NEUROSURGERY OUTCOMES 2017 - texaschildrens.org

N E U R O S U R G E R Y O U T C O M E S 2 0 1 7

N E U R O S U R G E R Y O U T C O M E S 2 0 1 7 1

TABLE OF CONTENTS

WELCOME 2

VOLUMES & OUTCOMES 6

PROGRAMS 12

CONGENITAL MALFORMATIONS / FETAL SURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

CRANIOFACIAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

EPILEPSY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

FUNCTIONAL NEUROSURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

HYDROCEPHALUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

SKULL BASE SURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

TRAUMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

TUMOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

VASCULAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

PATIENT STORIES 34

LUKE: TUBEROUS SCLEROSIS COMPLEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

EVERETT: SPINA BIFIDA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

MATTHEW: CRANIOSYNOSTOSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

FACULTY & PUBLICATIONS 40

FACULTY & STAFF DIRECTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

SELECTED PUBLICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

CONTACT US . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44


Dear colleagues, parents and friends,

It is my true privilege to introduce you to the Neurosurgery Division at Texas Children’s Hospital® .

Located in Houston, Texas, and academically affiliated with Baylor College of Medicine, Texas Children’s Hospital is the largest pediatric hospital in the United States and is ranked #4 nationally by U.S. News & World Report, an extraordinary distinction considering its founding only in 1954. We are one of five hospital sites that comprise the Neurological Surgery Residency program at Baylor College of Medicine, under Dr . Daniel Yoshor, chair of neurosurgery. At Texas Children’s Hospital, we are one of nine surgical divisions within the Department of Surgery, made up of nearly 120 pediatric specialty surgeons, under the leadership of Dr . Larry Hollier, Jr ., surgeon-in-chief .

I arrived in Houston in May 2016 after nearly 27 years working at a single institution in New York. The hospital’s ranking, size, scope and vision for growth over the next decade were only part of what attracted me to this opportunity. The most important reason was to join an outstanding team of six full-time pediatric neurosurgeons who were making incredible strides in treatment for children with neurological disorders. This is a group of devoted, caring, academically productive and skilled clinicians renowned for excellence in craniofacial, endoscopic, epilepsy, fetal, functional, hydrocephalus, spine, trauma, tumor and vascular pediatric neurosurgery . Every faculty member is innovating in a specific area of expertise with the goal of leaving pediatric neurosurgery better than they found it. It has been an honor for me to follow the great legacy of Dr. Tom Luerssen, who built this incredibly strong team and service here over the last decade .

We are extremely excited about the next phase of neurosurgery at Texas Children’s . Our collective vision is to be the primary destination for innovative, high-quality, attentive, world-class neurosurgical care for children, to train the future leaders of our specialty, and to investigate the conditions for which we have unique access and insight. Given the rich clinical experience for trainees, with approximately 1,000 operations performed annually, we have a highly sought-after ACPNF-accredited one-year post-residency fellowship in pediatric neurosurgery. Our eleven fellowship graduates hold prestigious academic positions in neurosurgery departments across the country .

We are delighted to share our recent experiences and outcomes with you in this overview of our program. We look forward to continuing to serve you and work with you in the years to come.

Sincerely,

Howard L. Weiner, M.D., F.A.C.S., F.A.A.P., F.A.A.N.S.Chief of Neurosurgery, Texas Children’s HospitalProfessor and Vice Chairman, Department of Neurosurgery, Baylor College of Medicine

WELCOME


Legacy Tower, Texas Children’s newest building, opens in 2018. The expansion includes new

high-intensity surgical operating rooms and a Neuro ICU.


TEXAS CHILDREN’S HOSPITAL

Texas Children’s Hospital® is one of the nation’s largest and most comprehensive specialty pediatric hospitals, with more than 2.4 million patient encounters in 2017. Texas Children’s mission is to create a healthier future for children and women throughout our global community by leading in patient care, education and research. Renowned worldwide for its expertise and breakthrough developments in clinical care and research, Texas Children’s Hospital is ranked #4 nationally by U.S. News & World Report .

Texas Children’s Hospital is located near downtown Houston in the Texas Medical Center, the largest medical center in the world. The medical center campus includes more than 600 licensed beds; the Wallace Tower for outpatient visits; the Feigin Tower for pediatric research; and Texas Children’s Pavilion for Women for comprehensive OB/GYN care . Located nearby is the Jan and Dan Duncan Neurological Research Institute® at Texas Children’s Hospital, a basic research institute dedicated to solving childhood neurological diseases . In 2018, the new Legacy Tower will be completed to increase capacity for critical and surgical care .

Texas Children’s Hospital® West Campus and Texas Children’s Hospital® The Woodlands bring specialty pediatric care, including acute and critical care beds, 24/7 pediatric emergency centers, surgical suites and more than 20 subspecialty clinics, to a rapidly expanding population of children west and north of Houston. Texas Children’s also operates Texas Children’s Health Plan™, the nation’s first HMO for children, and Texas Children’s Pediatrics™, the largest pediatric network in the nation. Texas Children’s Health Centers®, Specialty Care and Urgent Care locations provide enhanced access to care throughout the Greater Houston community. Texas Children’s Health Plan partners with the State of Texas to form STAR Kids, a Medicaid-managed care plan for children with disabilities and complex medical needs offering streamlined management and coordination of care .

