Chapters Transcript My Child's Head Looks Strange, is it Normal? Eric Thompson, MD, presents on the three categories of hydrocephalus. Obstructive, Communicating and Ex Vacuo. Well, good morning, everyone, and thank you for joining us for Early Bird rounds today. Today, our speaker is Doctor Eric Thompson, and he is specialized in pediatric neurosurgery. Um, as always, please keep your cameras turned off and your mic's muted during the session, and there will be time at the end for any questions, and you're welcome to unmute at that time or send your questions in the chat box. Um, I will also put the QR code up at the end for you all to scan for credit, and we'll go ahead and turn our attention to Doctor Thompson. All right. Thanks, Madison. Are you able to hear me OK? Yes. OK, perfect. All right, so, um, thanks for the invitation to talk and um you know, I have, you know, this presentation uh should not take an hour long, so hopefully we'll have plenty of time uh to answer questions on um this topic or really any pediatric neurosurgery topic, um, at the end of the the talk. So thanks very much. All right, so we'll go ahead and get started. Uh, these are my, uh, disclosures. Um, so first I wanted to talk about, um, hydrocephalus. So this is a schematic um showing the brain and essentially where uh cerebrospinal fluid is made and how it circulates throughout the the brain. Um, so what are the categories of hydrocephalus? Um, so the first category would be obstructive or non-communicating, um, which is a physical blockage of the, uh, cerebrospinal fluid flow through the ventricles, um, and, um, communicating, um, which would be the ventricles are, everything is all connected, um, but the spinal fluid, uh, for whatever reason cannot be absorbed or processed and, and therefore builds up in the brain. And then ex vacuo, um, which is not true hydrocephalus, but it's really, uh, due to brain atrophy, um, um, and so not necessarily an increase in fluid volume but an increase in atrophy, so ventricles look larger. So one of the most common presentation of hydrocephalus, it varies obviously in um preverbal and verbal children and infants. Um, so the majority present with irritability, uh, delayed milestones, nausea and vomiting, headache, lethargy, and new seizures, or if they have existing seizures change in their seizure pattern. In infants, um, it would be an increasing head circumference in the majority of patients. Uh, oftentimes, um, children have bulging fontanels, um, also delayed milestones, um, loss of upper gaze. We hear a lot about that, but that doesn't happen, um, in a lot of patients. It's actually um a a a minority of patients that actually have what we call sunsetting gaze or or loss of upward gaze. Uh, lethargy, um, and focal neurologic deficits, and, um, uh, approximately 12% have pathheema. And so we rely heavily um when we're diagnosing children with hydrocephalus on the three main components are imaging, um, their head growth charts, um, and their exam. And so, um, a common question I get is in an exam, um, or I'm sorry, in a, in a head circumference growth chart like this, is this concerning or not? It's actually even though it looks fairly concerning because the um the the growth chart is way up here, if you look back, this patient's always had a large head, so even at birth they were they were above the 99th percentile and actually they have been following the curve reasonably well. So it's what's less important is where they are on the curve. What's more important is how they're following the curve um itself. What's more concerning would be a um head growth chart looking like this where a patient had, you know, at birth started probably in the 25th percentile, but over time it's crossed multiple percentiles and now it's kind of um headed in this kind of trajectory. So this would be much more concerning for hydrocephalus. This over here would be more um uh uh typical with a benign familial macrocephaly. And what's really important is to adjust for for patients um gestational age, um, and we do this and fortunately with the advent of the um electronic medical record, this does, um, for example, API um does this automatically, but sometimes you still have to manually um adjust for it. And so again, this was uh the same uh head growth chart as I previously demonstrated which looks um somewhat concerning. However, If you, um, adjust, say for example, they were born just not extremely prematurely but uh prematurely, but born, say 4 weeks early, even that makes a huge difference on where they are on that growth chart. So say for the example, this patient was born at 36 weeks, if you actually look at it, their head circumference has always actually been really about the 99th percentile. So again, much less concerning than if they were born in full term and they had done something like this with their their head growth over time. Um, I also want to talk about just briefly, um, not to get too far off the topic of hydrocephalus, but about a premature fontanel closure. This is a common referral that I get in the clinic, and this is actually a great paper way back, um, in, in pediatrics from 1986. Um, showing essentially that um the pre the, uh, anterior fontanel closes, the median age, um, is about 13 months, but