Minimally invasive neurosurgery in pediatric practice: achievements and limitations

Ulyana A. Ulanova, Said-Magomed A. Osmanov, Magomed S. Aliev, Valeriia Yu. Kerdivar. Minimally invasive neurosurgery in pediatric practice: achievements and limitations. Cardiometry; Issue No. 33; November 2024; p. 63-70; DOI: 10.18137/cardi-ometry.2024.33.6370; Available from: http://www.cardiometry. net/issues/no33-november-2024/minimally-invasive-neurosur-gery

Minimally invasive neurosurgery (MINS) in pediatric practice is an important area of modern medicine focusing on high-precision interventions with minimal tissue injury and minimal incisions. Pediatric neurosurgery places special demands on treatment methods, since the anatomy and physiology of children differ significantly from adults, which makes traditional surgical approaches more risky. In this regard, minimally invasive methods have become an important tool for reducing the surgical burden on the child’s body[1].

The use of MINS in pediatric practice is associated with the development of new technologies and methods, such as neuroendoscopy, endovascular interventions, laser and ultrasound techniques, as well as robotic and navigation systems. These technologies allow complex operations to be performed with high precision, minimizing damage to healthy tissues, which is especially important for children whose tissues are more fragile and sensitive. For example, neuroendoscopic procedures allow the treatment of pathologies such as hydrocephalus without the installation of bypass systems, and endovascular methods allow the treatment of vascular brain abnormalities without open surgery.

Minimally invasive methods provide a significant reduction in rehabilitation time, which is critical for young patients whose recovery should take place as quickly and safely as possible. In addition, the smaller size of the incisions reduces the risk of infection and complications associated with wound healing, which makes such operations preferable from the point of view of safety [2].

However, minimally invasive neurosurgery in pediatrics has its limitations. One of the key problems is the need for expensive equipment and highly qualified specialists, which limits the spread of these methods in less equipped medical institutions, especially in developing countries. In addition, the anatomical features of children, such as the small volume of the cranial cavity and the structure of the brain that changes with age, require high precision and attention from surgeons when planning and performing operations.

Despite these difficulties, minimally invasive neurosurgery opens up new horizons for the treatment of many neurosurgical diseases in children. Modern advances allow surgeons to achieve better results, reducing risks and improving the quality of life of patients. In this context, the study of the achievements and limitations of minimally invasive neurosurgery in pediatric practice becomes an important topic for further scientific research and improvement of medical care.

MATERIALS AND METHODS

When writing a paper on this topic, it was based on a variety of theoretical research methods that allowed a comprehensive approach to the analysis of the topic and consider various aspects of the problem.

The analysis of the scientific literature made it possible to study and systematize existing research on the topic. This method included a review of scientific publications, articles, monographs and clinical studies in the field of minimally invasive neurosurgery, especially in pediatric practice. It made it possible to identify current achievements and existing problems, as well as identify gaps in knowledge and prospects for further development.

The comparative method made it possible to compare minimally invasive methods of neurosurgery with traditional surgical approaches. The comparison was carried out according to various criteria: the level of injury, the duration of the operation, the speed of recovery, the risk of complications and long-term results.

Through the application of the historical method, it was possible to trace the development of minimally invasive neurosurgery from its inception to the present day. The system analysis allowed us to consider minimally invasive neurosurgery as a comprehensive system, including medical technologies, specialist qualifications, organization of surgical interventions, as well as medical infrastructure. This approach made it possible to identify the relationship between various elements of the system and assess their impact on the final results of treatment.

The use of these methods allowed us to build a logical and structured work, analyze the problem in depth and suggest possible solutions.

RESULTS

Minimally invasive neurosurgery (MINS) has become one of the most significant technologies in pediatric medicine in recent decades. Its main goal is to minimize tissue damage, shorten the recovery period and reduce the risk of postoperative complications, which is of particular importance for children with their vulnerable anatomy and physiology [3]. Thanks to the development of techniques such as neuroendoscopy, endovascular interventions and robotic systems, pediatric neurosurgeons can solve complex clinical problems with minimal injury. This is especially important for patients whose tissues are at higher risk of damage, and the recovery process requires special attention and speed.

Neuroendoscopy occupies a central place among minimally invasive techniques in pediatric neurosurgery. It allows performing surgical interventions on the brain and spinal cord through minimal incisions, which significantly reduces the traumatization of surrounding tissues [4]. One of the most significant achievements of neuroendoscopy is endoscopic ventriculocysternostomy of the bottom of the III ventricle, which has become an effective alternative to traditional bypass surgery in the treatment of hydrocephalus. ETV allows you to create a natural outflow of cerebrospinal fluid, which eliminates the need to in- stall bypass systems associated with frequent complications such as infections and mechanical failures of shunts. The use of this method has reduced the number of repeated operations and improved the quality of life of patients, especially children, who require longterm and frequent interventions in the traditional treatment of hydrocephalus.

