Hi, I'm Mark Krieger. I'm the chair of the pediatric section, and it's really my great honor to be able to kick off what I think is going to be the highlight of this meeting, the Fellow Scientific Showcase. The section realized that fellows are really sort of the lifeblood of our field. They're sort of the new initiates into our field. We want to welcome them into the community and support them in any way we can. We've teamed up with the accreditation council for pediatric neurosurgical fellowships to help support. The ACPNF put on a boot camp yesterday for the fellows, which was highly successful, and today we have this jointly sponsored fellow showcase where we're having all 20 fellows this year in North America presenting themselves for this group. This group will go on for about an hour, and afterwards, we'll all move over to the remote platform, which is a social event for the opening reception, but at the beginning of that event, we'll announce the winner of the Molly Hubbard Prize for Best Abstract in the Fellow Section. This is named after Molly Hubbard, who was a fellow at Oregon and unfortunately passed away last year. So I will now turn the floor over to Dr. Kramath Marr, who is the current chair of the ACPNF, to kick off this session. Enjoy, Dr. Marr. Well, thank you very much, Dr. Krieger. First, I really want to congratulate you and the whole section leadership for working through all the challenges this year and putting on such a successful virtual meeting. I think it does really exemplify the idea that with good leadership, all of these unexpected problems that come up are really just an opportunity for growth and going in new directions, but still very successful directions. So hopefully this fellowship program that you've organized today is just another great example of that. So Dr. Bolo has asked me to speak very briefly on the current status of fellowship training in the field. I have no disclosures. I will try to stick to the facts of fellowship training and accreditation, but when I'm offering opinions, they're my own opinions and not necessarily those of the ACPNF or the CAST committee. So first, what is the Accreditation Council for Pediatric Neurosurgery Fellowships? Well, as the name implies, the ACPNF is the group that's concerned with accrediting these fellowships. We view our role as really central to ensuring that pediatric fellows receive the highest quality training experience possible. So I do want to acknowledge all the hard work of all of the current and former ACPNF directors you see listed on the screen. One really common source of confusion recently regarding the pediatric neurosurgery accreditation process is the relationship between ACPNF and CAST. I'm on both of these groups right now, and really for many years, the only pathway to accreditation was through the ACPNF, but then it became quite confusing. Starting about 10 years ago, CAST began to accredit pediatric programs as well as other neurosurgery specialty programs. This was redundant, a lot of confusion from programs, a lot of confusion from applicants. Hopefully, that's no longer the case. The two groups have signed an agreement that makes the ACPNF the only accrediting group for pediatric neurosurgery fellowships going forward. So an ACPNF director also serves as the solitary CAST member for pediatrics, really ensuring that the two groups are going to stay in very good alignment going forward. So ACPNF is the accrediting body for pediatric fellowships. So with the ACPNF, it's our mission to ensure a high quality training experience for fellows, in that we really are supporting the board's goal, the ABPNS goal to certify qualified individuals. So putting it simply, the pathway to ABPNS certification is through graduation from one of our accredited programs. Since the foundation of both of these groups about 30 years ago, pediatric neurosurgery training has been envisioned as a post-residency training period, ensuring both a real commitment to the field, as well as true fellowship level experience after one's already acquired core neurosurgical skills and training. Even in the era of unfolded fellowships, there's really been no enthusiasm for changing this longstanding policy. For the same reason, fellowships must last at least one year. And these fellowships are not apprenticeships like you see in some other neurosurgical fields like spine and tumor, where there's just a single faculty member. We believe that diversity of training is important. No programs are accredited for more than one fellow that can track towards certification. We don't want to dilute the training experience. And clinical learning environment is really important. Our accredited programs are at academic institutions. They have to be affiliated with a strong children's hospital with strong support from affiliated pediatric specialties. And finally, we've emphasized that the pediatric fellowship is a time to be exposed to all key areas of pediatric neurosurgery. It's not a time to focus only on one area within pediatric neurosurgery. So to this end, we've set up minimum case number standards to ensure compliance with that goal. We currently have 31 accredited programs spread throughout North America, including Canada. And if you're interested in learning more about all of the programs, I suggest that interested applicants should go to the acpnf.org website, which is shown here. I think you'll find it helpful. It's kept very up to date. And it does illustrate a lot of objective information about all of the fellowship programs, providing contact information for the fellowship programs. And in the age of COVID, there's even now some video tours of all of the fellowship programs available through this site. So I do recommend that applicants visit the ACPNF site. When you're on our site, you'll also get information about the pediatric neurosurgery match. The ACPNF is the sponsoring organization for the fellowship match. The match takes place in December during the last year of residency training. In the past, we considered moving the match earlier, but based on polls and feedback from recent graduates, we've actually found a high degree of satisfaction with the match process. So for now, we're leaving it in the chief year. This graph shows the number of people graduating from pediatric fellowships over the last 30 years. As you can see, there's been a notable increase in the number of graduates over this time period. The peak number was actually a few years ago in 2017. But I think if you look at the last decade or so from 2010, you'll agree that the number has been fairly constant in the low 20s. And it looks like that's what we're going to have this year as well. Last year, which is the last match data that we have available, 21 programs filled, 21 of 22 North American graduates matched, and 4 out of 10 international graduates matched. When we look at the percentage of women in our field, we're getting some encouraging data. In contrast to neurosurgery as a whole, where only 12% of graduating residents are women, we're seeing that that there's been an increasing percentage of women entering pediatric neurosurgery fellowships, certainly outpacing the field as a whole over the last several years. Certain residency programs have tended to send more people into pediatrics than others. In particular, what we're finding is that pediatric hospital-affiliated programs tend