it's actually a bell-shaped curve, um, that really closes anywhere from about 4 months to about 27 months, 26 months or so. So really anywhere between 4 and 26 months is within normal range for fontanelle closure. Um, additionally, um, it would be very unusual. I've actually never seen a patient with multiple suture craniosynostosis causing, uh, you know, a small head growth, um, that didn't have some type of known syndrome or clearly looked, um, um, abnormal. Now back to hydrocephalus. So what are the treatments of hydrocephalus? Um, so, um, when we talk about CSF diversion, the main thing that people think about are shunts, um, and there's different types of shunts, so we're shunting fluid from the brain to a different compartment, so that the most common would be a ventricular perineal shunt. Other types would be a ventriculo pleural shunt or a ventricular atrial shunt. Um, in some cases, we're able to physically open an alternative pathway for the spinal fluid to flow, which would be an endoscopic third matricuostomy. And more recently we've actually added um what's called a colexus cauterization in some patients, um, which actually decreases uh spinal fluid production, and that's always in association with, with an endoscopic uh third ventriculostomy. So this is a schematic from an old netter diagram showing a shunt essentially tube um that's inserted into the ventricle here, um, drains underneath the skin through a valve, um, and then it's tunneled um typically in the peritoneum and this one is also showing um into um the atrium again this wouldn't go into the atrium and the peritoneum. This is just a schematic, but uh to to show generally what it looks like. This is what the the shunt tubing roughly looks like. Um, the problem with shunts is they're, um, rough with, with complications. The the mainw of is a mechanical blockage. So approximately 38% of patients that have had a shunt insertion or any type of shunt revision fail within the first year, and this is a huge, uh, percentage, um, this is obviously very, um, uh, problematic, uh, for the patient, their families, for the medical system and resources. And up to 50% fail within the first two years and then it's roughly about 4% um thereafter. So this means the further you get from your shunt revision or insertion, the less likely it is to fail, but it never essentially um uh uh is a 0% risk of failing. Um, other, other main complication would be infection, um, and so this is typically, um, uh, it can be really any bacteria, but the most common are bacteria that live on, on, on skin like Staabbi or Staph aureus. Um, the overall infection rate rates from 3 to 10% and up to 20% of preterm infants. This is a hugely high, um, complication rate for surgery or infection rate for surgery. For example, our other types of surgery, say a, a common surgery that a pediatric neurosurgeon would form like a CRE decompression, the infection rate is really about 2% for that. So an infection rate up to 10 to 20% is really, really high. They can also break or become disconnected. Um, this typically occurs in children during periods of rapid growth, um, and typically often occurs here in the neck, and the reason for that is because of the constant movement um of of the neck. Sometimes the tubing itself can get kind of scarred into place and it's, even though it's made of silastic and it, it has a lot of elasticity in it, it can get tethered and break, um, especially during periods of rapid growth. And you can have distal cy complications. Again, the most common distal site is the peritoneum, um, but you can have what's called a pseudocyst where essentially the fluid is not being absorbed by the peritoneum but is walled off, um, and essentially accumulates. Um, if the, the shunt is in the the pleural, you can have pleural fusions. Um, and if the shunt is in the atrium or the hearts, you can have what's called shunt nephritis, which is a very rare but very uh problematic complication where the body essentially makes, um, antibodies to proteins in the cerebrospinal fluid and it can result in in kidney damage and kidney failure. You can also have over drainage. So again, you're shunting fluid from the central nervous system to a different compartment in the body, and so therefore you can have um slit ventricle syndrome where the ventricles become tiny, really difficult to treat, and patients can get headaches from this, um, or subdural hemorrhages, um, because everything essentially has collapsed because the the fluid is being shunted out and then therefore you have a potential space on the outside of the brain where blood can accumulate or fluid can accumulate. And so say you have a patient that has a ventricular perineal shunt, um, how do you evaluate for shunt failure? Um, really important as it is with any evaluation as the history, um, what is, if they've had a previous shunt failure, what did that look like and is is that similar to how they're presenting now? Um, do the parents think it's a shunt failure, um, do they have headaches, nausea, abdominal pain or swelling along the shunt tract? In physical exams, so in preverbal, um, uh, children, um, if they have a a full or body fontel, if they're excessively irritable or lethargic, or if they have this sunsetting gaze that I