Childs Nerv Syst (2010) 26:201–203 DOI 10.1007/s00381-009-1030-4

FOCUS SESSION

Should pediatric neurosurgeons still manage neurotrauma today? Jonathan C. Peter

Received: 17 September 2009 / Published online: 19 November 2009 # Springer-Verlag 2009

Abstract Introduction Neurotrauma remains a major global burden of injury, especially for young patients, and will consequently always be a condition that pediatric neurosurgeons are called upon to treat. However, the face of modern neurotrauma management is changing, presenting important challenges to today’s pediatric neurosurgeons. Objective This article summarizes some of the issues in neurotrauma facing clinicians whose responsibility it is to treat these children. Conclusion It is up to the individual neurosurgeon to familiarize him- or herself with the emerging literature on the modern management of pediatric neurotrauma. Keywords Pediatric neurosurgery . Neurotrauma . Neuromonitoring . Neurocritical care . Traumatic brain injury

The problem of pediatric neurotrauma The global burden of neurotrauma has not diminished in past years—if anything, it has increased with the rapid urbanization of societies around the world. In children and young adults, more lives are lost due to injury than to all other causes of death combined [17, 24]. The overall incidence of pediatric trauma in developing countries is usually higher than in the developed world and is caused primarily by road traffic accidents and violence. In countries like South Africa, the chances of dying due to injury in childhood (5–15 years) may be sixfold higher J. C. Peter (*) Division of Neurosurgery, University of Cape Town, H53 OMB Groote Schuur Hospital Observatory, 7925 Cape Town, South Africa e-mail: [email protected]

than in the developed world [3, 16]. However, even in the USA, injury remains the highest cause of death in children and adults 1–34 years of age [1, 15] and accounts for two thirds of deaths in children between 5 and 19 years [7]. Of all injured children, those who sustain traumatic brain injury (TBI) have the highest chance of dying or being permanently disabled [5, 10, 15, 18, 29]. TBI has been implicated in as much as 70–80% of accidental deaths after trauma in children [10, 13]. The direct and indirect injury costs of motor vehicle accidents alone were $146 billion in the USA for the year 2000 [15]. Hospitalization rates for TBI are increasing, and children in lower income countries, as well as the uninsured in developed countries, appear to be at the highest risks of poor outcome [2, 3, 16, 19, 25, 30]. The need for neurosurgical involvement in TBI research and management development is compelling. However, today, many neurosurgical centers delegate the responsibility of TBI to intensivists and traumatologists. Residents usually start their neurosurgical training enthusiastically looking after TBI patients. This enthusiasm often sadly diminishes with time and becomes replaced by a nihilistic attitude, which can easily exacerbate a potentially negative outcome. There are many reasons for this, but a main cause is often the misconception that little progress is being made in the management of TBI.

The changing face of neurotrauma management During the last 50 years, however, significant strides have been made in the neurosurgical management of TBI. Modern imaging has dramatically improved the outcome for TBI patients. Today’s resident could not imagine assessing an acute head injured child without at least a

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CT scan! Accident prevention and education campaigns about emergency measures to prevent secondary injury both at the accident site and in the trauma unit have all had significant impacts on outcome [17, 26]. Studies that showed the lack of benefit and dangers of steroids and hyperventilation, although disappointing, nevertheless enhanced our understanding [8]. New technologies for measuring intracranial pressure, cerebral blood flow, and brain oxygenation have spawned many studies that show that aggressive treatment appears to improve outcome—especially with a guidelines-driven approach combined with neuromonitoring [4, 6, 8, 9, 11, 14, 19, 21–23, 27, 31]. This reduction in mortality has not led to a higher proportion of disabled survivors or to higher costs [11]. There is, however, a growing awareness that, even if the intensive care unit (ICU) management strictly adheres to the standard TBI guidelines, secondary injuries can still occur [12, 28]. Although this is of concern it could provide a potential therapeutic window of opportunity. However, despite the many advances made, there still remains a large variation in the quality of care given to TBI patients both nationally and internationally [4, 9, 20].

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The challenge to the pediatric neurosurgeon In the ICU, teamwork is essential, and without minimizing the contributions that intensivists and trauma surgeons make to the management of TBI, I believe that neurosurgeons are the best persons to be the primary managers of patients with TBI, not only because of the large number of TBI patients that they are exposed to but also because they are daily, in every aspect of their work, engaged with the complex pathophysiological relationships that affect the brain. Consequently, it behooves all neurosurgeons to keep up with these evolving new technologies because it could be very easy to lose expertise in this rapidly developing field. For pediatric neurosurgeons to be relegated to being mere surgical technicians would be a very sad day indeed!

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