to send people into pediatric fellowships in much higher numbers. So there's something about good exposure during residency that's populating our field. And finally, what happens to fellows after their training is complete? Well, not surprisingly, most of our graduates go on to practice in an academic setting. Most of them have an entirely pediatric-focused practice. So in general, we're finding that the fellowship training process is good preparation for a future in pediatric neurosurgery. So once again, I want to thank the section leaders for putting on such a successful meeting, as well as Rob Bolo for the invitation to speak today. Next in the session, we have the opportunity to hear from a number of our current fellows, another great first for the meeting organizers this year, which hopefully we can carry forward into future years. And first up is Dr. Daniel Donahoe. Thank you once again. Hi, I'm Daniel Donahoe. Thanks so much for coming to this fellows showcase. I trained at the University of Southern California, where I benefited extensively from the guidance of Dr. Krieger, Dr. Giannata, Dr. Weiss, Dr. Zadeh, all of our wonderful faculty. We spend extensive time in our county and university hospitals, the Children's Hospital of Los Angeles, learning what to do, what not to do, and how to get the job done under all circumstances. During residency, I was fortunate to spend a year with Dr. Ed Laws at the Brigham and Women's Hospital training in Interior School Base. I also took medical education courses to develop my nascent interest in that field. During residency, I've been fortunate to help develop our carotid artery injury simulation model to take it on the road and train hundreds of surgeons how to manage carotid artery injuries. We've presented these results extensively in the next frontiers to use deep learning models to analyze the videos that we've collected during our training sessions, which we hope to develop methods of understanding and predicting surgeon performance. I'm currently the fellow at Texas Children's Hospital, where I benefit from a dizzying array of pathology and the wise guidance of many excellent mentors. Thanks so much for coming to this brief talk, and I look forward to meeting and speaking with all of you and our future careers together. Thanks so much. My name is Afshin Salih. I'm a fellow at St. Louis Children's Hospital. I'd like to talk to you about enhancing drug delivery to the brain with laser and syncytial chemotherapy, and augmented tumor cathetic with protism inhibitors. I developed a mouse model to live from ground up with real I developed a mouse model to live from ground up with real-time temperature recording. I performed a series of imaging with H&E, electron microscopy, and MRI to validate my animal model. I started with laser and non-tumor-bearing mice and performed fluorescent permeability assay from day three up to day 30. As quantified, there was significant fluorescent extravasation up to day seven with higher than control levels persisting up to day 30. I did immunohistochemistry for better spatial understanding. Ten days after tumors were implanted, mice had retrovital injections of human IgG and then sacrificed and brain stained. GL261 RFP tumors are visualized here in red, and in green, the anti-human IgGs, which shows permeability of human IgG in the laser tumor brain, as also quantified on the bar graph on the right. To prove that the measured IgG was extravascular, they did a CD31 staining, which stains the endothelial cells. As you can see in the image and quantified on the right, much of the human IgG is extravascular. To begin studying the mechanism, I stained the endothelial tight junction of a quantum 5 and showed a robust reduction in quantum 5, suggesting the disruption of the tight junction, which was confirmed with Horschreuter's proxylase injection technique using electron microscopy. Next, using a similar Horschreuter's proxylase injection technique, we showed an increase rate of transcendences in the laser-treated brain. To show that we can enhance drug delivery to the brain in the post-lip period, I started by injecting fluorescently tagged doxorubicin in an image in the gross brain. As you can see, the post-lip brain is permeable to doxorubicin, seen in red. To test if the increased drug delivery has an effect on tumor growth and survival, we designed the following experiments, in which after tumor injection, mice were treated with doxorubicin alone, laser alone, or a combination of laser plus doxorubicin, and we saw the following striking result, in which mice treated with doxorubicin post-lip survived almost twice as long. Furthermore, BLI imaging also confirmed a reduction in rate of growth in the laser plus doxorubicin treated. To take this step further, I'm in the beginning phases of setting ways to augment the kill effect of laser with drugs such as proteasome inhibitor, with the idea that inhibiting proteasome would increase the cell stress after LIT and increase the tumor kill effect of laser. Here's an in vitro study, whereby I show, with combining proteasome inhibitors, and bortezomib with heat, you can have an additive effect of heat on tumor kill. In summary, I've talked to you about my LIT animal model, showed you how LIT can increase blood-brain barrier and blood-tumor barrier permeability, provide a basic mechanism for this permeability, show how LIT and doxorubicin combined can increase mice survival, and share with you ways by which from a molecular level we can increase the tumor kill effect of LIT. I'd like to thank Dr. Albert Kim's lab and my other collaborators. Thank you. Hi, I'm Ziad Makoushi. I'm the current fellow at Nationwide Children's Hospital in Columbus, Ohio. I'd like to take this chance to tell you a little bit about myself. My early years were spent in professional gymnastics and competing internationally. I'd like to think I'm still able to do a few of those moves today. I completed medical school and internship at King Saud University and traveled to London to complete a master's in clinical neuroscience at UCL. After that, I had the opportunity to train under a great group of neurosurgeons and completed my residency at the University of Ottawa. I was fortunate to match at Nationwide Children's Hospital for my fellowship and train under Dr. Jeffrey Leonard and the outstanding neurosurgical team here. My interests include oncology and epilepsy as well as spasticity and selective dorsal rhizotomies. I also have an interest in resident education and have developed a curriculum for our residents here. One of my current research projects for selective dorsal rhizotomies are on the neurophysiological characteristics of stimulated rootlets. These are some results from our preliminary analysis of the data. Thank you. Thank you for the opportunity to present my research. This work began as a PhD student in Austin Smith's lab in Cambridge and was developed in Peter Dirks's lab at SickKids in collaboration with Bill Weiss at UCSF. I'm currently the Pediatric Neurosurgery Fellow at Johns Hopkins. In this showcase, I will give you a snapshot of how we've created a human model system to study medulloblastoma tumor genesis from normal human stem cells. Genetically engineered mouse models such as the heterozygous patch mutant developed by Matthew Scott in 1997 have been invaluable tools to study medulloblastoma. From these