mentioned before, um, you can always perform a a funduscopic exam and assess for apedema. However, paloedema oftentimes takes a few weeks to develop, um, even if the pressure is, is high, so in in an acute failure may you may not see papilledema. Um, if they have a a parent nose shunt, you can have abdominal distention. If they have something like a, a pseudocyst or an infection, um, you can have erythema or swelling or drainage incisions, which would be indicative of a, um, infection or wound breakdown, and boggy fluid along the shunt tract, um, itself, um, can, um, uh, be evident. Um, so, so diagnostically how do you evaluate, uh, for, for this, um, the key thing is, is really head imaging, um, which we, we prefer a quick brain MRI to avoid radiation, but if you're in an institution that doesn't have a quick brain MRI protocol that doesn't require sedation, then a CT scan is totally reasonable, um, and then always obtain a shunt X-ray to look at the integrity of the tubing itself. Um, in some cases that are equivocal, you can perform a nuclear medicine shunt flow study where we inject technicium 99 into the shunt and, and see that it goes into the ventricle and then drains out into the distal site. If they have a perineal shunt and you're you're worried about a pseudocyst or some type of abdominal complication, you can get an abdominal ultrasound to look for that. So, um, again, ventricular peroneal shunts are the most common way to treat hydrocephalus, but, you know, obviously they have a lot of, of complications, and we've been working, you know, as a, uh a uh a subspecialty to, to develop better alternatives. Um, and again, this is a back to the schematic of the cerebrospinal fluid flow. So say you have a blockage here, for example, from a tumor or some other type of congenital issue, um, you can create an alternative pathway with an endoscopic, um, third ventriculostomy, and this is a schematic of it essentially. Because the, the, the fluid is not able to pass through the fourth ventricle and then out of the frame one of Monroe and Lushka and circulate around the spine, this would be the alternative pathway in front of the brain stem as opposed to behind the brain stem. Um, and this is basically what the camera looks like essentially we insert it into a small hole in the in the uh skull, it does have to go through normal brain to get to the ventricle, but essentially then we poke a hole into the on the bottom of the third ventricle right here to create an ostomy for that spinal fluid to flow. And so say you have a patient um that has had this procedure, an endoscopic third ventriculostomy or an ETV. Um, the, um, and they and they present for, um, possible failure. Um, these are essentially, um, what the, the complications to look for. So it's really just mechanical blockage. So say for example you have a very young child and it's healed over, um, this is, these are essentially the, um, the results of that, so 30% in the first year and then 40% and then 3% after so a better profile than thanunts and I'll I'll show a Kappa Mayer curve showing that. But the great thing is an infection would be extraordinarily rare um for the after this procedure, and you don't have to worry about breakage or disconnection. You don't have to worry about any distal site, um, complications because there is no distal site, and you don't have to worry about over drainage because again you're not shunting fluid from the brain to another compartment, it's all staying in the central nervous system, it's just has an alternative pathway to flow. And so this is a Kaplan Meyer curve, uh, from a nice paper, um, showing essentially the success rates of an endoscopic ventricuostomy over a shunt. So essentially, um, Patients up to about, you know, 4 to 6 months or so, a shunt is a little bit more favorable for not failing, but over time you can see that the, the line continues to to go down here. So even way out, you know, several years you can have shunt failure, whereas if you've had an endoscopic ventricuostomy, if you make it past 6 months or so, the chance of you ever needing another surgery is extraordinarily low. And we have actually pretty good data um and predictors to, to say who is gonna um uh be successful or or or what patients are good candidates for this. So if patients are older, um, they're better candidates, um, and that's because um they're less likely to heal over. um, if they've had an etiology that's more obstructive in nature like aqueductal stenosis or a tactile glioma, for example, they're more likely to succeed and if they've never had a previous shunt, they're more likely for this to be successful as well. Um, and again, to evaluate for ETV failure, it's really just headache, nausea, vomiting, lethargy. Again, you wouldn't, you know, you wouldn't really need to evaluate for um infectious complications, um, in this, um, in this setting. And again, you wouldn't need to obtain an X-ray because there's no hardware uh to look at. You would essentially just obtain a quick brain MRI is actually really nice here or some type of MRI because oftentimes you can see the turbulent flow itself through the ostomy that you've created a CT you could see the ventricle size, but you wouldn't be able to see the flow itself, and sometimes