An example of the use of neuroendoscopy can be considered in the treatment of obstructive hydrocephalus in a child. Hydrocephalus is a condition in which an excessive amount of cerebrospinal fluid accumulates in the ventricles of the brain, causing their expansion and increasing pressure on brain structures [5]. In a child with an obstructive form of hydrocephalus caused by impaired fluid outflow due to a tumor or congenital narrowing of the brain’s plumbing, traditional shunt treatment is associated with a number of complications, such as infections or mechanical failures of the shunt system.

To minimize these risks, surgeons used endoscopic ventriculocysternostomy of the bottom of the III ventricle. Using a neuroendoscope inserted through a small incision in the skull, the surgeon reached the third ventricle of the brain and made a small hole in its bottom. This hole made it possible to create an alternative path for the outflow of cerebrospinal fluid, bypassing the blocked area [6].

The endoscopic surgery was successful: the child avoided the shunt installation, and the fluid flow was restored naturally. The recovery period was significantly shorter than after traditional bypass surgery, and the risk of infections and long-term complications was minimized. Endovascular techniques based on the use of catheters and microspirals play a key role in the treatment of vascular pathologies of the brain, such as aneurysms and arteriovenous malformations. Endovascular procedures allow for embolization, that is, the overlap of pathologically altered vessels from the inside, which eliminates the need for open operations. This is especially important in pediatric practice, where invasive interventions are associated with a high risk for children with a vulnerable vascular system. The use of these techniques significantly reduces the likelihood of postoperative complications, such as bleeding and infections, and shortens the recovery period. Due to minimal traumatization, children return to normal life faster, and the likelihood of repeated operations decreases, which makes endovascular methods one of the leading achievements in modern pediatric neurosurgery [7].

One of the striking examples of the use of endovascular techniques in pediatric neurosurgery is the case of the treatment of arteriovenous malformation (AVM) in a child. AVM is an abnormal connection of arteries and veins in the brain, which can lead to dangerous hemorrhages. A child diagnosed with AVM had a high risk of vascular rupture, which could lead to stroke or other serious complications. Instead of open surgery, which involves complex intervention and a long period of rehabilitation, doctors used the endovascular embolization method. Using a catheter inserted through the femoral artery, the surgeon reached the affected area of the brain and injected microspirals to close the pathological vessels. This procedure made it possible to isolate the malformation by stopping blood flow in the abnormal junction.

Due to the minimal invasiveness of the intervention, the child was able to avoid extensive brain surgery, which significantly reduced the risk of complications such as infection or prolonged blood loss. After a short recovery period, the patient was discharged, and subsequent examinations confirmed the successful elimination of AVM without any complications.

In recent years, intraoperative neuronavigation systems and robotic manipulators have significantly improved the results of neurosurgical interventions, especially in pediatric practice, where accuracy and minimal invasiveness are critically important [8].

Specialists have described a case of treating a brain tumor in an infant using an intraoperative navigation system and robotic equipment. The child was found to have a small but difficult-to-access tumor in an area associated with important neural structures. In order to achieve high accuracy and minimize the risk of damage to surrounding healthy tissues, it was decided to use modern navigation and robotic technologies.

Before the operation, detailed neuroimaging studies, including MRI, were performed to create a three-dimensional model of the brain and tumor. During the operation, the neuronavigation system monitored the position of the instruments and their interaction with the brain model in real time, which allowed the surgeon to plan and adjust his actions more accurately [9]. This system provided information about the exact location of the tumor and allowed to avoid critical areas, minimizing the risk of damage to important neural structures [10]. Robotic manipulators were used to perform the operation itself, which provided the highest degree of accuracy in removing the tumor. Robotic instruments allowed the surgeon to perform microscopic movements with incredible precision, which is especially important in the limited space of the cranial cavity in infants. Robotic systems have also helped to reduce the physical strain on the surgeon, improving his ability to focus on the operation.

Thanks to the use of navigation systems and robotic technologies, the operation was successful: the tumor was removed with minimal impact on the surrounding tissues. The child’s recovery process was significantly accelerated compared to traditional methods, and the risk of complications was minimized. These technologies have made it possible to achieve high results with minimal risk and provided safe treatment for a patient at such a vulnerable age.