mice, we've learned that medulloblastoma occurs through aberrations of normal development. They occur when progenitors in the developing brain deviate from their normal developmental course. However, the specific cell populations that are vulnerable to tumor genesis in the developing human brain and the molecular drivers of this process are still unclear. The human brain is strikingly different to the mouse with regard to anatomical and cellular diversity, chromosomal synteny, and also tumor genomics. There are cell populations in human that simply don't exist in the mouse. For these reasons, parallel human systems are required to complement mouse models and to fully understand the critical factors unique to human brain tumor genesis. My approach has been to start by isolating normal human stem cell populations from the hindbrain that are putative cells of origin. I discovered that precursors of the cerebellum in the human fetal hindbrain neuroepithelium can be captured in vitro as long-term self-renewing neuroepithelial stem cells or NESS cells. These cells retain hindbrain identity and culture and generate cerebellar cells both in vitro and in vivo. They represent the ideal platform to study cerebellar development and tumors that arise from these cells. We know NESS cells represent five to six week cerebellar primordium. In this cell paper, we showed that somatic mutations in NESS cells such as NMIC that can lead to the formation of sonic hedgehog subtype medulloblastoma after orthotopic transplantation in mice. Interestingly, the genetic profile of the NESS cell-derived tumors closer to the human medulloblastoma than the mouse counterpart. Importantly, we can also derive similar hindbrain NESS cells in vitro from iPS cells derived from patients who are susceptible to medulloblastoma such as individuals with Gorlin syndrome. By molecular reprogramming, we can essentially turn back time for these individuals with Gorlin syndrome to a cell that represents five to six week cerebellar primordium. Transplantation of these predisposed cells with germline mutation in patch also led to sonic hedgehog subtype medulloblastoma similar to the patch mouse model. Cooperative mutations that are found in the patient tumors can be layered on top of the Gorlin background to study the molecular process by which they accelerate tumor genesis. This stem cell model gives us an important look into previously inaccessible aspects of medulloblastoma, the early events, using a functional approach. My current work strives to understand the molecular processes that kickstart medulloblastoma and to identify strategies to prevent tumor progression. I'd like to thank my mentors, Peter Dirks, Austin Smith, Bill Weiss, the Dirks Lab, my collaborators, and the Wellcome Trust for funding me, and thank you all for listening. Hello everyone. My name is Yasunaga Hama. I'm currently a pediatric neurosurgery fellow at Children's Hospital Colorado. During medical school, I participated in HHMI-NIH Research Scholars Program, allowing me to interact with and learn from some of the most prominent neuroscientists, such as Dr. Leslie Younger Leiter and Dr. Eric Kandel. I gained exposure to and became fascinated by the complexity of the human brain and learned that neurosurgeons can play unique roles as neurosurgeon scientists to push neuroscience research. During my clinical training at the University of Iowa and at UCLA, I had the privileges of training with Dr. Howard and Dr. Freed, able to gain firsthand experience of how they incorporated their epilepsy clinical practice into their highly respected NIH-funded neuroscience research. I'd like to pursue a career as an academic pediatric neurosurgeon with a primary clinical focus in pediatric epilepsy surgery. As a neurosurgeon scientist with unique access to the human brain, I'd like to emulate Dr. Howard and Dr. Freed and incorporate my clinical practice into neuroscience research using invasive intracranial recording to further understand neural basis for higher-order cognition and developing human brain in collaboration with neuroscientists. Thank you very much for your attention. Hello, my name is Leila Mohammed, and I'm the 2020 Pediatric Neurosurgery Fellow at Ann and Robert Lurie Children's Hospital of Chicago. I will be discussing the impact of the COVID-19 pandemic on the presentation of central nervous system tumors requiring surgical intervention to the Pediatric Neurosurgery Service. Although the first known report of COVID-19 in the United States was on January 21, 2020, it was not until mid-March that the rapid rise of case counts accelerated, resulting in a heightened sense of avoidance of the hospital setting and suspension of non-emergent clinical activities. In this study, we reviewed if this delay in care resulted in a delay in presentation of central nervous system tumors that required surgical intervention. We retrospectively reviewed the number of CNS tumors that presented to our academic children's hospital from January, 2015 to September, 2020 with the newly diagnosed CNS tumor that required surgical intervention. We excluded vascular lesions, dermoid cysts, recurrent tumors, previously treated or monitored tumors, cortical dysplasia, abscesses, and autoimmune processes. We collected data including demographics, number of surgeries, and median income. 126 total patients were collected from March to September of 2015 to 2020 with 22 presenting after COVID-19 from March to September, 2020. Age, gender, race, and median income were found to be similar and not significant between the two groups. When reviewing the number of CNS tumor surgeries performed each month, they were found to be similar and not statistically significant, ranging from zero to nine surgeries per month with an average p-value of 0.46. When looking at the average age of patients each month, this was again statistically insignificant, averages ranging from seven to 11 years of age with an average p-value of 0.36. In regard to median income, the averages range from 42,000 to $120,000 with an average p-value of 0.56. In conclusion, this demonstrates that the delays in non-emergent clinical activity due to COVID-19 resulted in no delays in CNS tumor surgical intervention at our institution. This is likely because CNS tumors requiring surgical intervention are considered non-elective surgeries and patients with neurological presentations are less likely to delay seeking medical attention. This preliminary data is reassuring, but large-scale national reviews are still warranted. Thank you. Hi, I'm Hannah Goldstein, and I'm currently the Pediatric Neurosurgery Fellow at Seattle Children's Hospital. The title of my presentation today is Interoperative Neuromonitoring Potentials Show Evidence of Preserved Neuronal Surgatory Below the Anatomical and Functional Level in Complex Spinal Dysraphism Patients Undergoing Reoperation Detethering. I have no disclosures. Spina bifida represents one of the most common birth defects occurring in approximately one to two cases per 1,000 live births worldwide. Although functional level is highly variable among patients with myelomeningocele and thought to be correlated with anatomic level of the lesion, the majority of myelomeningocele patients do not grow up to be functionally or economically independent. While a large portion of this may be attributable to the concomitant hydrocephalus and or complications of shunting, the morbidity associated with lower extremity dysfunction and lack of bowel or bladder control also plays a significant role. For this study, we retrospectively reviewed our series of complex spinal dysrhaphism patients and found 21 patients who underwent detethering reoperation with complete neuromonitoring data and at least one year of clinical follow-up. Preoperative radiographic and clinical level of dysrhaphism, intraoperative neuromonitoring, both motor evoked potentials and electromyography responses, as well as postoperative clinical exam was collected and compared. The lowest level of functional response was used for comparison. In all 21 patients who underwent complex detethering reoperations, intraoperative MEPs could be generated at or below the level of clinical function. Compared to their preoperative clinical exam, five or 24% of patients had MEP responses that were one level better. 