ACADEMIC AFFILIATION

Texas Children’s Hospital is affiliated with Baylor College of Medicine in the areas of pediatrics, pediatric surgery and obstetrics and gynecology . Baylor is ranked by U.S. News & World Report as one of the nation’s top 10 medical schools for pediatrics . Currently and throughout our 63 year partnership, Texas Children’s Hospital serves as Baylor’s primary pediatric training site . The collaboration between Texas Children’s Hospital and Baylor is one of the top five such partnerships for pediatric research funding from the National Institutes of Health .

With a staff of more than 11,000 employees and more than 2,000 board-certified physicians, pediatric subspecialists, pediatric surgical subspecialists and dentists, Texas Children’s offers more than 40 subspecialties, programs and services . Physicians are employees of Baylor College of Medicine, not Texas Children’s Hospital . Because they practice at Texas Children’s Hospital, they may be referred to as “our team” or “Texas Children’s physicians” throughout this report .


TEXAS CHILDREN’S NEUROSCIENCE CENTER

Texas Children’s Neuroscience Center is made up of three renowned and integrated components – Neurology, Neurosurgery and the Jan and Dan Duncan Neurological Research Institute® .

One of the largest pediatric neurology programs in the country, the Neuroscience Center receives more than 30,000 clinic visits and performs more than 1,000 surgeries each year . It is a comprehensive destination for children suffering from common neurological conditions like epilepsy and muscular dystrophy to more complex and rare disorders like lissencephaly and Rett syndrome. By combining clinical care with easy access to surgery, we are able to streamline treatment for patients and their families . Experts in pediatric neurology, neurosurgery, neurophysiology, neurological critical care and genetics deliver complete care in 13 clinics . In 2017, U.S. News & World Report ranked Texas Children’s Hospital fourth in the nation for pediatric neurology and neurosurgery .

Neuroscience team members are also active participants and consultants in the hospital’s Level 1 Trauma Center and in research efforts at the Jan and Dan Duncan Neurological Research Institute (NRI) at Texas Children’s Hospital . The world’s first basic research institute dedicated to childhood neurological diseases, the NRI is committed to providing scientists with a world-class technology infrastructure carefully designed to foster collaboration among basic faculty and clinician-scientists with the goal of accelerating the pace of discoveries and developing treatments for childhood neurological diseases .

PIONEERS IN PEDIATRIC NEUROSURGICAL CARE

In 1975, Dr . William R . Cheek established a full-time pediatric Neurosurgery Division at Texas Children’s Hospital, and was the first chief of service. At that time, Dr. Cheek was also the acting head of the Division of Neurological Surgery at Baylor College of Medicine . A graduate of Baylor College of Medicine, Dr . Cheek completed his neurosurgical residency training at the Columbia University Neurological Institute in 1960. He was a distinguished leader in the field, serving as president of the American Society of Pediatric Neurosurgeons and chair of the AANS/CNS Section on Pediatric Neurological Surgery . Dr . Cheek recruited pediatric neurosurgeons Dr . Jack Laurent in 1980 and Dr . Robert Dauser in 1994 to Houston. Dr. Laurent served as chief of Neurosurgery from 1993 to 2003. In 2006, Dr. Thomas Luerssen was named chief of service, where he remained for a decade. Under his leadership, Texas Children’s Hospital grew into one of the top pediatric neurosurgery programs in the nation, pioneering breakthrough surgical treatments for epilepsy, spina bifida and much more. Dr. Howard Weiner was recruited in 2016 from NYU Langone Medical Center, as chief of Neurosurgery .


V O L U M E S & O U T C O M E S



Our program is among the largest and most experienced pediatric neurosurgery units in the United States. Despite being a national and international referral center for many of the most complex and difficult-to-treat cases in pediatric neurosurgery, our outcomes consistently defy expectations and offer new hope for conditions previously considered untreatable.


OUTPATIENT VISITS

SURGICAL CASES BY DIAGNOSIS

CASES, ADMISSIONS AND CONSULTATIONS by year

Year Hospital Admissions Hospital Consultations Surgical Cases

2015 1,192 1,082 906

2016 1,154 1,121 890

2017 1,126 1,008 1,001

7,000

7,100

7,200

7,300

7,400

7,500

7,600

7,700

7,800

7,900

8,000

2015 2016 2017

Hydrocephalus

EpilepsyCraniosynostosis

TumorCongenital Malformations

Functional Neurosurgery

VascularTraumaSpine (Non-Traumatic)

ChiariInfection/Inflammation

Minor Scalp & Skull Lesions

PainO

ther

Hydrocephalus







PainO

ther

Hydrocephalus







PainO

ther

323

101

63 67

20

5538

24 28 26

3 5

52

101

285

112

5140

5538

2813 16

3 3

70 70

106

364

145

49

2442

922 22 24

4 4

83

119

400

300

200

100

0

2015 2016 2017

90


11.3%

10.17%

3.95%

3.95%

3.39%

1.69%

1.69%

0.56%

Shunt Failure

CSF Leak

Post-Operative Infection

Shunt Infection

ETV Failure

Post-Operative Hemorrhage

Residual Brain Tumor

Other

Baclofen Pump Revision

Post-Operative Raised ICP

EVD Failure

0% 10% 20% 30% 40%

37.29%

18.08%

7.91%

BREAKDOWN OF INDICATIONS FOR UNPLANNED RETURN TO THE OPERATING ROOMwithin 30 days of initial surgery

