Neurological Surgery
Our Expertise
Our pediatric neurosurgeons provide expert care for the following conditions and diseases:
- Chiari I malformation
- Craniosynostosis
- Epilepsy
- Hydrocephalus
- Spasticity
- Tethered spinal cord, including spina bifida
- Tumors
- Vascular Conditions
Chiari I malformation
The pediatric neurosurgeons of Morgan Stanley Children's Hospital have particular expertise in Chiari I malformation, a condition which requires surgical decompression at the base of the skull. Most children who have the surgery do quite well with an improvement in their symptoms.
For the past several years, our pediatric neurosurgeons have been using intraoperative electrophysiological monitoring to help determine whether opening the dura (a thick membrane that surrounds the brain and spinal cord) is a necessary component of surgery for children with Chiari I malformation. We have found that the majority of improvement in nerve impulses through the brain and spinal cord occurs after bony decompression, but we noted no further improvement by opening the dura, suggesting that children may not require this additional step of surgery. Our neurosurgeons now perform a less invasive operation where the dura is not opened, and we can report excellent results with significantly fewer complications than if the dura was opened during surgery.
Chiari I malformation also may cause fluid to collect in the spinal cord, a condition know as syrinx. When the Chiari malformation is treated, the syrinx generally will resolve on its own.
Most recently, we are exploring the relationship between autism and Chiari I malformation having evaluated a number of children with Chiari's who also have autism spectrum disorders.
Craniosynostosis
When a baby is born, the skull bone is composed of a collection of many smaller bones that abut one another at sites known as sutures. The most noticeable is the anterior fontanel or "soft spot" where four bones meet. As the brain grows, the sutures allow for rapid expansion in a symmetrical fashion. Under normal circumstances, the brain essentially determines the head size and shape. If for any reason one or more sutures closes too early, the brain is forced to grow in a different direction where the bones do not resist growth, a condition known as craniosynostosis or craniostenosis.
Certain craniosynostoses can be detected at birth, while others are not obvious for several months. The first year of life, when the most rapid head growth occurs, is usually the most significant time to diagnose and treat these conditions.
If the synostosis is left untreated, in certain cases increased pressure in the head can cause brain injury or marked facial and head deformity. For these reasons, surgery is often recommended in the first few months or year of life. The procedure involves the expertise of both a neurosurgeon and a craniofacial plastic surgeon who together operate to remove, recontour and replace the skull. To secure the skull bone, our neurosurgeons employ surgical sutures and wires and insert very fine resorbable plates and screws that are too small to be felt under the skin and that ultimately dissolve. In experienced hands, surgical results are excellent and rarely require further surgery.Epilepsy
The epilepsy and functional neurosurgery program of Morgan Stanley Children's Hospital is one of the most active on the East Coast, involving close collaboration between pediatric neurosurgeons and pediatric neurologists to treat all types of seizure disorders.
Our physicians use subdural grid electrodes implanted in the brain to identify the site of the seizures and map critical areas of the brain prior to epilepsy surgery. This enables the neurosurgeon to pinpoint which areas can safely be removed. Infants and children's brains are more resilient and less rigid than an adult's. When an area of the brain is removed involving a certain function, other areas of the brain can take over. For example, removing an area of the brain responsible for language before 6 years of age may slow a child's language development; however, it should not significantly impair his or her ability to speak later on. This neuronal plasticity gives the neurosurgeon the ability to remove larger areas of the brain with a greater likelihood of curing the young patient, without an increased risk of postoperative neurological deficits.
A diagnostic evaluation for epilepsy and other seizure disorders may reveal a hypothalamic hamartoma, a rare benign brain tumor of the hypothalamus. The hypothalamus controls such body functions as temperature, blood pressure, fluid and electrolyte balance, and digestion. The epileptic syndrome associated with this tumor begins in infancy and symptoms include frequent gelastic seizures (also called laughing seizures). Because these seizures resemble natural laughter, they often go undiagnosed. Hamartoma lesions can be removed using an endoscope that is inserted through a very tiny incision. Patients frequently return to normal function following the procedure.
Hydrocephalus
In early infancy, hydrocephalus is usually detected by the family or their pediatrician. In the first 6 to 12 months of life, the diagnosis often can be made with an ultrasound of the brain. After the skull fuses, diagnosis is best made with MRI or CT.
Surgery is the standard treatment of hydrocephalus. If a definable tumor is causing the obstruction, it may be possible to remove the mass and allow for resolution of the hydrocephalus. More often then not, however, the blockage cannot be removed and the fluid needs to bypass the normal circulation. Our surgeons use various types of systems called shunts to channel the fluid from the ventricles to other sites in the body where spinal fluid is more readily absorbed and returned to the blood stream.
