Parents want to make the best decisions to ensure proper growth and development for their children. Many of those decisions have to do with timing. When do I introduce solid foods? At what age does she learn to read? When should she start preschool, and at which school?
It turns out that timing is also a topic of discussion among surgeons who have children as patients. One such surgeon is Dr. Richard C.E. Anderson, a pediatric neurosurgeon at Columbia University Medical Center/Morgan Stanley Children’s Hospital of NewYork-Presbyterian.
Dr. Anderson recently gave his perspective on the timing of his surgical procedures at a symposium held by pediatric specialists from the Department of Anesthesiology at Columbia. The findings from the session were also reported in the Journal of Neurosurgical Anesthesiology*.
Many of the issues around surgical timing have to do with anesthesia. While anesthesia is generally safe, doctors are looking very carefully at its effects on a young child’s developing brain.
In order to ensure optimal brain development, some studies have shown that it might be best to delay exposure to anesthesia by performing surgeries as late as possible. Yet many surgical procedures have to be performed earlier in order to ensure the best outcomes.
This dilemma—weighing the benefits of earlier surgeries versus minimizing early anesthesia exposure—was the subject of the symposium. During the session, Dr. Anderson joined his Columbia colleagues in pediatric surgery, urology and ophthalmology in examining how certain surgeries in young children should be timed.
In his discussion, Dr. Anderson focused on two neurosurgical conditions he commonly treats in young children. The first, called craniosynostosis, occurs when the spaces between the bones of the skull, which are normally present at birth, close too early.
This causes premature fusion of the skull bones, leaving little room for the brain to grow. If not diagnosed and treated early, this can lead to problems with the child’s development.
Dr. Anderson explained that if the infant’s craniosynostosis is diagnosed by six months of age, neurosurgeons can do a procedure called endoscopic surgery. In this procedure, a camera (called an endoscope) is inserted through a small scalp incision for visualization, while a strip of prematurely fused bone is removed.
This is easier to do in young infants, while the bones are still soft, and results in a quicker recovery time. The surgery itself is faster as well, meaning less exposure to anesthesia as well as less blood loss. Here, earlier may be better where surgery is concerned.
The second condition addressed by Dr. Anderson is known as tethered spinal cord. The spinal cord runs through a central space surrounded by the bones, or vertebrae, in the center of the back. It carries the nerves that run out to parts of the body—muscle and skin, for example—and are responsible for movement and sensation.
Normally the spinal cord ends in a flexible, elastic group of fibers called the filum terminale. But in some children it is attached to the surrounding soft tissue or bones. When this happens, the nerves become stretched as the child grows. This can lead to permanent nerve damage if untreated.
Tethered spinal cord may cause symptoms such as pain, difficulty walking and problems with bladder and bowel control. But infants and young children can’t show us those signs the way adults can. Thus, doctors need to look for clues on regular physical examinations—a dimple, a tuft of hair, or a hemangioma on the lower back, for example—to begin to make the diagnosis.
Dr. Anderson explained that in this case, early treatment is most often the best choice.
While surgery is often necessary in young children, there is encouraging news as far as safety is concerned. Surgeries continue to be quicker, safer and more effective, thanks to newer technologies like endoscopic surgery.
And Dr. Anderson and his surgical colleagues will continue to have conversations with anesthesiologists and parents to ensure the best timing for their smallest patients.
*Full list of authors: Dr. Riva R. Ko, Dr. Teeda Pinhayvat, Dr. Steven Stylianos, Dr. Sarah M. Lambert, Dr. Richard C. Anderson, Dr. Pamela F. Gallin, Dr. Lynne G Maxwell, Dr. Christopher G. Ward, Dr. Jayant K. Deshpande, Dr. Constance S. Houck
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