these patients, um. Their ventricles don't significantly change, um, because again, you're not shunting fluid away from the central nervous system, um, but their symptoms are better. They have more soft signs that their, um, pressure is more normal as far as being able to see the salsa and gyri normal patterns, um, at the convexity of the brain and so forth. And talking about um endoscopic ventricullostomy for those patients without obstructive hydrocephalus. So as I as I mentioned before, we're experimenting with um trying not only the endoscopic ventriculostomy, but also cauterizing the choroid plexus to reduce the amount of cerebral spinal fluid. So this has been met with kind of mixed results. Um, initially we were very, um, uh, I think um enthusiastic or or encouraged by initial results, um, as, as we've done more and more endoscopic ventriculostomies and cholexus cauterization, we now understand that it's, it certainly doesn't work for everyone and we can't, and we still have to play shunts in some patients. So this is a Kaplan Meyer curve here. The this is the ETV CBC or recorded lexus cauterization is in the solid line here. The ETV or I'm sorry, the shunt here is in the the dotted line here. So again, trying to avoid placing shunts in patients with things like myemigacele, post hemorrhagic hydrocephalus of, of infancy or IVH and prematurity and so forth. It's been met kind of with with mixed results, um, but there's still a reasonable chance that it'll survive past 6. Months about 40% in a lot of these cases and for a lot of parents, um, that they, they're willing to take that um chance even though they know that there's more than likely going to need an additional surgery just to avoid the placement of a shunt and all the potential issues with having hardware um lifelong. So this is the view actually that we give with our endoscope um into the ventricle. So this is looking actually down at the third ventricle, and this would be um looking anteriorly. This is medial, this is the foramen of Monroe, so we're in the lateral ventricle now. This is the corri plexus here and this is the thalmos right vein. And now we've advanced the camera um into look at the bottom of the the the third ventricle or the tuber scenarium, which is right here essentially. So these are the mammary bodies, this is the inventdibular recess here, and this is where we poke the hole that ostomy that I showed before on that previous schematic. Um, and this is a picture of a, uh, a wire, actually, a cautery wire, um, poking through this hole, and I have a video of this as well. Um, this is sped up as well. So, so we're again at the same, um, uh, in the lateral ventricle, about to head down to the third ventricle and it's sped up a little bit. So these are our little graspers for scope. So we head down into the floor of the third ventricle here and then we explore this, and we're gonna poke our hole essentially right here. They pop through, and then we open these graspers a little bit. There's a lot of ways to do this, but just to make the hole a little bit bigger, we can stretch it open a little bit here, get that tissue open. And then we um put the camera into the hole itself. In order to see, so this is an amazing view. So this is the basilar artery. These are all the perforators and so forth, um, from the basilar artery, um, supplying the brain stem. This is the 6th nerve itself, and this is the skull base. Um, so this was actually the procedure that convinced me to go into neurosurgery. Um, this is the first procedure I saw when I was a medical student. I was just blown away by the anatomy, but this works incredibly this is a very gratifying procedure when it works well. And the reason why we actually drive the camera through that hole is to make sure that there's no adhesions and so forth here. Sometimes there can be these pre-ons adhesions that they don't, even though you've poked the hole into the bottom of their metric, there's a bunch of adhesions below it, the flow is not going to be adequate um to to stay open. There's the basilal artery. Pulsating there and then so this is the choroid plexus part of it. So we take this little bugy wire and essentially with electrocautery just cauterize the roid plexus here, and you can see we just kind of you can see it becoming white here and a little bit of this um bubbles forming. So this is essentially what we do here. We just cauterize as much as we safely can, and this all this white is, is cauterized coreflexes here. Obviously we have to be careful of the the normal arteries and veins and so forth and the the other anatomy that's it's um important to to keep um integral here. All righty. So what are the variables associated with the success of an endoscopic ventriculostomy and cord lexus cauterization? Um, again, if they, um, if they've had infection, if, um, um, uh, hydrocephalus due to meningitis, this is not, this procedure is not gonna work. If they've had aqueductal stenosis or myeminingocele, it's more likely to work. Post hemorrhagic hydrocephalus or or intraventricular hemorrhage or prematurity, it's so, so, um, you know, the more data we get that shows that it probably doesn't work that well. If patients are older, um, so if patients, you know, are born, um, and they clearly need