MORTALITY RATEwithin 30 days of initial surgery

Year Overall Cranial Procedure

Spine Procedure

CSF Shunting/ Diversion Procedure

Peripheral Nerve

Procedure

Other Procedure

2015 1 .22% (11/905) 2 .27% (7/308) 0% (0/113) 0 .31% (1/322) 0% (0/7) 1 .94% (3/155)

2016 0 .9% (8/889) 0 .96% (3/314) 0 .76% (1/131) 1 .4% (4/286) 0% (0/4) 3 .25% (5/154)

2017 0 .7% (7/997) 0 .29% (1/346) 0% (0/108) 1 .37% (5/365) 0% (0/1) 0 .56% (1/177)

UNPLANNED RETURN TO THE OPERATING ROOM within 30 days of initial surgery

Year Rate

2015 6 .28% (57/906)

2016 6 .29% (56/890)

2017 6 .39% (64/1001)



P R O G R A M S



The pediatric neurosurgeons at Texas Children’s Hospital are committed to setting a new standard for the surgical treatment of infants and children with neurological disease and to pioneering innovative therapies for children with life-threatening and severely debilitating conditions. Our expertise continues to grow in the following robust programs and subspecialties.


CONGENITAL MALFORMATIONS / FETAL SURGERYThe Neurosurgery Division at Texas Children’s Hospital treats all forms of congenital malformations of the brain and spine . Many of our patients are diagnosed prenatally and seen by the Neurosurgery team at Texas Children’s Fetal Center® before they are even born to discuss the abnormality and possible treatment options . Most malformations are treated postnatally and many do not need surgery at all . In 2011, a randomized control trial was conducted in the United States that showed that closure of an open neural tube defect, myelomeningocele (MMC), a type of spina bifida, could have significant benefits to the baby’s development after birth. Texas Children’s Fetal Center started offering this treatment option in November 2011 . It has been shown to decrease the risk of hydrocephalus in spina bifida patients and it preserves lower extremity strength over the course of the

pregnancy, however, the surgery requires opening the uterus during the second trimester, which increases the chance of prematurity and complications .

Seeking a less-invasive alternative to open fetal surgery, Texas Children’s OB/GYN-in-Chief Dr . Michael Belfort and Texas Children’s neurosurgeon Dr . William Whitehead pioneered a fetoscopic procedure that offers the same benefits of in-utero spina bifida repair with less risk of prematurity and complications . In a recently published study of their first 28 procedures, Belfort and Whitehead reported zero deaths, fewer fetuses needing shunts after birth, and longer pregnancies, on average, compared to the open procedure . Many of the mothers were able to have vaginal deliveries, an option that is not typically not possible following open fetal surgery.


22

36

26

0

10

20

30

40

2015 2016 2017

Volu

me

Postnatal Closures Fetal Closures

VOLUME OF PATIENTS SURGICALLY TREATED FOR MYELOMENINGOCELEby year

PERCENTAGE OF MYELOMENINGOCELE PATIENTS WHO REQUIRE TREATMENT FOR HYDROCEPHALUSfrom 2015-2017

70%

22.92%

0%

20%

40%

60%

80%

100%

Postnatal Repair Fetal Repair

Perc

enta

ge


CRANIOFACIAL

CRANIOSYNOSTOSISThe multidisciplinary craniofacial surgery program at Texas Children’s Hospital provides specialized care for skull and facial abnormalities, offering a comprehensive approach that is centered on the needs of patients and families . Conditions treated include positional plagiocephaly, craniosynostosis and other craniofacial syndromes . Our highly active clinic screens over 1,000 abnormal head shapes in babies every year, most often helping to distinguish between positional plagiocephaly and craniosynostosis .

Positional plagiocephaly, an asymmetric head shape without a fused suture, is addressed by nonsurgical therapy such as repositioning, physical therapy or helmet therapy . Craniosynostosis is a congenital premature fusion (closure) of one or more sutures on a baby’s skull that is usually addressed by surgery . Sutures are seams that connect individual skull bones and when patent as expected (open and not fused), allow the skull to expand when the brain is growing rapidly in infancy. When a suture has closed too early, the skull cannot expand in a uniform fashion, which leads to an abnormal head shape. In some cases, this may lead to increased pressure on the brain (elevated intracranial pressure), which can produce signs and symptoms such as headache, irritability, visual changes and developmental delay . Elevated intracranial pressure occurs around 10 percent of the time when a single suture is affected and up to half the time when more than one suture has fused early .

Our surgical team works together to perform the safest procedure with the best results at the right time for each patient . We tailor treatments to each patient and family to provide the most positive experience possible . Types of surgeries offered include endoscopic craniosynostosis surgery, calvarial vault remodeling, frontal orbital advancement, posterior vault distraction and Monobloc advancement .

We stay engaged with patient families throughout the year, not just when medical needs arise, with an active support group and a Family Advisory Board to help us continually improve the program .