In addition, certain types of hydrocephalus can be treated with endoscopic third ventriculostomy, a relatively new surgical procedure that involves making a hole in the floor of the third ventricle to allow free flow of spinal fluid into the basal cisterns for absorption.
Spasticity
The Spasticity Center at Morgan Stanley Children's Hospital is one of the few multidisciplinary programs available to care for patients with spasticity conditions. Our team includes pediatric specialists in neurosurgery, neurology, orthopedic surgery, as well as physical and occupational therapists.
This healthcare team provides consultation and treatment services to the child during a single visit, which avoids the need for patients to come in for a number of appointments spread over several months. Patients undergo a thorough examination to determine the optimum management plan for their particular condition. This may involve a combination of physical and occupational therapy (including positioning, bracing, splinting, and casting), Baclofen and other oral medications, Botox intramuscular injections, Baclofen pumps that are implanted under the skin to dispense medication directly into the spinal fluid, and orthopedic surgery.
Our Spasticity Center is the only program in the tri-state area and among the few nationwide that performs minimally invasive selective dorsal rhizotomy to decrease spasticity due to cerebral palsy. Traditionally this operation involved removing five levels of bone during an eight-hour surgery. Today, our surgeons remove just one level of bone through a minimally invasive approach. The operation is much quicker and children recover faster, allowing them to begin the process of retraining their relaxed muscles with physical therapy and rehabilitation at an earlier stage.
Tethered Spinal Cord
Tethered spinal cord is a group of complicated developmental malformations of the spinal cord. These conditions, which can lead to major consequences if left untreated, commonly exhibit a tugging of the spinal cord at the base of the spinal canal. As children grow, their spinal cords do not grow as quickly as their spinal columns. The spinal cord must be able to freely ascend on the inside of the spinal column during growth, and if various abnormal structures are holding onto the spinal cord from below, the spinal cord is stretched and can lead to progressive loss of function. If there is a problem in one site of the spinal cord, there may be other problems such as syrinxes (fluid collection in the spinal cord). For this reason, it is important to image the entire spinal cord and potentially the brain prior to treatment.
Our pediatric neurosurgeons recommend surgery in order to protect the growing spinal cord. With surgery, the spinal column is opened from behind to expose the extent of the sites of tethering of the spinal cord. During surgery, neurophysiologists monitor the spinal cord and nerve function to minimize risk to these delicate structures. Most children tolerate the surgery well and improve or at least stabilize their level of function. The spinal cord may potentially retether as the child gets older, and for this reason it is vital that he or she be closely followed.
Spina Bifida
Among the tethered spinal cord deformities is spina bifida, a congenital birth defect in which the spinal column is imperfectly closed and part of the spinal cord protrudes, often resulting in hydrocephalus and other neurological disorders. Children born with spina bifida should be aggressively treated both medically and surgically. Approximately 80 to 90 percent of patients will develop hydrocephalus (an increase in the size of the fluid filled spaces in the brain), which can be treated effectively, using a shunt to channel the fluid sites in the body where spinal fluid is more readily absorbed.
Early surgical closure of the spinal cord, as well as management of hydrocephalus if present, is performed to prevent infection or ongoing trauma to the exposed spinal cord. The goal of surgery is to preserve nerves, close the defect, restore the normal anatomy, and minimize the progression of long-term disability.
Tumors
Tumors of the nervous system are the most common solid tumors found in children.
Several recent advances have greatly improved the pediatric neurosurgeon's ability to remove almost all tumors. These include better imaging techniques to pinpoint location of the tumor, specialized pediatric anesthesia, improved monitoring of brain and spinal cord functions during surgery, and state-of-the-art surgical technology and instrumentation.
At Morgan Stanley Children's Hospital, our physicians consult together at a "tumor board" to help plan the best course of treatment based on the child's age and level of function, as well as the nature of the tumor.
Vascular Conditions
There are many rare conditions that can affect the blood vessels in the brain of newborns, infants and growing children. While frightening, many if not most of these disorders can be successfully addressed at very select medical centers such as Morgan Stanley Children's Hospital. Here an experienced team of pediatric neurosurgeons, interventional radiologists, neurologists and pediatric intensivists work together to treat conditions that include aneurysms, arteriovenous malformations (AVM), and Moyamoya, a rare and progressive cerebrovascular disorder caused by blocked arteries at the base of the brain. In fact, Morgan Stanley Children's Hospital serves one of the largest Moyamoya patient populations in the country.
If a vascular lesion is found, our pediatric radiologist and interventional radiologist perform an angiogram to identify the vessels involved and potentially embolize or close off these vessels prior to surgery to remove the lesion. Embolization decreases the risks of bleeding or stroke during the surgical procedure. In addition to embolization and surgery, some vascular lesions may be treated with gamma knife radiosurgery.