11 or 52% of patients had MEP responses that were two levels better than their preop clinical exam. And four or 19% of patients had MEP responses that were three levels better than their preop clinical exam. In all but three patients, EMG responses were also present at or below the level of clinical function. Eight or 38% of patients had EMG responses at the level of function. Seven or 33% of patients had EMG responses one level below the level of preop clinical function. And three or 14% of patients had EMG responses two or more levels below the level of preop clinical exam. So in conclusion, the presence of positive stimulation potentials below the level of clinical function in patients with complex spinal dysrhaphism undergoing reoperation detethering is evidence of some degree of preserved neuronal connectivity These findings suggest that with future devices that can properly stimulate these nerves, either on a continual or intermittent basis, one could harness the action potentials to create function beyond the level that currently exists. Thank you. Hello, I'm Lauren Simpson. My research presentation topic is the burden of chronic back pain in adults with spinal dysrhaphism. The value of patient reported outcomes is reflected by their utilization in healthcare to evaluate our performance as neurosurgeons. Chronic pain can be debilitating and it's a significant detractor from quality of life in all diseases, especially spina bifida. Although multidisciplinary care is often available in childhood, finding appropriate care as an adult is more challenging. Poorly executed transition plans can result in fragmented treatment, increased hospitalizations, worse outcomes, and undertreatment or exacerbation of pain. Patients with spinal dysrhaphism harbor most of their pain in the low back, buttock, groin, and proximal lower extremities. Potential pain sources include deformity, bowel-bladder dysfunction, degenerative spine disease, and tethered cord syndrome. Neuropathic, musculoskeletal, and joint overuse pain associated with these and other health factors contribute to this multifactorial problem. This project arose from an observation that patients with closed spinal dysrhaphism almost uniformly developed a life-altering, chronic, high level of pain that prevented them from pursuing enjoyable activities and adversely impacted their quality of life. Yet the majority seem to accept this burden as a component of their illness for which little could be done. To study the hypothesis that patients with closed spinal dysrhaphism suffer disproportionately, this research sought to reveal the burden of pain in adult spina bifida clinic patients. An observational retrospective single institution cohort study was performed. 222 patients were included. 42 of them had closed spinal dysrhaphism of various forms. Pain metrics were collected. Diagnostic and demographic variables were analyzed for association with pain and between variables. The primary outcome for analysis was pain documentation as a major concern in the most recent clinic note. Self-reported pain index score was also collected as an acute metric. Our results showed that patients with closed spinal dysrhaphism had eight times higher odds of major pain complaints. In comparison, demographically similar patients with myelomeningocele were not as severely affected. Acute pain scores were modest, suggesting altered perception and impact of pain. In conclusion, patients with closed spinal dysrhaphism are plagued with a high burden of life-dominating pain that deteriorates their quality of life. Future research on repeat untethering for patients with closed spinal dysrhaphism is a necessary next step. After release for tethered cord syndrome, nearly all patients with back pain demonstrate acute significant improvement, conferring its potential for select patients with a protracted course of pain refractory to multimodal therapy. A randomized control trial is needed to study the safety and efficacy of further surgery for patients with a high burden of pain and to determine which patients with closed spinal dysrhaphism may benefit the most from additional untethering. Hi, this is Virendra Desai, and I'll be talking about patient-reported outcomes in spinal column shortening in children. Tethered cord syndrome is a traction-induced spinal cord injury that leads to neurologic, urologic, and orthopedic symptoms. Etiologies include fatty phylum, previous myelomeningocele repair, split cord malformation, lipomas, and others. Surgical detethering is the mainstay of treatment with generally favorable outcomes, especially for relieving pain with lesser improvement in pain. The mainstay of treatment is for treating pain with lesser improvement in neurologic and urologic symptoms. Unfortunately, though, recurrence rates up to 50% have been reported, with higher rates for complex spinal dysrhaphism and lower for simple phylum lysis. While there are isolated reports of good outcomes after revision detethering, especially for properly selected patients, overall outcomes are poor, with the majority experiencing no benefit while incurring significant risk of complication given the need to operate through scar tissue. The mainstay of treatment is spinal cord tension modality that, put simply, releases spinal cord tension by shortening the spine. Briefly, spinal column shortening involves a 1.5 to 2 centimeter wedge of bone resection in a straight segment of the spine with posterior screw fixation. Early reports have shown good outcomes in terms of symptom relief and recurrence rate in the short term, but a quantitative analysis of quality of life outcomes is lacking. We did a retrospective chart review of demographics, procedural data, and outcomes, as well as logistic regression to identify factors associated with mild, moderate, and severe disability as scored by the PSQL. 42 patients met inclusion criteria with an average age of 15.5 years and a mean follow-up of four months. Fewer prior untetherings was significantly associated with mild disability, while older age and longer hospitalization showed a trend towards moderate and severe disability. As expected, the PSQL score improved over time, even up to one year post-operatively for both patient and parent reports. Traditionally, outcomes have been measured via objective measures such as operative time, EBL, length of stay, complication, or recurrence rates, but in this emerging pay-for-performance era, subjective measures should be incorporated