FrontalBone

AnteriorFontanelle

ParietalBone

MetopicSynostatic

Trigonocephaly

SagittalSynostatic

Scaphocephaly

LambdoidSynostatic Posterior

Plagiocephaly

BicoronalSynostatic

Brachycephaly

UnicoronalSynostatic Anterior

Plagiocephaly

(All Sutures Open)Deformational Posterior

Plagiocephaly

PosteriorFontanelle

Metopic (Frontal)Suture

CoronalSuture

SagittalSuture

LamboldSuture

OccipitalBone


AVERAGE LENGTH OF STAYby procedure type

VOLUME OF CRANIOFACIAL SURGICAL CASES by procedure type

12 14

10

46

29 30

11

15

0

10

20

30

40

50

2015 2016 2017

Volu

me

Endoscopic Open Craniosynostosis/Craniofacial Reconstruction Cranioplasty/Skull Reconstruction

18

2

5.8 6.02

8

6

4

2

0Endoscopic Open Craniosynostosis/

Craniofacial Reconstruction Cranioplasty/

Skull Reconstruction

Day

s


UNPLANNED RETURN TO THE OPERATING ROOM within 30 days of initial surgery


Procedure Rate

Endoscopic 2 .78%

Open Craniosynostosis/ Craniofacial Reconstruction 0%

Cranioplasty/Skull Reconstruction 2 .27%

Procedure Rate

Endoscopic 0%

Open Craniosynostosis/ Craniofacial Reconstruction 0%

Cranioplasty/Skull Reconstruction 0%


EPILEPSYOur goal is to become the best pediatric epilepsy program for our patients, and thanks to a concerted multidisciplinary focus and several major innovations in recent years, we are well on our way towards achieving this goal.

The core foundation of our program is our team . We have assembled an outstanding faculty of recognized leaders in both pediatric neurology and neurosurgery, who attract patients to Texas Children’s from all over the United States and the world for evaluation and treatment. Several other top-ranked pediatric hospitals directly refer their patients to us for epilepsy surgery on a routine basis because we are uniquely well

positioned to offer this care . We have all of the state-of-the-art imaging modalities (MEG, PET, SPECT, fMRI and TMS) under one roof for comprehensive and convenient pre-surgical work-ups, and we have surgical expertise in both traditional brain surgery and minimally invasive epilepsy surgery . Our faculty members are invited as featured speakers at medical conferences around the world.

Having finished assembling our epilepsy team in May of 2016, our capacity to take on new cases has dramatically increased . Epilepsy surgical case volume increased 7.6% between 2015 and 2016, and it increased 28.2% between 2016 and 2017.

VOLUME OF SURGICAL PROCEDURESby year

9

24 21

42

14

26 24

39

30

39

23

40

0

9

18

27

36

45

Invasive Monitoring Laser Ablation Resection Stimulation (VNS/RNS)

Volu

me

2015 2016 2017


VAGUS NERVE STIMULATION (VNS) INFECTION RATE by year

Year Rate

2015 0%

2016 0%

2017 0%


FUNCTIONAL NEUROSURGERYAt Texas Children’s Hospital, we have a multidisciplinary team of expert specialists in neurology, neurosurgery and physical medicine and rehabilitation, who care for children with a variety of functional neurologic conditions, including movement disorders such as spasticity and dystonia, and pain . A number of cutting-edge surgical interventions are available, including deep brain stimulation (DBS), intrathecal pump therapy, selective dorsal rhizotomy, spinal cord

stimulation, vagal nerve stimulation, peripheral nerve stimulation, transcranial magnetic stimulation (TMS) and neuro-ablative procedures . Patients are seen and evaluated first and then their case is discussed at a multidisciplinary conference, during which the team collectively determines the optimal treatment for that individual child . The Neurosurgery Division is major referral center for children in need of functional neurosurgical interventions .


BACLOFEN PUMP INFECTION RATEby year

VOLUME OF PATIENTS SURGICALLY TREATED FOR SPASTICITY by year

36 37

63

0

14

28

42

56

70

2015 2016 2017

Volu

me

2.38% 2.33% 2.08%

0%

2%

4%

6%

8%

10%

2015 2016 2017

Rat

e


HYDROCEPHALUSThe most common disease treated by pediatric neurosurgeons is hydrocephalus . All members of the Neurosurgery Division are skilled at the diagnosis and treatment of hydrocephalus . We offer all available treatment options for this condition including endoscopic ventriculostomy with or without choroid plexus coagulation and shunting. The division also conducts extensive clinical research in the condition with the goal of improving the lives of children with hydrocephalus.

We actively participate in the Hydrocephalus Association and we are a member of the Hydrocephalus Clinical Research Network. Over the last several years, we have made hydrocephalus quality improvements a priority, and we have worked diligently to decrease our shunt infection rate, improve our shunt survival rate and create better selection criteria for endoscopic ventriculostomy .