a shunt or need CScept diversion in the first week of life or so, then this is unlikely to work for them, um, but if we can, um, if patients, if we can get them to 6 months before doing a procedure, they're more likely to be successful, and again, if they've had no prior shunt, this is more likely to be successful. And no cisternal scarring, this is the, the adhesions I was talking about in front of the ponds, um, as long as they don't have that kind of scarring, and this is more likely to work. The question is, you know, if we're cauterizing chore plexus, does this affect, um, you know, this is normal tissue, right? We're cauterizing normal tissue that produces spinal fluid. Um, what are the, what are the cognitive outcomes? And this was an excellent paper actually in New England Journal in 2018. It's a busy slide, but these are the female patients that they enrolled and the male patients, and they were um randomized to shunt versus ETV and CBC. This is just actually showing just the brain volume. It shows that there's actually no difference whether or not they've, um, the brain volume itself, whether or not they've had a shunt or an ETV CBC, and they also showed that the other cognitive other cognitive outcomes that I won't show or or get too far in the weeds were were similar for the group, so it does appear to be safe, um. Um, in, in long term follow up. So in conclusion here for this hydrocephalus section, I'll talk about positional platetocephaly next. Um, the main methods for CSF diversion are, are shunts and endoscopic ventriculostomy, plus or minus cho plexus cauterization. Um, both have similar failure rates for obstructive hydrocephalus, but the endoscopic ventricuostomy is more favorable, much more favorable adverse, um, event profile than a shunt. And then I will, um, actually I'll I'll move on here. I'll take questions at the end. I think it'll work a little bit better that way just so I can get through this and we'll have plenty of time for questions as we're only 22 minutes into this. So that's the, the subsection on hydrocephalus. I wanted to um discuss now position of plagiocephaly again, it's a very common thing that that we see and I'm sure that you see in your your practice as well. Um, so I just wanted to, um, uh, um, have essentially a high level kind of conversation about positional plateiacephaly and happy to answer any questions. So the incidence um in infants is about 12% in singletons and actually over half of twins have some degree of, of uh flagecephaly, and this was largely due to the back to sleep um campaign that was rolled out by the American Association of Pediatrics years ago now, um, to reduce uh the incidence of SIDS. Um, and so it's, um, for, for some reason it's unclear why exactly. Probably just in in general, boys tend to reach some motor milestones a little bit, um, later than girls, um, and so it tends to happen in boys more than girls, and it tends to happen on the right more than the left, which again, I don't completely understand why that would be. Um, there's clear things that make positional lagerocephaly more common, um, in patients with torticollis, um, which I think is actually, um, fairly common. I think it's more common than we realize that, um, patients are just not able to move their heads, um, bilaterally equally, um, and it can be very subtle, um, but I do think that those patients that have had a degree of toolis are more likely to have it. Obviously, if patients have had developmental delays. Um, then they are more likely to have positional lageiacephaly, say they have, um, hypotonia and are less likely to be able to move their head, um, normally, um, delayed as far as, you know, being able to roll over and meet those other kind of gross, um, motor milestones. And patients that have had a history of of familial microcephaly or benign familial microcephaly, um, as we discussed in the in the um the hydrocephalus uh talk are much more likely just because the head is larger, say you have a patient that's always been in the 99th percentile, they're more likely to have position lagecephaly just because their head is large and their skull is just a bit more malleable, um, and so those are the the most at risk um patients. Um, regarding the treatment for, um, positional plagiocephaly, the majority of retrospective case series, um, have found a benefit of helmetin versus repositioning, and there's no question about that. But again, these are retrospective case series, um, you know, not prospective kind of randomized, um, a case controlled studies, so the quality of the data in, um, in these, um these studies is, is, is so, so at best I would say. So this is the the phenotypes um of positional platocephaly versus lambdoid synostosis. I always uh tell our neurosurgery residents that the key ways to differentiate between plaggocephaly and lambdoid craniosynostosis, which is rare. It's a, it's a relatively rare kind of craniosynostosis, is that the position of plagiocephaly looks like a parallelogram essentially. Not only do they have occipital flattening, it's usually just it's one side typically more than the other. Often sometimes you can get bilateral, um, where they have um real brachiocephaly or kind of a a shortened head. But the, the, the, the ear says so this