Paediatric Neurosurgery

Hydrocephalus (Fluid on the Brain)

Hydrocephalus is the enlargement of the ventricles caused by a disturbance in the balance between circulation and absorption of cerebrospinal fluid (CSF). The aim of treatment is to lower the pressure safely and to protect brain development.

Symptoms & Signs

• Rapid increase in head circumference, a tense fontanelle (soft spot)
• Restlessness, vomiting, feeding difficulties
• Downward gaze of the eyes (sunset sign)
• Regression in developmental milestones

Diagnosis

• Ultrasound (while the fontanelle is open) and MRI/CT are used to assess ventricular size and the possible level of blockage.

Treatment Options

• Ventriculoperitoneal (VP) shunt: CSF is diverted into the abdominal cavity; an adjustable valve may be preferred.
• Endoscopic third ventriculostomy (ETV): in suitable anatomy the blockage is bypassed; this offers the possibility of a shunt-free solution.

Surgery & Follow-up

• General anaesthesia; most cases are monitored with a short hospital stay.
• In shunt cases, follow-up is needed for infection, blockage and over-/under-drainage.

The decision is made by considering age, cause (blockage/absorption problem) and anatomical suitability together.

Spinal Dysraphism (Meningocele, Myelomeningocele)

These are developmental closure defects of the spine and spinal cord. A meningocele sac contains CSF; a myelomeningocele sac also contains nerve tissue. Early surgery aims to reduce infection and neurological loss.

Symptoms & Signs

• A sac/visible opening in the midline of the lower back
• Weakness/sensory deficits in the legs, foot deformities
• Bladder and bowel problems

Diagnosis

• MRI after birth to assess the level of the lesion and any associated hydrocephalus/Chiari malformation.

Treatment

• Microsurgical repair: closure while preserving the nerve tissue, with a secure dural closure.
• Multidisciplinary approach: urology, orthopaedics, physiotherapy.

Follow-up

• Neurological rehabilitation, bladder and bowel management, foot and posture support.

Tethered Cord Syndrome

The lower end of the spinal cord is anchored by an abnormal band, fatty tissue or similar, which restricts its movement and stretches it. The tension can increase with growth and spinal movement.

Symptoms & Signs

• A dimple, hair tuft or skin mark in the lower back/sacral area
• Leg pain/numbness, walking difficulties
• Changes in bladder/bowel control
• Scoliosis may be present

Diagnosis

• MRI is used to assess the thickness of the filum terminale, any lipoma/fibrous tissue and the level of the spinal cord.

Treatment

• Microsurgical untethering: cutting the filum or separating the adhesions.
• In symptomatic cases it is planned without delay; the goal is to stop progressive damage.

Recovery

• Day case or short stay; close neurological and urological follow-up.

Diastematomyelia

The spinal cord is split into two halves by a bony, cartilaginous or fibrous structure. It is often accompanied by tethered cord, scoliosis and other vertebral anomalies.

Symptoms & Signs

• Skin marks or asymmetry in the lower back/back
• Weakness/sensory deficits in the legs, walking difficulties
• Scoliosis, foot deformities

Diagnosis

• MRI shows the split in the cord; CT clearly shows the bony spur.

Treatment

• Microsurgery: the bony/fibrous structure in between is removed and the cord is released.
• Simultaneous or staged planning for scoliosis and orthopaedic problems.

Follow-up

• Long-term follow-up with neurological examination and imaging.

Craniosynostosis

Premature closure of the skull sutures can lead to an abnormal head shape and, in some cases, raised intracranial pressure. With early diagnosis and the appropriate technique, cosmetic and neurological outcomes improve markedly.

Symptoms & Signs

• Abnormal head shape (scaphocephaly, trigonocephaly, plagiocephaly, etc.)
• In some cases headache, effects on development

Diagnosis

• Clinical assessment; when needed, CT to analyse suture closure and cranial structures.

Treatment Approaches

• Open cranial reconstruction: opening the sutures and correcting the shape.
• Endoscopic technique: in selected babies at an early stage; a moulding helmet may be used after surgery.

Surgery & Follow-up

• General anaesthesia; blood management and safe haemostasis are critically important.
• Monitoring of growth with early imaging and measurements.