VOLUME OF INITIAL PROCEDURES FOR TREATMENT OF HYDROCEPHALUS by year

33

60

54

20 19 22

0

20

40

60

80

2015 2016 2017

Volu

me

First Endoscopic Third Ventriculostomy/Choroid Plexus Cauterization (ETV/CPC)

First Endoscopic Third Ventriculostomy (ETV)

First-Time Ventricular Shunts


SHUNT INFECTION RATEby year

3.28% 3.17%

5.81%

0%

2%

4%

6%

8%

10%

2015 2016 2017

Rat

e


FIRST-TIME VENTRICULOPERITONEAL (VP) SHUNT SURVIVAL

PERCENTAGE OF SHUNTS FUNCTIONING AT ONE YEAR AFTER PLACEMENTby year

2013 2014 2015 2016

71 .7% 84 .3% 67 .3% 83 .6%

PERCENTAGE OF ETV FUNCTIONING AT ONE YEARby years

2012-2016

39 .6%

FIRST-TIME ETV/CPC SURVIVAL

0.00

0.25

0.50

0.75

1.00

0 1 2 3 4 5Years

0.00

0.25

0.50

0.75

1.00

0 1 2 3 4 5Years


VOLUME OF SKULL BASE SURGERIESby year

SKULL BASE SURGERYSkull base tumors are rare in the pediatric population, but need to be addressed . These types of tumors require accurate diagnosis, detailed pre-operative planning and multidisciplinary care . Started in 2007, our skull base program includes a team of otolaryngologists, plastic surgeons, ophthalmologists, neuroradiologists, neuropathologists and oncologists . As these cases tend to be complex, they are reviewed and discussed by the entire physician team and surgical plans are meticulously made in advance . We offer both open and minimally invasive techniques, depending on the pathology . Texas Children’s Hospital typically cares for 5-10 skull base tumor patients annually and our outcomes are tracked on a regular basis .

9

5

9

0

1

2

3

4

5

6

7

8

9

10

2015 2016 2017

Volu

me


NUMBER OF CEREBROSPINAL FLUID (CSF) LEAKS AFTER SKULL BASE SURGERY by year


Year Rate

2015 0%

2016 0%

2017 0%

Year Number

2015 0/9

2016 0/5

2017 2/9


TRAUMATrauma is the most significant cause of morbidity and mortality in children. As one of the few accredited Level I Trauma Centers for pediatric patients in the country, Texas Children’s Hospital is committed to the prevention, treatment and rehabilitation of all types of traumatic injuries. We care for all aspects of traumatic brain injury, spinal cord injury and peripheral nerve injury. Neurosurgical treatment is provided in coordination with the trauma team which includes pediatric surgeons, critical care specialists,

orthopedic surgeons, otolaryngologists and physical medicine and rehabilitation specialists . We see over 500 trauma patients each year and approximately 10% require surgical intervention . Should a patient require rehabilitation for a traumatic brain injury, Texas Children’s Hospital has one of the only pediatric inpatient rehabilitation units in the southwest United States, providing a variety of intensive treatment options including cognitive testing, physical therapy, occupational therapy and speech therapy .

VOLUME OF TRAUMA CONSULTS AND SURGICAL CASES by year

516 509 484

55 55

0

70

140

210

280

350

420

490

560

2015 2016 2017

Volu

me

Inpatients Seen by Neurosurgery Surgical Cases

42


TUMOR

VOLUME OF SPINE AND BRAIN TUMORSby year

We offer comprehensive, multidisciplinary care for children with tumors of the central nervous system, in conjunction with our colleagues in pediatric neuro-oncology, neurology, ophthalmology, physical medicine and rehabilitation, endocrinology, radiology, pathology and pediatrics .

With a surgical volume exceeding 100 brain and spinal tumors annually, we are one of the busiest pediatric neurosurgical oncology programs in the United States . We utilize state-of-the-art surgical technology, including frameless stereotactic image guidance, microsurgery, brain mapping, intra-operative MRI imaging, robotic assisted surgery and awake craniotomy to care for our

many patients who may have posterior fossa, pineal region, suprasellar, hemispheric, intraventricular and deep-seated brain tumors .

Texas Children’s Cancer Center® is ranked 4th in the nation by U.S. News & World Report for pediatric cancer and Texas Children’s Hospital is a member of several collaborative consortia, including the Pediatric Brain Tumor Consortium (PBTC), which allows us to offer our patients the very latest novel therapeutic options . This overall effort is also enhanced by several ongoing basic science brain tumor research projects underway at Baylor College of Medicine .

68 62

13

0

20

40

60

80

2015 2016 2017

Volu

me

of p

atie

nts

Recurrence - Spine Tumor New Diagnosis - Spine Tumor Recurrence - Brain Tumor New Diagnosis - Brain Tumor

17

78

18


RATE AT WHICH PATIENTS REQUIRE TREATMENT FOR HYDROCEPHALUS FOLLOWING POSTERIOR FOSSA TUMOR RESECTIONby year

17.65%

28.57%

36.67%

0%

25%

50%

75%

100%

2015 2016 2017

Rat

e


Year Rate

2015 1 .04%

2016 0%

2017 0%


VASCULAR

VOLUME OF ENDOVASCULAR AND OPEN PROCEDURESby year

Neurovascular or cerebrovascular disease refers to conditions affecting blood vessels in and around the brain and the spine . While neurovascular disease affects people of all ages, children often have a different biology than adults . For instance, these diseases can be related to genetic factors and can progress or come back as children are growing. Children with neurovascular or cerebrovascular disease face the risk of either bleeding in the brain (hemorrhagic stroke) or the risk of stroke from not enough blood supply to the brain (ischemic stroke) . Both types of stroke can be life-threatening, and can also cause serious damage to the brain . Our goal is to diagnose and treat children before they are affected by such dangerous events . Conditions we treat include arteriovenous malformation, moyamoya, cerebral cavernous malformation, arteriovenous fistula, aneurysm, dissection, stroke and vein of Galen malformations .