patient has um right sided um flatting ear, the right ear is pushed anterior uh to compare to the left ear when looking above, and oftentimes their forehead um is pushed um anterior as well. Um, and then this is differs significantly from, from lambdoid, uh, synostosis where you have, um, say the right side is fused, you have flattening of this side, very similar to this, but you don't have any of this other um movement of the ear and of the forehead forward on that, on that unilateral side. Sometimes you can see this kind of uh a tilted skull base, but that's a little bit more subtle, um, especially in patients that have some degree of of to cause and so forth. So as I mentioned, the majority of of of literature are retrospective case the saying that Helmanin works better than um uh physical therapy and so forth. As far as I know, this is the only randomized controlled trial that looked at this, and this was in the British Medical Journal back in 2014, so now, you know, 10 years old. Um, and so what it did essentially is randomized patients. I believe this was in Norway, um, randomized patients, um, into helmets versus natural course and by natural course they it wasn't really natural. They, they had, you know, fairly, um, aggressive physical therapy, you know, things that we could easily do um here by referring to a physical therapy. Uh, but this is just a table showing that the, the, the two populations, they had 42 in the helma therapy, 42 in the natural course were very similar as far as, um, degree of health problems, as far as their median age, and, and, um, and so forth. And this is the the outcomes table. So again, a bit of a busy table, but I'll I'll um wanna focus right here on these P values, so. So this is the p-value, this is the univariate P value, um, showing that there was no difference um in the lagocephaly change score or the brachocephaly change score uh between these two interventions. And even after they adjusted, um, you know, for in a multivariate analysis, um, there was still no significant difference between those two, those two groups. And this is um a study that came out um again in about 6 years ago in 2018 in the journal Neurosurgery Pediatrics, looking at the long term um outcomes of patients that have been treated with helmet versus um uh physical therapy and positional um uh repositioning and so forth. And the key things here are that they, they looked at the flatness score, asymmetry score, this, um, and I forget exactly what this acronym is, but these are just essentially asymmetry and kind of um morphometric um scores here and cephalic index and so forth. So the, the lines down here are the um unaffected uh controls here. So as you can tell, the line, the unaffected controls are always much different than the other two. But if you look up here, these are the, the treated cases and untreated cases kind of in these these dotted lines here. As you look here, especially over time, these lines um essentially kind of merge, um, and so their their error bars here are overlapping. And so what this means is that there's really by age 3, there's really no significant difference between um uh molding um with a helmet versus um physical therapy and um uh positional avoidance, um, if you will. I always, I always counsel parents that the helmet may get them there a bit quicker. Um, but by age 3 or so, there's no, there's gonna be no difference, um, in, in the outcomes, unless they have severe placephaly don't talk about that. So in conclusion for the plagiocephaly uh portion of the um the talk here, the best evidence from the single randomized control studies show that there was no clear difference in outcomes. And there are drawbacks to helmeting, right? Um, so the, the drawbacks to helmeting is they have to wear, uh, patients have to wear the helmet 23 hours a day, so the patients need to be diligent about in that hour that it's off, um, to make sure that they're not getting skin irritation or skin breakdown, and if they are, they need to go back to the helmeting vendor so that they can make adjustments. Um, there is a financial implications here, so a lot of times this is not covered by um private, um or commercial insurance. Um, and, um, the, the bar is actually very high for Medicaid to, to pay for this. They actually typically have to see a neurosurgery provider. Um, and so oftentimes if they're paying out of pocket, it's very expensive. I think it's at least $3000 and maybe even more. The other thing is that the, the multiple trips to the orthotics provider. So typically, um, the, the number of trips they make while they're in their while kids are in their helmet, which can be anywhere from really, you know, 3 to, you know, 4 or 5 months or so, is really every other week. And so if you have a patient that lives in a rural area or that has limited needs and limited transportation, it can be very onerous to go to a medical appointment every other week for for 4 months. Um, and so my treatment recommendations, um, is if they're mild or moderate, um, that, that, um, I typically recommend repositioning and, and always physical therapy. I think patients are always gonna benefit from physical therapy. But if they're severe, so say they have severe um uh plagiocephaly or they have developmental