into outcomes analysis. PSQL is a generic measure that can be broadly applied across various disease states, which is important in this case given the relative rarity of tethered cord syndrome and the lack of established quality-of-life measure. What we found is that patient-reported outcomes in spinal column shortening can be related to certain risk factors that should be assessed preoperatively, and we hope that these results can help guide proper patient selection. In future studies, we hope to obtain more robust data on quality-of-life outcomes via both generic and disease-specific measures and correlate these with objective measures like radiographic or urodynamic studies, and further to compare these outcomes with other treatments for recurrent tethering. Thank you. Hello, I'm Ahmed Belal, Pediatric Neurosurgery Fellow at Children's Memorial Hermann Hospital in Houston. Today, I'm gonna talk about spinal column shortening for secondary tethered cord syndrome, radiographic, clinical, and urodynamic short-term outcomes. The gold standard treatment for tethered cord syndrome is a tethered cord release. However, the tethering involves significant risk for spinal cord injury and high rates of re-tethering. So the concept of spinal column shortening here is to decrease the spinal cord tension. We include the 41 patients in this study with average age of 15.9 years. Preoperative symptoms were mainly pain, weakness, bladder and bowel dysfunction. The most common level of osteoarthromy was T12, and the most common level of fusion is between T10 to L2. Follow-up was about 22.6 months. Primary outcomes of this study is the need for re-operation due to re-tethering or surgical complication. 0% of our patients required re-operation at mean of 22.6 months of follow-up. The outcome were to evaluate the spinal fusion. 100% of our patients had a solid arthrodesis with proper alignment observed at 12 months of follow-up. The clinical symptoms, 91% was resolved with preoperative pain, 66% was resolved with preoperative weakness, 51% was resolved with preoperative bowel and bladder dysfunction, 36% without preoperative gait ability or gait ability after surgery, though that wasn't statistically significant. Neurodynamics, nearly improving in one classification category, around 58% improved, 35% remained at the same, and 5.9% worsened. One-third of our patients needed subsequent urologic procedure after that, including botulinum toxin injection, bladder augmentation, and replacement of artificial urinary sphincter. Complication, interoperative complication, two patients with acute blood loss and one small unintended urotomy. No complication of neurologic deficit is applicable to infection or death. During surgery, 33 patients were transfused for hemodynamic instability. Limitations of the study and recommendations. Post-op urodynamic were not performing on all patients. Only those with available tracing were amenable for review. Also, future studies are needed to investigate lengths of symptoms prior to surgery and its association with clinical outcome, volume-tethered cord release or spinal colon shortening. Spinal fusion of skeletally immature children is a concern and must be balanced with the increased risk of permanent urologic damage that can occur due to prolonged intention on the spinal cord. So to address this concern, future studies are needed. A prospective comparative study of spinal colon shortening and traditional untethering is recommended here. Spinal colon shortening is a safe and effective method for treating post-secondary tethered cord syndrome. Thank you. Good afternoon. My name's David Gruber and I'm here with Doug Brockner and I want to thank all of you for attending this session. For those of you that have questions in the interest of time, we'd like to defer those questions to the conversation lounge where you can ask questions of the particular individual presenters. For those of you that may have questions about the process of accreditation after you've completed your fellowship and transitioning towards accreditation with the American Board of Neurological Surgery and American Board of Pediatric Neurosurgery, please feel free to reach out to me or any of the other directors and thank you very much for your attendance. So the question is for the abstracts regarding spinal column shortening, are there standardized indications for SCS or for reoperation? I think, again, we'll defer those questions to the conversation lounge. My name is Alfred. I am the fellow at Boston Children's. I trained at the joint program run by Brigham and Boston Children's. Luckily, I was able to spend a year in endovascular neurosurgery with Dr. Sultan and Dr. Orbach, followed by a year at Barrow with Dr. Albuquerque and Dr. Ducre. Finally, I spent the last year at University of Illinois with Dr. Schrebel and Dr. Hanjani, learning microsurgical approaches and quantitative assessment of cerebrovascular disease. You may have guessed that I'm excited to be able to learn from Dr. Smith and Orbach again, focused on pediatric neurointerventions and vascular surgery. My clinical interests relate to combined multimodal approaches based on my experience at the NIH-funded image-guided surgery suite at Brigham. This experience was critical when working with Dr. Schrebel in simultaneous microsurgical and endovascular approaches to brain AVMs last year. Thus, I envision not only sequential multimodal treatment, but an increasingly hybrid procedural environment. I hope to study normal and pathologic cerebrovascular flow with quantitative tools before and during surgeries. Although there have been studies in adult cerebrovascular disease, this is not well-described in children, and I hope this understanding will help better model and simulate pediatric disease to improve treatment planning and outcomes. I look forward to meeting you all in the future and hearing about your work during the remainder of this conference. This is Nikita Alexiades. I'm the fellow at the University of Utah, and I'm presenting a modified Delphi study looking at the medical management of children with spinal cord injury. I have no disclosures. I'd like to thank all of the participants in this study. This quote from the 2013 PETE trauma guideline sums up the rationale for the study in that there's no information in the literature describing the medical management of pediatric patients with spinal cord injury. Traumatic spinal cord injury is not a particularly common occurrence in children, especially in the very young. Importantly, we also encounter spinal cord injury in patients following deformity correction surgery, an area in which there's very little evidence to guide medical management. The Delphi method was originally developed in the 1960s. It's a way of building consensus around expert opinion using repeated questionnaires. It's been modified to include an in-person meeting to discuss topics near consensus. We've used it successfully in the past for several difficult to study areas. We identified a multidisciplinary group of 19 physicians experienced in caring for children with spinal cord injury. An initial survey of current practices was distributed in July of 2020, and based on responses, a follow-up survey of 54 best practices was distributed in September. A four-point Likert scale was used. The consensus defined is greater than 80% agreement. An in-person final meeting will take place during this PEED section. Participants were asked to estimate the number of spinal cord injury cases they saw per year by age group. The important take home here is that even at high volume academic centers, these cases just aren't that common. Of note, most centers felt that they saw more cases of traumatic spinal cord injury than iatrogenic spinal cord injury per year. Importantly, 42% of participants always manage spinal cord injury from trauma similarly to spinal cord injury from iatrogenic means. 