The Neurosurgery Division is part of a multidisciplinary vascular anomalies clinic at

Texas Children’s Hospital, alongside specialists in neurology, neuroradiology, neurocritical care, genetics, hematology/oncology, physical medicine and rehabilitation, ophthalmology and more . We continue to develop new understandings of the basis for and the treatment of neurovascular anomalies, and our patients have access to the latest diagnostic and treatment technologies and investigational studies . Each patient has an individualized treatment plan endorsed by the multidisciplinary team, and our goal is to see patients who previously had few options thrive and grow over time.

Open neurosurgery, endovascular interventions or medical therapies are options for addressing pediatric neurovascular or cerebrovascular conditions . We evaluate, diagnose and treat each patient with consideration to the most appropriate approaches, choosing from various neurosurgical, neurointerventional and medical therapies and often combining these modalities to achieve the safest and most effective results .

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Endovascular Open

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All data is represented by academic year which runs from July 1- June 30, unless otherwise noted.



P A T I E N T S T O R I E S



LUKE STEMLE

At 3 weeks old, Luke Stemle was diagnosed with tuberous sclerosis complex (TSC), a rare disease that causes tubers, or benign tumors, to grow on the brain and other vital organs .

Luke underwent his first brain surgery at 5 weeks old at a hospital near his home in Kentucky . Unfortunately the seizures returned after 10 days, landing him in critical condition in the ICU . With medication and time, his seizures became more manageable, but he still continued to experience them, which limited his independence and quality of life as he continued to grow.

When Luke was 3 years old, his doctor recommended a new type of surgery for children with TSC, which was available at Texas Children’s Hospital. It was less invasive than a traditional craniotomy, which removes a portion of a patient’s skull to grant access to the brain and is therefore only recommended for patients with the most serious and life-threatening conditions .

Pioneered by Texas Children’s neurosurgeon Dr . Daniel Curry, this laser ablation technique requires a hole only the size of a pen and uses an MRI-guided laser to destroy the tubers causing the seizures . The surgery has had tremendously positive results for patients with TSC.

In fall of 2016, Luke and his family came to Texas Children’s Hospital. He underwent two surgeries to ensure that all of the affected areas of his brain were removed.

“When we received the results of his EEG, I was moved to tears . In addition to his seizure activity, Luke’s brain used to show abnormal activity nine seconds out of ten. The last EEG had just one abnormality in 45 minutes,” said Luke’s mother, Stephanie . “The surgery has done much more than stop Luke’s seizures, it has given Luke peace for the first time in his life,” she said. “His brain is being given the chance to grow and learn and build relationships uninterrupted . It is a sigh of relief and gratitude after years of holding our breath in fear and chaos .”

Luke has not had a single seizure since leaving Texas Children’s more than a year ago, and his doctors and family are hopeful and optimistic it will stay that way.


EVERETT KERRES

At an 18-week ultrasound, Johnna and Adam Kerres were devastated to learn that their first child, Everett, had a severe form of spina bifida. A doctor told them Everett would likely never walk.

The Kerres immediately put their nesting and baby shower plans on hold while they learned everything they could about the condition . Their doctor pointed them in the direction of Texas Children’s Fetal Center®, where doctors had recently developed a less invasive fetal surgery option with tremendous promise to help babies like Everett .

Unlike open fetal surgery, which cuts open the uterus to directly operate on the fetus, the fetoscopic method offers the same benefits of in-utero spina bifida repair with less risk of premature labor and associated complications .

“We believe this option can lead to dramatically better outcomes for babies with spina bifida, and we’re working hard to get the word out to OB/GYNs everywhere,” said Dr. Michael Belfort, OB/GYN-in-chief, who pioneered the procedure with Texas Children’s Hospital neurosurgeon Dr . William Whitehead .

At 24 weeks gestation, Belfort and Whitehead led a large multidisciplinary fetal surgery team to successfully perform the procedure . Afterwards, Johnna’s pregnancy proceeded without complication, and at 39 weeks and 1 day, she delivered Everett vaginally. From birth to now more than a year old, Everett has continued to defy the odds . Today, he is happy, smart and extremely chatty and currently working on learning how to walk.

“Everett’s repair was one of the best reversals I’ve seen since we’ve been performing this intervention,” said Dr . Whitehead . “The outcome was remarkable.”


MATTHEW BOLER

It’s widely known that many newborns have abnormally shaped heads due to positioning in the womb or journeying through the birth canal . For that reason, Megan and Michael Boler weren’t too concerned about the long skinny shape of their baby Matthew’s head, though they did wonder when it would round out.

At a routine 2-month wellness check, their pediatrician was alarmed to find that the soft spot in Matthew’s head – which isn’t supposed to close until 18 months – was hard. She referred the Bolers immediately to Texas Children’s Hospital, where he was diagnosed with craniosynostosis, a rare and serious birth defect that causes the skull bones to fuse together too early .

