping and patient-reported outcomes are needed. Systematic review registration no.: CRD420251112828 ( www.crd.york.ac.uk/prospero/ )
OBJECTIVE Responsive neurostimulation (RNS) is increasingly being used for pediatric drug-resistant epilepsy (DRE), but the safety of the procedure in children remains unclear. The authors systematically reviewed published clinical outcomes in pediatric RNS, with an emphasis on complications and other adverse events. METHODS The authors performed a PRISMA-guided systematic review and meta-analysis. PubMed, Embase, Web of Science, and the Cochrane Library were searched from inception through August 12, 2025. They included observational studies reporting outcomes of RNS in patients aged ≤ 21 years at implantation and extractable pediatric data. Two authors independently screened articles and extracted data. The primary outcome was the proportion of patients experiencing at least 1 complication. A sensitivity analysis restricted to extractable patients aged ≤ 18 years was also performed. RESULTS Thirty-five studies met inclusion criteria, representing 358 pediatric patients who underwent RNS implantation. Most studies were case series (62.9%), followed by case reports (25.7%) and cohort studies (11.4%); all were conducted in the United States. The mean patient age at implantation was 14.8 years, and the mean follow-up was 20.3 months among studies reporting follow-up. Overall, 38 patients experienced at least 1 complication. The most frequently reported complications were infection (3.4%), transient neurological deficits (3.1%), return to the operating room (2.2%), and explantation (2.0%). Less common events included stimulation-related side effects (1.4%), CSF-related complications (1.1%), and wound dehiscence and device malfunction (0.6% each). Random-effects meta-analysis demonstrated a pooled overall complication proportion of 10.3% (95% CI 7.0%–14.9%; I 2 = 0.0%). In the ≤ 18-year sensitivity analysis, 31 studies comprising 203 patients were included, with a pooled complication proportion of 8% (95% CI 4%–16%). CONCLUSIONS Published pediatric RNS experience suggests that complications are comparable to rates reported for similar procedures and are most often transient neurological symptoms, reoperation, or infection. However, the evidence base is largely limited to small observational reports with heterogeneous outcome definitions and high risk of bias. Higher-quality multicenter prospective studies with standardized reporting and longer follow-up are needed to better define safety and effectiveness of RNS in pediatric DRE. Systematic review registration no.: CRD420261339088 ( https://www.crd.york.ac.uk/prospero/ )
OBJECTIVE The aim of this study was to report the results of a bibliometric analysis of the 12-decade body of literature on selective dorsal rhizotomy (SDR). METHODS The authors queried the Web of Science database for English-language articles relevant to SDR. Article authorship, keywords, and citations were captured with high fidelity and extracted using analyses performed primarily using the Bibliometrix tool in the R statistical package. Reference publication year spectroscopy (RPYS) was used to explore high-impact years with seminal papers advancing the understanding of the SDR technique and applications. RESULTS Between 1912 and 2025, the mean annual growth rate of publications on SDR was 0.98%, leading to a comprehensive corpus of 1184 documents (793 articles) from 3747 unique authors. International co-authorship increased over the 12-decade period analyzed, with contemporary analysis demonstrating international collaboration on 20.47% of articles published from 2010 to 2025. The Journal of Neurosurgery , and later the Journal of Neurosurgery: Pediatrics , demonstrated consistent impact, while the journal Developmental Medicine and Child Neurology published the most articles, published articles that were cited most frequently, and published articles that had the highest impact. Early in the publication record, etiologic and technical terms such as pain, stimulation, and gait analysis were prominent. More recently, research focus has shifted toward unified outcome measures, including gross motor function, along with procedure reliability, follow-up, and surgical outcomes. The terms "children," "cerebral palsy," and "spasticity" have remained constant areas of interest measured via keyword analysis. Using RPYS, 31 foundational articles on SDR were identified, with contemporary RPYS articles highlighting cross-discipline discussion and patient selection strategies. CONCLUSIONS Interest in SDR increased in the late 1980s and early 1990s, coinciding with advances in cerebral palsy classification and improvements in gross motor function scales. The focus of SDR research demonstrated a shift from technique and etiology to outcomes and cross-disciplinary patient selection. The modern era is characterized by collaborative research that spans international borders and involves neurosurgical patient selection in collaboration with colleagues in rehabilitative fields.