53% sometimes manage it similarly, and only 5% always manage it differently. The survey of current practices included 70 questions across 11 categories. While this was not a consensus-generating round, notable findings included that 89% of participants always admitted patients to the PICU, 89% of participants used MAP goals rather than systolic blood pressure goals, and 89% of participants used a numerical range rather than percentiles above normal for blood pressure. While there's insufficient time to go through each of the 42 statements that reach consensus, the important point to note is that participants frequently managed patients with iatrogenic injury similarly to how they managed patients with traumatic injury. In terms of spinal immobilization, pharmacologic therapy, notable in that steroids were only recommended in the setting of intradural spinal cord surgery, hemodynamic management, DBT prophylaxis, urologic management, GI and nutrition management, pressure ulcer prophylaxis, and in the initiation of physical therapy. The limitations in the study are obvious in that it's an expert opinion-based study by design. Consensus was reached on 42 statements with six additional statements near consensus. Clinical management strategies notably are largely similar between traumatic and iatrogenic etiologies. Further studies needed to determine if implementation of these statements will improve outcomes for children with SCI. Thank you. Hi, my name is Malene Martinez-Sosa and I am the Pediatric Neurosurgery Fellow at Johns Hopkins All Children's Hospital. I grew up in San Juan, Puerto Rico. I majored in biology at Columbia University. I participated in leukemia research at MD Anderson Cancer Center afterwards. I studied medicine at the University of Michigan where I was fortunate to receive a full merit scholarship. I did research on intervertebral discs, Chiari malformation, arachnoid cyst, and scoliosis. I completed my neurosurgical training at the University of South Florida and during my elective year, I focused on pediatric neurosurgery and worked with Dr. George Jalot to gain more clinical experience with pediatric patients and patients with intermediary spinal cord tumors. I have continued this work during my fellowship collaborating in several publications and book chapters. Our latest accepted manuscript studies the benefit of repeat imaging during outpatient follow-up after a mild TBI. Data showed that these scans are very low yield, and we recommend ordering only if there is a clinical change. Thank you for listening. Good afternoon. My name is Khoi Nguyen, and I am the current fellow at the Children's Health Care of Atlanta in Georgia. Thank you for giving me the opportunity to present to you one of our projects on the removal of subdural to peritoneal shunt after resolution of subdural collections. The authors do not have any disclosures. Chronic subdural hematomas in the pediatric population is commonly associated with non-accidental trauma. There is no general consensus on the treatment of chronic subdural hematomas in infants. The most commonly accepted treatments are a transfontanel tap, burr hole drainage with or without subdural drain placement, and subdural peritoneal shunt. In patients treated with a subdural peritoneal shunt, there remains no consensus on whether to remove the shunt after resolution of subdural hematoma. In order to obtain data on the safety of removal of subdural peritoneal shunt, we perform a retrospective analysis of patients in our institution less than two years of age who underwent a subdural shunt placement and subsequent removal of the shunt. There were five surgeons at our institution who all used the same operative technique for placement of shunts with a valve-less system. Patient variables that we looked at were etiology of subdural hematoma, presenting symptoms, head circumference, and subdural hematoma size before shunt placement and after shunt removal, and length of follow-up. Primary outcomes were need for subdural shunt reinsertion and complications from shunt removal. Statistical analysis were performed using the shown methods. A total of 24 patients were included in the analysis with an average age of 10 months. The most common presenting symptoms were vomiting, seizure, gaze palsy, and increasing head circumference. The average head circumference in all but two patients were greater than the 99th percentile. The average size of the subdural hematoma prior to shunt placement was 1.5 centimeters with a standard deviation of 0.4 centimeters. Four patients had intervention prior to shunt placement, three of which had a transfontanel tap, and one had a burr hole drainage without a subdural drain. Mean time from shunt insertion to removal was 10 months. Imaging was obtained using a 3D printer to document resolution of subdural hematoma prior to removal of the shunt. Mean follow-up after shunt removal was four months. Follow-up imaging after shunt removal was obtained in 10 patients, with all of them having no recurrences. Mean head circumference before and after shunt removal was 99th and 94th percentile, respectively. 23 out of 24 patients had no perioperative complications from shunt removal and required no subsequent intervention. Three patients had significant neurologic deficits due to their underlying brain injury from child abuse. One patient required replacement of the subdural shunt and eventually developed post-traumatic hydrocephalus and required a ventricular peritoneal implant. Limitations of our study include the fact that it was a retrospective analysis. Another limitation was surgeon preference. This led to variation in interventions prior to shunt placement, duration of the shunt, length of follow-up after shunt removal. The one patient that required replacement of the subdural peritoneal shunt after removal was a nine-month-old patient. The subdural peritoneal shunt after removal was a nine-month-old who presented with accelerated head growth and suspected NAT. His MRI showed a large left chronic subdural hematoma. Of note, this patient had the largest subdural hematoma in our study. The patient initially underwent a burr hole drainage without subdural drain and eventually required a subdural peritoneal shunt. The shunt was in place for seven months before removal with imaging showing resolution of subdural hematoma. The patient presented to clinic two weeks later with persistent vomiting and a CT showing recurrent subdural collection and a subdural peritoneal shunt was replaced. The patient's symptoms continued despite shunt placement and an EVD was placed that showed increased intracranial pressure and a VP shunt was placed. With the understanding that the patient developed post-traumatic hydrocephalus. The results of our study show that the removal of subdural peritoneal shunts after resolution of chronic subdurals in patients less