When a baby’s skull closes prematurely, the brain at first continues to grow, which causes the skull to form in an unsual shape . Eventually, the baby’s brain has no room to grow and this can cause lifelong neurological problems and even death in extreme cases .

“It was very fortunate that Matthew’s pediatrician caught this very early, giving us a chance to fix it before any long-term damage could occur,” said Dr . Sandi Lam, director of the cerebrovascular neurosurgery program at Texas Children’s Hospital .

When Matthew was 10 weeks old, Lam led a successful five-hour surgery to remove the fused bone at the top of his skull .

At first, the recovery was worse than the surgery itself,” Megan said. “He was unrecognizable, so swollen, and for a while he was inconsolable. But eventually on the third day, he perked up, started breastfeeding again and returned to his usual cheerful self .”

After the surgery, Matthew needed to wear a special helmet 24 hours a day. Every two weeks the helmet was checked and adjusted to aid in Matthew’s recovery. In fact, he progressed so well that he was released from helmet therapy after only four months. Now over 3 years old, Matthew’s parents report he is happy, healthy and developmentally normal, with a perfectly boring shaped head .



FA C U LT Y & P U B L I C AT I O N S



FACULTY & STAFF DIRECTORYHoward L. Weiner, M.D., F.A.C.S., F.A.A.P., Chief Guillermo M . Aldave, M .D ., Ph .D .Brandy Berger, M .S .N ., R .N ., C .P .N .P .-P .C . Natalie Cormier, M .S .N ., R .N ., F .N .P .-B .C . Daniel J . Curry, M .D . Robert C . Dauser, M .D . Brian J . Kelley, M .D ., Ph .D .

Heidi Kerns, M .S .N ., R .N ., F .N .P .-B .C . Sandi K . Lam, M .D ., M .B .A . Amee Moreno, M .S .N ., R .N ., C .P .N .P .-P .C . I-Wen Pan, Ph .D . Brenda Perry, C .P .N .P .-P .C . Lucia Ruggieri, P .A .-C . William E . Whitehead, M .D ., M .P .H .

Howard L. Weiner, M.D., F.A.C.S., F.A.A.P.Chief of Neurosurgery, Texas Children’s HospitalProfessor and Vice Chairman, Department of Neurosurgery, Baylor College of Medicine Dr . Weiner has become one of the country’s leading pediatric epilepsy surgeons, attracting patients from across the United States and abroad because of his innovative approach . Over the last 20 years, he has become a recognized national and international leader in the surgical treatment of childhood epilepsy, and has been a pioneer in advancing the care of children with tuberous sclerosis complex, for which he is considered one of the world’s leading experts. His expertise also includes the operative treatment of childhood brain tumors, spasticity, hydrocephalus, congenital malformations, tethered cord, Chiari malformation, craniosynostosis and spina bifida.

Guillermo M. Aldave, M.D., Ph.D. Assistant Professor, Pediatric Neurosurgery, Baylor College of Medicine Dr . Aldave’s clinical interests include maximizing the safe treatment of pediatric brain tumors and improving patients’ clinical outcomes and quality of life . His research interests include the use of oncolytic virus in the treatment of high grade pediatric brain tumors and the development new and unique strategies of treatment for tumor patients, such as the use of five aminolevulinic acid for the resection of high grade gliomas.

Daniel J. Curry, M.D.Associate Professor, Pediatric Neurosurgery, Baylor College of MedicineDr . Curry’s clinical interests include minimally invasive treatment in epilepsy surgery, treatment of pediatric movement disorders and chronic pain . His research interests include study of the mechanisms of dystonia and non-invasive detection of epilepsy networks.

Robert C. Dauser, M.D.Associate Professor, Pediatric Neurosurgery, Baylor College of MedicineDr . Dauser’s clinical interests include the diagnosis and treatment of moyamoya, hydrocephalus, brain tumors and craniofacial abnormalities . His research interests include spinal cord regeneration, optic nerve regeneration, as well as moyamoya.

NEUROSURGEONS


SELECTED PUBLICATIONSAldave G, Hansen D, Hwang S, Moreno A, Briceno V, Jea A “Spinal Column Shortening for Tethered Cord Syndrome Associated with Myelomeningocele, Lumbosacral Lipoma, and Lipomyelomeningocele in Children and Young Adults . J Neurosurg Pediatr June . 2016 .

Aldave G, Hansen D, Luerssen T, Jea A . Assessing Resident Operative Skills for Shunt Surgery in Pediatric Neurosurgery . J Neurosurg Pediatr April . 2016 . Boerwinkle VL, Vedantam A, Lam S, Wilfong AA, Curry DJ. Connectivity Changes after laser ablation: Resting-state fMRI . Epilepsy Res 2017 Sep 28.pii:S0920-1211(17)3035-0. doi:10.1016/j.eplepsyres.2017 09.015.

Boom M, Raskin JS, Curry DJ, Weiner HL, Peters JM . Technological advances in pediatric epilepsy surgery: implications for tuberous sclerosis complex . Future Neurol 12:101-115, 2017 .