OBJECTIVE Concussions (i.e., mild traumatic brain injuries [mTBIs]) commonly produce transient neurocognitive and somatic symptoms that may overlap with baseline characteristics of neurodiverse populations. The relationship between autism spectrum disorder (ASD) and concussion/mTBI remains poorly characterized. This scoping review sought to synthesize existing literature evaluating concussion/mTBI risk, baseline neurocognitive testing, and symptom reporting in individuals with ASD. METHODS A scoping review was conducted in accordance with PRISMA guidelines. Embase, Scopus, PubMed, Web of Science, PsycINFO, and CENTRAL databases were searched for studies evaluating ASD and concussion or mTBI. The central research question was the following: What is the current state of knowledge related to concussions/mTBI in patients with ASD? This review sought to evaluate the areas of baseline testing, acute symptomatology, injury characteristics, and recovery. Studies were required to explicitly evaluate ASD in relation to concussion/mTBI outcomes or neurocognitive testing. Studies that did not isolate ASD from other neurodevelopmental disorders, as well as reviews, editorials, and conference abstracts, were excluded. RESULTS The search identified 374 studies, of which 7 (1.9%) met full inclusion criteria after screening. Most studies evaluated baseline neurocognitive testing using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) platform in pediatric/adolescent athletes. Three studies (42.9%) reported that individuals with ASD were more likely to produce invalid baseline neurocognitive scores and demonstrated differences in certain cognitive composites compared with controls. Two studies (28.6%) evaluated baseline concussion-like symptoms, with one reporting higher symptom endorsement among athletes with ASD and the other finding no statistically significant differences from controls. Epidemiological studies did not demonstrate a clear association between ASD and increased risk of concussion. Notably, no identified studies evaluated acute postinjury symptom trajectories or recovery outcomes following concussion in individuals with ASD. CONCLUSIONS Existing literature examining ASD and concussion/TBI primarily evaluated baseline neurocognitive testing and suggested potential differences in testing performance and symptom reporting among individuals with ASD. However, the authors identified a critical lack of studies evaluating acute symptoms and recovery trajectories following concussion/mTBI in this population, which represents a significant barrier for clinicians—from athletic trainers to pediatricians to pediatric neurosurgeons—in accurately diagnosing, risk stratifying, and managing these patients in the postinjury setting. Prospective investigations are needed to better define concussion/mTBI presentation, recovery patterns, and optimal management strategies for individuals with ASD.
OBJECTIVE In pediatric cerebral arteriovenous malformation (AVM), the long-term outcome data are scarce. The aim of this study was to analyze the clinical and radiological long-term outcomes from an institutional experience of children and adolescents treated for AVM over 25 years. METHODS The authors reviewed clinical and radiological data from a consecutive series of patients (age ≤ 18 years) treated for AVM at a single institution from 2000 to 2024, with at least 1 year of follow-up. RESULTS Overall, 96 patients were treated for AVM (48 males and 48 females, mean age 12.8 ± 4.8 years). Spetzler-Martin grades were I in 18 patients (19.4%), II in 33 (35.5%), and III in 30 (32.3%), and 14.6% of patients had an infratentorial location. Overall, 8.3% of patients were asymptomatic and 54.2% presented with hemorrhage. Moreover, 11.5% of patients experienced new or repeated hemorrhage during the initial observation or ongoing treatment. The stand-alone treatment was microsurgery in 38.5% of patients, radiosurgery in 28.1%, and embolization in 2.1%, while 9.4% of patients were treated conservatively. The treatment was multimodal in 21.9% and repeated in 49.4% of patients. The obliteration rate in patients with completed treatment (n = 75) was 80% (higher in those presenting with hemorrhage: 91.1% vs 63.3%, p = 0.003). The obliteration rate was 88.6% after microsurgery and 57.9% after radiosurgery (higher in the hemorrhagic group: 87.5% vs 36.4%, p = 0.026). Recurrence occurred in 8.3% of patients at a median of 60 months (range 36–68 months), and following microsurgery in all cases. A favorable clinical outcome (modified Rankin Scale scores 0–2) was achieved in 83.2% of patients, nonsignificantly less in those with hemorrhagic presentation (76.5% vs 90.9%, p = 0.061). The overall mortality rate was 5.3%, without a significant difference between the hemorrhagic and nonhemorrhagic groups. Hydrocephalus, hemorrhage volume, nidus size, infratentorial location, and Spetzler-Martin, supplementary, and combined grades were negative predictors of a good outcome in the univariate analysis, with the combined grade being the strongest predictor. Hemorrhage was a strong predictor of obliteration in the multivariate model, whereas radiosurgery and the number of treatments were predictors of nonobliteration. CONCLUSIONS Although more than half of children and adolescents with AVM presented with hemorrhage, most patients had a favorable clinical outcome. In our experience, microsurgery and radiosurgery resulted in the highest obliteration rates, particularly in hemorrhagic cases, while the role of endovascular treatment was only supplementary.
