Endoscope Used To Minimize Surgery In Children

November 30th, 2009 -- A report from a pediatric neurosurgeon at the Cleveland Clinic (Di) shows promise for a less invasive type of Chiari surgery for children. While there is an ongoing debate in the medical community regarding minimally invasive surgery - meaning, the dura is not opened, the focus of this publication is using an endoscope for visualization, which allows for a less intrusive surgical approach.

An endoscope is a thin flexible tube which can be inserted into the body through a small opening. The endoscope contains a lens and light which allows the surgeon to view internal structures on a monitor and guide the surgery (Figure 1). Endoscopes have been used for various procedures for some time now, but are not commonly used for Chiari surgery. Instead, larger opening are made and then many surgeons use a microscope for work near the spinal cord and brainstem. Thus, in theory, using an endoscope should allow for a less invasive surgery, which in turn would lead to less trauma and a quicker recovery.

Figure 1: How Endoscope Is Used In Chiari Surgery

Endosc1.jpg

In this publication, Dr. Di reports on his experience with 26 pediatric, Chiari patients. The group was comprised of 16 boys and 10 girls, ranging in age from 18 months to 16 years. As to be expected, headache and neck pain were the most common presenting symptoms (Table 1), followed by weakness and numbness in the extremities, swallowing and gastrointestinal issues, and developmental delays.

MRIs showed that each child clearly had a Chiari malformation and were candidates for surgery. In addition, 5 children also had syrinxes, 4 had hydrocephalus, and 1 had PTC. The children underwent a similar surgical procedure which involved a 2cm incision, a craniectomy, and a C1 laminectomy.

There were no CSF related complications, however one child did develop meningitis which was effectively treated. With no complications, most of the children only spent 1 or 2 nights at the hospital. In terms of outcome, the surgeon reports that 18 of the group had an excellent outcome and an additional 6 were improved (Table 2). Two patients did not improve, and one girl required an additional surgery after suffering a neck trauma at a later time.

While the success and complication rates reported are very good, it is unfortunate that this report did not compare the endoscopic surgery with a more traditional approach. In other words, does it really result in less pain for the children and shorter hospital stays? It is also important to note that a clear definition of the different outcome levels was not provided, so the difference between excellent and improved is not known.

Until this surgical technique is directly compared to others, it is very difficult to evaluate its merits and potential drawbacks. However, the author does note one drawback, namely that it takes a good bit of practice to be able to use the endoscope effectively in this way.

Table 1: Presenting Symptoms of 26 Pediatric Chiari Patients

Symptom Number With
Headache, neck pain 11
Weakness, numbness in limbs 8
Swallowing problems, nausea, vomiting 7
Developmental delays 6
Ataxia 5
Sleep apnea 2

Table 2: Surgical Outcome of 26 Pediatric Chiari Patients

Outcome Number
Excellent 18
Improved 6
No Change 2

Notes: Outcome levels were not clearly defined in publication


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