Brian J. Kelley, M.D., Ph.D.Assistant Professor, Pediatric Neurosurgery, Baylor College of Medicine Dr . Kelley’s clinical interests include complex spinal deformity and scoliosis in collaboration with the Orthopedic Surgery program, congenital spinal dysraphism, cranio-cervical junction instability (traumatic and congenital), traumatic brain and spinal cord injuries, spondylolysis/spondylolisthesis, Chiari malformation, tethered cord syndrome and spinal tumors . His research interests include neurotrauma (basic science and clinical), including therapeutic treatment modalities and advanced neuroimaging techniques .

Sandi K. Lam, M.D., M.B.A.Associate Professor, Pediatric Neurosurgery, Baylor College of Medicine Dr . Lam’s clinical interests include pediatric cerebrovascular surgery, epilepsy surgery and craniofacial surgery . In particular, Dr . Lam applies minimally invasive surgery through endoscopic approaches for epilepsy and craniosynostosis . Quality improvement is incorporated into her clinical practice . Dr . Lam’s areas of research include health services research for pediatric neurosurgery and the analysis of national and institutional data to look at patterns of care, health care utilization and health outcomes to understand disparities and to develop models for improving health care delivery .

William E. Whitehead, M.D., M.P.H.Associate Professor, Pediatric Neurosurgery, Baylor College of Medicine Dr . Whitehead’s primary clinical interests relate to the treatment of hydrocephalus, complex shunt problems, spina bifida and other congenital malformations of the nervous system, brain and spine tumors, vascular malformations and skull base diseases . His research focuses on hydrocephalus and fetal myelomeningocele repair . He also has a major grant from PCORI (Patient Centered Outcomes Research Institute), which focuses on the surgical treatment of hydrocephalus.


Cherian J, Belfort MA, Shamshirsaz AA, Espinoza J, Olutoye OA, Cass DL, Olutoye OO, Whitehead WE . Two-Port Endoscopic Fetal Closure of Myelomeningocele. Videoscopy 2017, DOI: 10 .1089/vor .2017 .0452 .

Hidalgo ET, Orillac C, Hersh A, Harter DH, Rizzo WB, Weiner HL . Intrathecal baclofen therapy for the treatment of spasticity in Sjogren-Larsson Syndrome. J Child Neurol 32:100-103, 2017 .

Kelley BJ and MG Vitale . Early Onset Scoliosis and Congenital Spinal Anomalies, In: Orthopedic Knowledge Update – Series 5; Ed . E . Truumees and H . Prather; AAOS 2017 .

Kelley BJ, Minkara AJ, Angevine PD, Vitale MG, Lenke LG, Anderson R CE . Temporary Occipital Fixation in Young Children with Severe Cervical-Thoracic Spinal Deformity. Neurosurg Focus (accepted) .

Lopresti M, Daniels B, Buchanan E, Monson LA, Lam S . Virtual surgical planning and 3D printing in redo calvarial vault reconstruction . J Neurosurg Pediatr 19(4):490-494 . Apr 2017 .

North RY, Raskin JS, Curry DJ . MRI-Guided Laser Interstitial Thermal Therapy for Epilepsy . Neurosurg Clin N Am 2017 Oct;28(4):545-557. doi 10.1016/j.nec 2017.06.001.

Raskin JS, Hansen D, Mohan AC, Pan IW, Curry DJ, Lam S . Perioperative antibiotic use in vagus nerve stimulator implantation – a clinical series . Childs Nerv Syst 33(5):801-804 . May 2017 .

Sato M, Gunther JR, Mahajan A, Jo E, Paulino AC, Adesena AM, Jones JY, Ketonen LM, Su JM, Okcu MF, Khatua S, Dauser RC, Whitehead WE, Weinberg J, Chintagumpala MM . Progression-free survival of children with localized ependymoma treated with intensity-modulated radiation therapy or proton beam radiation. Cancer 123(13): 2570-2578, 2017 .

Wallace S, Guo DC, Regalado E, Mellor-Crummey L, Bamshad M, Nickerson DA, Dauser R, Hanchard N, Marom R, Martin E, Berka V, Sharina I, Ganesan V, Saunders D, Morris SA, Milewicz DM. Disrupted nitric oxide signaling due to GUCY1A3 mutations increases risk for moyamoya disease, achalasia, and hypertension . Clin Genet 90(4): 351-60, 2016 .

Wellons JC, Shannon CN, Holubkov R, Riva-Cambrin J, Kulkarni AV, Whitehead WE, Browd S, Rozzelle C, Simon TD, Tamber MS, Oakes WJ, Drake J, Luerssen TG, Kestle J for the Hydrocephalus Clinical Research Network. Shunting Outcomes in Posthemorrhagic hydrocephalus: results of a HCRN prospective Cohort Study . J Neurosurg Pediatr 2017 Jul; 20(1): 19-29 .

CONTACT USTo refer a patient to Texas Children’s Neurosurgery program, please visit texaschildrens.org/refer or contact us directly .

Clinic Location Mailing Address Phone6701 Fannin St ., 9th Floor 6701 Fannin St ., Suite 1230 .01 832-822-3950Houston, TX 77030 Houston, TX 77030

For additional information about the Neurosurgery Division, visit texaschildrens.org/neurosurgery .

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