than two years old is safe and may reduce the anxiety and complications of having internal hardware. Thank you very much for your attention and I'll be happy to answer any questions. Hello, my name is Jocelyn Woodard and I am currently the Pediatric Neurosurgery Fellow at OHSU. I'm originally from Irvine, California but spent much of my education throughout the country. Going to Yale for undergrad, followed by Stanford for medical school and UCLA for my neurosurgical training. My clinical background is in the field of ophthalmology and I'm currently in my final year of training. My clinical interests are posterior fossa tumors and peripheral nerve tumors, which lends into my next year as I'll be doing a separate fellowship in peripheral nerve at UCSF. On the research side, I'm focused on big data, outcome studies and predictive models in neurosurgery. I was a National Clinician Scholar at UCLA and intend to re-engage in this at UCSF. I believe educating oneself is paramount but equally important is then passing on your knowledge to improve those coming behind you. I have a master's in teaching and taught high school in Chicago prior to medicine. Other fun facts are I was a dedicated track athlete in college, I love to travel and still enjoy physically demanding activities. I hope to meet you all in person someday soon. Thank you. Good afternoon. This is Carrie Yvonne, the Chief Fellow at SickKids in Toronto and I'll be presenting on geographic variations in DBS outcomes for childhood dystonia. DBS is a well-recognized treatment for dystonia, including pediatric patients and has been available for over 20 years. We previously identified reports from 16 countries with individual patient data for DBS outcomes in childhood dystonia. That we'd reported with a meta-analysis. We hypothesized that there would be variation outcomes across countries that could help in understanding global practice differences for these pediatric patients. In our analysis, we found a wide range of variations and outcomes from some centers and countries with more consistent improvement in outcomes to those with a wide range. Those countries with the highest improvement in outcomes after DBS included Hungary, Portugal, Czech Republic, Turkey, Iran, and China. Those countries that had a much broader variation in terms of outcome response, included Japan, Portugal, South Korea, the Netherlands, and the Czech Republic. The wide variation in the movement and disability outcome scales across countries may reflect underlying differences in practice at the national and regional levels, along with variation in patient populations and selection of patients. These results will be further informed by expanding the model to account for socioeconomic factors as well as regional characteristics. Obviously, given the resource intensive nature and cost of deep brain stimulation, there is an inherent bias towards high and middle income countries with no reports from low income countries of childhood dystonia. We also found that there was a significant increase in the number of patients in low income countries of childhood dystonia DBS. We plan to expand this analysis after further data collection to examine these factors. This work would not be possible without the many surgeons and scientists who've pushed for DBS for pediatric dystonia patients and without my mentors and team here at SickKids, especially Dr. Ibrahim. Thank you for joining. Thank you. Hi, everybody. My name is Derek Eces. I'm the current pediatric neurosurgery fellow at Stanford where I also did residency. I'm interested in all aspects of pediatric neurosurgery, but especially pediatric neuro-oncology, pediatric neurovascular disease and epilepsy. From a research standpoint, I've been fortunate to be involved in a number of different efforts focused on working to develop optical coherence tomography and Raman spectroscopy for intraoperative tumor margin detection as well as tumor subtyping. And also several efforts with our neuroradiology colleagues on using preoperative MRI imaging to help diagnose and subtype different types of pediatric brain tumors as well as predict postoperative outcomes. And I've also collaborated on a few projects with our neuropath colleagues on identifying some new targets for a pentamoma for targeted agents. So I'm very grateful to all my mentors here at Stanford for all their guidance throughout residency and fellowship and look forward to meeting all of you once we can be back in person sometime in the future. Thanks again. Hi, I am Mustafa Shahin, a pediatric neurosurgical fellow at Nicholas Children's Hospital. I'll be presenting the evolution of epilepsy surgery over three decades in our center. Epilepsy occurs in around 1% of the US population and only 1500 undergo surgery. Utilization of the different and more advanced MRI technologies improve the localization and decrease the need of two-stage approach for such cases. Nicholas Hospital has a strong quaternary epilepsy program and the first in the country to perform procedures such as subdural implantation, SAEG, LAT and focused ultrasound. We aimed in this study to assess the trends in epilepsy surgery over the past 30 years in our center. We retrospectively reviewed all the epilepsy surgeries over 30 years since we started the program. We divided the patients into two eras, the early and late one. We evaluated two years of follow-up for each case. The total number of cases included 1240 patients. 113 patients were excluded being older than 19 years old. In the early era, we performed 453 surgeries on a total of 408 patients. However, in the late era, we performed 674 surgeries on a total of 547 patients. 55% of the whole cohort were males and 45% were females. As you can see from the graph, the age of the seizure onset and seizure surgery has increased in the late era. This is the breakdown of our cohort. The majority of patients, around 63% of the population had a lesion on MRI, which included developmental tumors, focal cortical dysplasia and hippocampal sclerosis. In the late era, we performed fewer hemispherctomies and multilubral resections and more focal resections and cortisectomies. The number of palliative procedures has remained similar in the early and late era. However, in the late era, we have performed less corvoscalosotomies and more neuromodulation, including RNS and VNS. Comparably, the number of implantation cases have decreased in the late era. Our center started let four patients in 2013, which is reflected only in the late era. Favorable outcome defined as at least 50% seizure reduction is high in both eras. On the right, you can see a more detailed breakdown of the two-year seizure outcome captured in both eras. So in summary, surgical volume has increased over the years. Most of the surgical candidates were found to have lesion in MRI. Better and advanced imaging technique led to gradual reduction of two-stage implantation cases, fewer multilubral resection and hemispherctomies and tailored more limited resection. Thank you. Hi, my name's Carly Bullis. I'm a Pediatric Neurosurgery Fellow at Children's Hospital of Los Angeles. My presentation is Time-Static Tagging and Monocontrast Preservation MRI as a Diagnostic Tool for Chiari Malformation. As we all know, Chiari malformation involves a caudal displacement of cerebellar contents through the foramen magnum. This can lead to stenosis of CSF flow with