delays and so forth, then um helmetin is certainly an option for those children. So I'm not um claiming to say that no child should be helmeted, um, but I do think that there is, um, I think we are over helmeting patients in general that have somewhat mild or moderate um positional lageiacephaly when they really would do the same, um, as far as their outcomes from just physical therapy and repositioning. All right, so that's the end of my, my talk. Um, so we have plenty of time here, um, so this is our Washington University and Saint Louis Children's pediatric neurosurgery team, so there are 4 of us, um, so I came in as the, uh, division chief in um August, so I've been here just a few months. Um, but on the left here we have Sean McAvoy, Jared Roland, and, and Jennifer Straley, um, who are the other three pediatric neurosurgeons, so there's 4 of us, and this is our team of outstanding, um, advanced practice providers. There are, there are 5 of us. Um, and then I'm happy to answer any questions. This is my email, um, if you'd like to. Um, email me, um, any questions, um, any patient questions, I'm happy to um answer those, and this is my cell phone too. Happy to, um, if you have any questions, uh, concerns, um, I'm happy to, uh, chat directly or text however you'd like to do it. Well, thank you for your talk this morning. Um, we'll leave your slide up with your email and cell phone just so everyone can um. Gather that information real quick and then I will, in just a minute or so, put up the QR code for everyone. Um please remember to um Take our survey, let us know, um, feedback on early bird rounds, and then if you would like to unmute for any questions, please feel free to do so or put put your questions in the chat. Yeah, happy to answer questions about these topics or really anything, pediatric neurosurgery, if anyone has any other questions. Can you see the chat here, Doctor Thompson? Yeah, let me open up the chat. I saw something um. The company that's promoting helmets is saying how commonla He is and changing helmets frequently. Um, so, so there's there's a huge uh variety of companies that, um, that provide orthotic companies that provide helmets. Personally, um, one of the, the more there's there's Hanger, there's um. And and some of them have merged as well. There was one called Double 4. There's um uh cranial technologies, um, and what I've found actually is is some are are kind of much more aggressive in um in their kind of spiel to parents than others, I think. Um, uh, cranial technologies, which makes the dock band, tends to be kind of the most aggressive. It, it kind of almost scaring parents sometimes into thinking that it's critical for their kids to have, um, Helmeting or else they may result in, um, you know, cognitive uh delays or temporomandibular joint misalignments and so forth, which none of those of which are really legitimate unless kids have, um, you know, for the TMJ issue unless they have severe uh plagiocephaly, but um, yeah. Um, does plastic surgery feel the same about helmets? Yeah, they do. I mean, we work, so we work all of our patients with um craniosynostosis, um, we work together as a team and so it's always um a pediatric neurosurgeon and a pediatric plastic surgeon, uh, for any sort of craniosynostosis cases cases. The way that the our workflow here is that the majority of of patients, um. Uh, referred for position of Piacephaly, um, or plastic sur plastic surgery advanced practice provider that actually has a PhD in, um, in plagiocephaly, um, and, um, but they have, um, to the question, they have very similar kind of thoughts on, on, um, the options for helmetin versus just um physical therapy and and um repositioning. So that one is our helmets the only treatment for brachocephaly if um it's See if it is not to to cause issue. Um, so, so even with brachocephaly, um, you know, which is essentially bilateral lageiacephaly, um, this can still be the same. I mean, physical therapy can still be very helpful, um, because the patients, when they, when they're referred to physical therapy, they don't, they don't go, um, you know, many times and, you know, when I've talked to parents, they're typically seen 1 to 3 times and then essentially. They're given booklets on the exercises to do with kids as far as strengthening and stretch um stretching neck muscles and um and core muscles really. Um, and so that's what the physical therapy helps with, um, and so, so it can still help with brachocephaly, um, and not just positional plate of cephaly, yeah. Um, yes, insurance, uh, typically covers PT, yeah, yeah, I've never had a, um, issue where insurance, regardless if it's commercial or Medicaid, um, doesn't cover, uh, PT. Um, and then, The companies also market heavily to the uh PT's offices, so providers should be aware that PTs often, yeah, yeah, that that is true, that is true. I've definitely had some parents that have gone to PT and then said, well, we need to go to to um um send you to get a helmet, um, and so that is true. Um, I think a lot of physical therapists though are also aware, you know, of the, um, you know, the bias that and the and the kind of um. You know, the incentives that that how many companies employ, you know, essentially they don't get paid unless they get kids