Ultrasound and laser technologies have become important tools in minimally invasive neurosurgery, allowing surgeons to safely and effectively remove tumors and other pathological formations in the brain and spinal cord. Consider the case of removing a brain tumor from a child using laser technology. The patient was diagnosed with a deep-seated tumor located in a hard-to-reach area close to important neural structures. Traditional surgical removal methods could lead to damage to surrounding tissues and an increased risk of postoperative complications [11].

Laser surgery was chosen as a method with high precision. During the operation, a laser beam was used to target tumor cells. The laser method allows you to create minimal incisions and coagulate tissues as the tumor is removed, which reduces bleeding and minimizes damage to surrounding structures. As a result, the tumor was removed with a high degree of accuracy, and the risk of complications was significantly reduced. The patient’s recovery process was faster, and the risk of secondary lesions was minimized [12].

In another example, consider the use of ultrasound aspiration to remove a dense tumor, such as a hemangioblastoma, in a child. Ultrasonic aspiration is a method in which ultrasonic waves destroy tumor tissues, turning them into an emulsion, which can then be safely removed by aspiration.

During the operation, an ultrasonic aspirator was used to destroy the tumor, which made it possible to effectively and safely remove its components. The method is particularly effective for removing dense and well-vascularized tumors, minimizing the risk of significant blood loss and damage to neighboring tissues. After the procedure, the patient experienced minimal postoperative symptoms, and recovery was faster compared to traditional methods.

These technologies help neurosurgeons achieve high results in the treatment of tumors and other pathologies, reducing the invasiveness of operations, reducing recovery time and improving treatment outcomes for patients, especially for children, whose tissues and body require special attention and caution.

In one of the randomized studies, the effectiveness of endoscopic ventriculocysternostomy of the bottom of the III ventricle was evaluated compared with traditional bypass surgery in children with obstructive hydrocephalus. The study included children with diagnosed obstructive hydrocephalus, who were randomly divided into two groups.

One group received ETV, and the other received traditional bypass surgery. The main evaluation criteria included the effectiveness of treatment, the frequency of complications, the need for repeated operations and the quality of life of patients [13].

The EV group showed better results in controlling the symptoms of hydrocephalus compared to the bypass group. The complication rate was significantly lower in the EV group. Shunt infections and dysfunctions were less common.

Patients who underwent EV had less need for repeated operations compared to the bypass group. The improvement in quality of life was more pronounced in the group receiving ETV, which is associated with fewer complications and better long-term results.

A randomized study confirmed that endoscopic ventriculocysternostomy of the bottom of the III ventricle is an effective alternative to traditional bypass surgery in the treatment of obstructive hydrocephalus in children, providing better clinical results and reducing the risk of complications.

These clinical cases and the results of randomized trials highlight the importance of neuroendoscopic techniques in pediatric neurosurgery, showing their advantages in precision intervention, reducing complications and improving the quality of life of patients.

DISCUSSION

It is also necessary to consider the limitations in the use of MINS in pediatric practice.

Anatomical features of children play a key role in the planning and conduct of neurosurgical operations. Taking into account the peculiarities of the growth and development of the body, surgeons need to carefully adapt their methods and approaches. In newborns and infants, the tissues of the brain and its membranes (meninges) are thinner and more delicate than in adults. This makes them more susceptible to injury even with minimally invasive interventions. The risk of damage to these structures, which can lead to serious consequences such as impaired brain function or the development of infections, requires extreme caution and precision from neurosurgeons [14].

Children’s blood vessels are also thinner and more fragile, which increases the risk of bleeding. When performing operations, it is necessary to take this feature into account in order to minimize the risk of impaired vascular blood flow and subsequent complications [15].

In newborns and infants, the skull has a special structure, which makes it more mobile and can affect surgical approaches and the method of their execution. In addition, the presence of fontanelles (soft areas between the bones of the skull) requires special attention, since they are vulnerable to injury.

During the child’s growth, the skull and brain also develop. This means that operations should be planned taking into account possible changes in anatomy. For example, the implantation of shunts or other devices should take into account future changes in the size and shape of the skull in order to avoid problems in the future.

As the child grows, the shapes and sizes of various anatomical structures, such as the ventricles of the brain, also change. This requires a dynamic approach to operation planning and constant monitoring. The use of preoperative scanning and intraoperative navigation systems helps to take these changes into account and adjust interventions in real time. The functions of various brain regions also change with age. In children, the brain is actively developing, and functions that can be well compensated for at a younger age may change during adulthood. It is important to take this into account when planning operations aimed at removing tumors or treating other pathologies, so as not to disrupt critical brain functions [16].