other consequences, including hydrocephalus and syringomyelia. The goal of surgery is decompression of the craniocervical junction and restoration of flow. Evaluating the CSF flow in this region preoperatively can be very helpful for both operative planning and prediction of success from surgery. There are currently several options for imaging to evaluate CSF flow, which include phase contrast or SINAE studies, time-slip MRI sequence, and the more recent timestamp sequence. Phase contrast is currently the most widely used of these studies and involves a 2D view where protons that are stationary have the same pulse and produce no overall contrast. Moving protons, however, in the CSF have different pulses that produce a visible contrast. Time-slip or special labeling inversion pulse MRI is a tag-based technique that uses regional inversion pulses to create a brightly tagged region of CSF. Changes in the background around the CSF on these sequences can lead to some ambiguity in interpretation. The sequence also depends on cardiac or respiratory gating. Timestamp is a newer tag-based technique that allows for improved interpretation and quality over time-slip with little additional scan time. It allows for non-gated consistent interval study. The overall advantages include a more reliable contrast from flowing CSF, improved compensation for patient movement, decreased sedation, shorter scan time, and elimination of cardiac gating. The overall goal of this study was to establish timestamp MRI as an effective tool for the workup of CRI malformation. This is an example of a timestamp MRI sequence showing good flow anterior to the craniocervical junction and no flow posterior to the craniocervical junction, also seen as an upper cervical syrinx. We obtained timestamp MRI sequences on 22 children to evaluate CRI malformation, 16 had CRI1 and six had CRI2. The scan parameters are listed here. We compared the findings of stenosis or no stenosis of flow on the timestamp MRI to other findings, including cervical modulary cisternal volume, tonsillar descent, clinical symptoms, and decision to operate. We found that 10 of 22 patients had stenosis of some degree on the timestamp study. This included six of 16 CRI1 and four of six CRI2 patients. There were variable correlations seen between the distance of tonsillar descent and posterior fossa volume with the CSF flow on timestamp studies. In other words, the actual flow seen on the timestamp study is clinically relevant and not necessarily correlated with the level of tonsils or the posterior fossa volume seen on plain MRI. Overall, we found in this study that there's additional information that can be clinically relevant in the timestamp MRI that cannot be derived from an ordinary brain MRI. It is a fast and easy way to interpret the flow of CSF around the frame of magnum. Though eliminated by the number of patients, this study is the first to directly evaluate the timestamp MRI in the workup of CRI malformation. These are my references. Thank you very much for your time. Good afternoon. My name is Ruthie Patel, and I'm currently the Pediatric Neurosurgery Fellow at the Cincinnati Children's Hospital Medical Center. Today, I'll be discussing factors underlying postnatal outcomes in fetal occipital encephalocele, development of the imaging-based prediction parameters. Occipital encephalocele is a rare congenital neural tube defect with an estimated incidence of 0.8 to 2 in every 10,000 live births. One in three patients with OE do not survive, with a majority passing within the first year of life. Of those who do survive, approximately half have some evidence of neurodevelopmental disability. The presence of hydrocephalus, other intracranial abnormalities, larger size and contents of the herniated sac, microcephaly, and history of infection have all been described as risk factors for a poor prognosis in the literature. Because prenatally diagnosed OEs display significant heterogeneity in their morphology and associated pathologies, cognitive and survival outcomes are variable. The purpose of our study was to determine if specific imaging findings on fetal MRI could help predict postnatal course and prognosis in this patient population. We conducted a retrospective chart review of 18 patients with a prenatal diagnosis of OE. Pre- and postnatal imaging was evaluated for encephalocele size, ellipsoid volume, ventricular size, and based on the presence of particular findings, each patient was assigned an imaging score and encephalocele grade. For statistical analyses, imaging score and encephalocele grade were treated as independent variables. Imaging score ranged from zero to 11 depending on the presence or absence of predefined imaging features listed here. Encephalocele grade was assigned based on the volume of brain tissue present within the OE sac. Here's a case example of a fetal MRI showing a grade zero occipital encephalocele with an imaging score of one. Here's a case example of a grade two encephalocele with an imaging score of five. Finally, a case example of a grade four encephalocele in which the 75% of the sac is filled with cerebral tissue. In our patient cohort, the survival rate was 83%. Of the three patients who did not survive, two passed within the first 30 days of life. Imaging scores vary, but two of three patients had an imaging score of six or greater. 75% of patients who survived had some form of developmental delay. A minority of patients were tracheostomy or O2 dependent, and about one third of patients were NG or G-tube dependent. We noted in our results that there was a statistically significant increase in encephalocele size, volume, and overall MR imaging score between the fetal and postnatal periods. High imaging scores positively correlated with higher encephalocele grade as well. Interestingly, a higher encephalocele grade was positively correlated with the involvement of cerebellar tissue, occipital lobe, lateral ventricles, and presence of microcephaly. Clinically, higher imaging scores were found to be negatively correlated with motor and verbal development. The presence of these findings on fetal and postnatal imaging studies may help counsel patients regarding expectations for the postnatal course in patients with OE. In addition, modifications of the imaging score to include ventricular size, presence of other intracranial abnormalities, and even incorporate our encephalocele grading system may add value for more comprehensive counseling. The authors would like to thank the AANSCNS pediatric section for the opportunity to present our work. Thank you. Hi, this is Dr. Brockmeyer and Dr. Gruber again. And on behalf of the ACPNF, I wanted to thank all of the participants in the fellow scientific showcase. I thought all the introductions and the presentations were terrific and it was wonderful to hear from future leaders of pediatric neurosurgery. In the interest of time, we invite you to present your questions and answers in the conversation lounge on the remote platform. And we wish everybody a wonderful evening and we will see you in the chat rooms and conversation lounges. Thanks a lot.

pediatric neurosurgery

research studies

Fellow Scientific Showcase

Accreditation Council for Pediatric Neurosurgical Fellowships

patient-reported outcomes

spinal cord injuries

epilepsy surgery

Chiari malformation

deep brain stimulation

fetal occipital encephalocile