in helmets. So I, you know, I think a lot of physical therapists are are completely aware of that and also aware of the data that's presented and are and are right you know, rightfully, um, you know, skeptical of of some of the the things that are being told by the helmetting um people. Yeah, so another question is, um, helmetting when when to do helmetine, like when the best time is for it. It's, it's true, you know, um, the earlier you do, um, helmeting, the more likely it is to change because you get, you know, you know, someone that's that's, uh, you know, 10 months, I wouldn't even consider someone for a helmet because they Even though their head is still growing, you know, they've gotten off that really fast part of the growth curve. So 1010 months is my limit is except for in very rare circumstances, um, I would say 10 months is the limit, but if you can. If they, if patients are severe and they do need a helmet, if you can, you know, get them into a helmet by 6 months, that would be ideal. You know, I still think that some patients with severe um um platerocephaly will still get some benefit, you know, at least 6 to 10 months or so, but the earlier the better. Good morning, I did have a question. Um, wonderful talk. So, um, I've heard that, um, the treatment of synostosis, which is a little off topic, is purely cosmetic, and, you know, they, they presented studies suggesting that untreated synostosis has no neurodevelopmental consequences. Could you comment on that? Yeah, that's a great question. It's, it's, uh, it's controversial. So, um, you know, so I, when, when we have a patient that's evaluated that has craniosynostosis, um, we always recommend surgical correction, and the reason is really twofold. One is aesthetically, you know, with uncorrected cranial synostosis, you know, it can be very stigmatizing because their head shape is totally abnormal, um. And so, um, it can be it can be, you know, aesthetic is is by far the number one. However, there is some data, um, and it's actually, um, More um imaging related data showing that actually if a patient has, say, sagittal craniosynostosis, that there is actually some um pressure on the brain that results in slight abnormalities in profusion and so forth and in blood perfusion, um, and so forth and and it's unclear if that would long term affect patients' outcomes. There is some data to show that if uh kids that have craniosynostosis, regardless if you correct them or not, they may have more difficulty, you know, with neurocognitive development, may have more subtle, you know, difficulties in school and so forth. So just doing a craniosynostosis correction is not gonna, you know, change that person from having difficulty in school to not having difficulty in school per se. Um, but there is this theoretic benefit of relieving that kind of focal pressure on the brain itself, again that that it's unclear because this is, you know, these kind of advanced imaging techniques are relatively recent. Um, and so, but, uh, but by far the most important part is, is the, the, um, aesthetic part of the craniosynostosis, yeah. Obviously it's a different story with with multiple suture synostosis, um, is a different, you know, can of worms because then you do have issues with um elevated intracranial pressure. So even, even with you know you'll say one suture that has synostosis. Um, there is still a non, um, you know, there's still, it's about a 5 to, you know, 8% chance that they actually have increased intracranial pressure and so the more sutures you have, um, the higher that risk gets, um, which makes sense. So if you have example, a patient that has sagy and lambdoid craniosynostosis, it's much higher, it's like 20 to 30%. So from that perspective, then, um, especially in multiple suture synostosis, the not only is it cosmetic, but also there's a good chance you're going to relieve their elevated intracranial pressure, which obviously if you do have elevated intracranial pressure, then you do have issues with cognitive development and so forth. So hopefully that answered your question. Um, the one question is, would I recommend PT for all patients getting a helmet? I think so a lot of the, the, the folks that work at helmeting places have physical therapy, um, training, um, or at least they have someone on site. So if you have someone that just clearly needs a helmet, then, um, I, I, you know, again, I wouldn't all patients I think are gonna benefit from PT. Um, that's just me personally, but they will have some of that probably at the helmede place as well. But, um, you know, I think anyone, any, yeah, so long story short, any patient that has, um, place stuff I think will benefit from PT, yeah. Any further questions this morning? We really appreciate everyone's uh participation and uh we really appreciate your time this morning, Doctor Thompson. Uh, I'm gonna send in the chat for next week for everyone um to know what to expect, and next week will be our last early bird rounds for 2024, then we'll be off for the Um, holiday week, so hopefully you all can join us then. Created by Presenters Eric M. Thompson, MD Professor of Neurological Surgery, Division Chief of Pediatric Neurosurgery, Department of Neurosurgery, Division of Pediatric Neurosurgery View full profile