In addition, the immune system of children is not yet fully developed, which makes them more vulnerable to infections after surgery. This requires special attention to infection prevention and strict adherence to asepsis and antiseptics during and after surgery.

The healing process in children may differ from adults. Tissue regeneration in children is faster, but this does not exclude the risk of scarring or other long-term consequences. It is also important to take this into account when planning postoperative care and rehabilitation [17].

Thus, the anatomical features of children, such as thin and fragile tissues, changes in the size and shape of the skull, as well as the immaturity of the immune system, require a special approach in neurosurgery. Neurosurgeons should take these factors into account when planning and performing operations to minimize risks and ensure the best results for young patients. The development of minimally invasive techniques and technologies, such as neuroendoscopy, intraoperative navigation systems and robotic technologies, helps the surgeon to perform interventions more accurately and safely, taking into account the peculiarities of pediatric anatomy.

Minimally invasive neurosurgery (MINS) has advanced significantly in recent decades, offering new opportunities for the treatment of various diseases of the central nervous system (CNS). However, despite its advantages, there are cases when MINS is not the optimal solution. Some CNS diseases still require traditional open surgeries due to the limitations of modern technology.

One of the main limitations of MINS is the size and location of the tumor. Large tumors, especially those with complex anatomy and extending over large areas of the brain, can be difficult to remove using minimally invasive techniques. Removal of large tumors requires access to many parts of the tumor, which can be difficult to achieve through small incisions or endoscopic access [18].

When removing large tumors through minimally invasive methods, there is a risk of insufficient removal of tumor masses, which can lead to a recurrence of the disease. In such cases, open surgery may be preferable to ensure complete removal of the tumor and control of residual areas. Complex vascular malformations such as arteriovenous malformations (AVMs) or cavernous malformations can be difficult to treat with minimally invasive techniques. These malformations often have a complex and intricate anatomy, which makes their removal or treatment through endoscopic methods less effective and more risky. The treatment of complex malformations requires detailed and precise access to the affected areas, which is sometimes possible only with the use of open surgical methods that allow better visualization and control of the intervention [19].

Some pathologies are located in deep or hard-to-reach areas of the brain, such as the basal ganglia or brainstem. These structures are difficult to achieve using minimally invasive techniques due to the limited access and complexity of manipulations in a limited space. When working in deeply located areas, there is a high risk of damage to critical neural structures. Open methods can offer better visualization and control, reducing the risk of neurological deficits.

The presence of concomitant diseases, such as infections, swelling, or changes in anatomy, can complicate the use of MINS. For example, the presence of significant swelling may limit visibility and access through minimally invasive methods. In children and the elderly, anatomical features may change, which also affects the possibility of using MINS. In children, for example, a rapid change in the size of the skull may require a special approach [20].

Although minimally invasive neurosurgery represents an important advance in the treatment of CNS diseases, its possibilities are not unlimited. Large tumors, complex vascular malformations, and access to deep brain structures may still require open surgery to achieve the best results. The need for careful planning and an individual approach to each case emphasizes the importance of choosing an appropriate surgical technique, taking into account the specific characteristics of the patient and pathology [21].

Minimally invasive neurosurgery (MINS) offers significant benefits, including reduced tissue injury, minimization of postoperative complications, and faster patient recovery. However, the successful application of these technologies requires the availability of modern and high-tech equipment, which is not always available in medical institutions, especially in developing countries. MINX requires the use of complex and expensive technologies such as neuroendoscopes, robotic manipulators, intraoperative navigation systems and laser devices. This equipment often has a high cost, which makes it inaccessible to many medical institutions, especially in regions with limited financial resources.

MINS equipment requires regular maintenance and calibration to ensure its reliable operation. In regions with limited access to maintenance and qualified personnel, this can be an additional problem.

Even in countries with advanced healthcare systems, modern equipment for MINH is often concentrated in large medical centers and university clinics. In small or remote institutions, access to such technol- ogies may be limited, which creates inequality in the quality of medical care [22].

The effective use of high-tech equipment requires specialized training from medical personnel. The lack of trained specialists in the field of agriculture, especially in regions with limited resources, may limit the possibilities of using modern technologies. The introduction of new technologies requires not only the availability of equipment, but also support from medical institutions and authorities. With a lack of funding and infrastructure, staff training and support for new technologies can be difficult. The lack of modern equipment limits the ability of medical institutions to perform minimally invasive operations. This may lead to the need to use more traumatic and less effective traditional methods of treatment, which affects the quality of medical care.

Lack of equipment can also lead to increased risks and complications for patients, as less effective treatments may not produce the desired results and increase the likelihood of postoperative problems [23].

Solving this problem requires a comprehensive approach, including financing, training, development of affordable technologies and improved resource allocation. Effective minimally invasive neurosurgery can significantly improve the quality of care and treatment outcomes, and working to overcome these barriers is crucial for global health.

Minimally invasive neurosurgery (MINS) is an area that requires not only specialized equipment, but also highly qualified and experienced surgeons. The success of such interventions, especially in pediatric practice, largely depends on the professional skills and continuous training of specialists. Let’s take a closer look at which aspects of surgeons’ qualifications are of critical importance and what problems may arise with an insufficient level of training. MINS requires surgeons to master the use of high-tech equipment such as neuroendoscopes, robotic arms, navigation systems and lasers. Surgeons must be proficient in the management of these instruments in order to successfully perform interventions with minimal incisions and high precision.

The features of the anatomy of the child’s brain require deep knowledge and experience. Neurosurgeons should understand how different age groups affect the anatomy and functional characteristics of the brain, which is critical for successful minimally invasive surgery [24].

Technologies in the field of neurosurgery are constantly evolving, and in order to maintain their qualifications, surgeons must regularly undergo training in new methods and techniques. This includes participation in workshops, symposiums and specialized courses on minimally invasive techniques. Surgeons working in the field of MINS must have the appropriate certification and licenses confirming their qualifications to use specialized equipment and perform complex operations.

Not all medical institutions have the opportunity to provide access to modern training programs and trainings. In regions with limited resources, it may be difficult to organize specialized training for surgeons. Participation in international conferences and training in new technologies may be limited due to financial and organizational barriers, which creates knowledge and skills gaps, especially in institutions with fewer resources.

Working with children requires a special approach due to their unique physiological and anatomical characteristics. Surgeons should be trained in specific methods and techniques that are used only in pediatric practice to ensure the safety and effectiveness of operations. In addition to technical skills, neurosurgeons should be able to interact with children and their families to reduce stress and fear associated with surgical procedures [25].

The qualification of surgeons plays a crucial role in the success of minimally invasive neurosurgical interventions. A high level of training, continuous training and access to resources are key factors determining the effectiveness of MINH, especially in pediatric practice. Solving problems related to a lack of qualifications requires an integrated approach, including educational programs, financing and certification, which will improve the quality of medical care and treatment outcomes [26].

CONCLUSIONS

Minimally invasive neurosurgery (MINS) represents a significant step forward in the treatment of diseases of the central nervous system (CNS), especially in children. The considered aspects emphasize both the achievements and limitations of this field of medicine. MINS provides minimal tissue intervention, which leads to reduced injury and reduced pain after surgery. This is especially important for children whose tissues are thinner and more sensitive.

Due to the smaller volume of surgical intervention, children recover faster, which reduces the time spent in the hospital and accelerates the return to normal activities.

Minimally invasive methods reduce the risk of postoperative infections and bleeding, which contributes to safer operations and reduced postoperative complications.

MINS is not always suitable for certain types of pathologies. Large tumors, complex vascular malformations, and diseases requiring access to deep or hard-to-reach areas of the brain may require traditional open surgery to achieve the best results. The successful application of MINS requires the availability of modern and expensive equipment, which may not be available in institutions with limited resources or in developing countries.

The success of the MINS largely depends on the qualifications and experience of surgeons. The need for continuous training and certification of specialists requires additional resources and efforts, especially in regions with limited educational opportunities.

To improve the skills of surgeons, it is necessary to organize regular courses and trainings on modern methods and technologies of the Ministry of Health. This will help to improve the skills and knowledge of specialists working with children.

It is important to support funding programs and grants to ensure access to modern medical equipment, especially in regions with limited resources. The need for careful planning and an individual approach when choosing a treatment method for each patient underlines the importance of a comprehensive assessment and selection of the most appropriate intervention.

It is expected that further innovations in the field of medical technologies will contribute to the expansion of the capabilities of MINS, improving its accessibility and effectiveness. The development of new technologies and the improvement of existing methods can help to solve the current limitations. Collaboration between neurosurgeons, radiologists, anesthesiologists and other specialists will contribute to the more successful use of MINS and ensure better treatment outcomes for children.

Minimally invasive neurosurgery is an important and rapidly developing aspect of medicine that has significantly improved the treatment of CNS diseases in children. Despite its advantages, it faces certain limitations and challenges, such as access to equipment and the qualifications of specialists. To further advance in this area, it is necessary to continue to develop educational programs, improve access to technology and introduce innovative methods. These steps will help maximize the potential of MINH and ensure the best results for young patients.