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AANS Neurosurgeon | Volume 29, Number 1, 2020

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Pediatric Neurosurgery: First in Neurosurgery’s Subspecialty World

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Editor’s Note: One obvious way to think about the world of neurosurgery is that it is the culmination of all the care delivered across the subspecialties. Just a few decades ago, subspecialization (and the whole world of CAST, enfolded fellowships, post-residency fellowships, etc.) was the exception, limited to just a small number of academics. Today it plays a much larger role across the neurosurgical spectrum. In a series of pieces, AANS Neurosurgeon explores each of the subspecialties in neurosurgery’s orbit. 

The trends toward subspecialization have strengthened in neurosurgery over time, with increasing focus on subspecialty training from the American Board of Neurological Surgeons (ABNS) and the Committee on Advanced Subspecialty Training (CAST). Pediatric neurosurgery was the first subspecialty field to develop unique, advanced accreditation. Even before this formalization, the first pediatric neurosurgical service in the United States was created at Boston Children’s Hospital (BCH) in 1929 by Franc Ingraham at the instruction of Harvey Cushing.1,2 He was soon joined by others, including Eben Alexander, Donald Matson and Edgar Bering. Following Ingraham’s death in 1965, Matson took charge of the service at BCH, where he pioneered surgical techniques for management of craniopharyngiomas in the pre-microsurgical era and developed the lumbo-ureteral shunt for hydrocephalus.3,4

Subspecialty Grows

With the success of the BCH service, the subspecialty grew rapidly as other hospitals established their own pediatric neurosurgical services. William Keith established a service at the Hospital for Sick Kids, Toronto in 1935, which was later spearheaded by Drs. Hendrick, Hoffman and Humphreys (“the 3 Hs”).5 Meanwhile, Eugene Spitz and Luis Schut likewise founded the service at Children’s Hospital of Philadelphia (CHOP) in the 1950s. Luis Amador brought Chicago its first pediatric neurosurgical service at Children’s Memorial (now Lurie Children’s Hospital of Chicago) in 1950.6 Internationally, Kenneth Till in London and Jacques Rougerie and Jean-Francois Hirsch in France, among others, established their own services.5

Organizations Followed

Following the proliferation of pediatric neurosurgical services in the United States and abroad, multiple societies arose, bringing together neurosurgeons with shared interests in pediatric neurosurgical topics as well as the field at large; the Society for Research into Spina Bifida and Hydrocephalus (1957) the European Society for Pediatric Neurosurgery (1966) and the AANS/CNS Section on Pediatric Neurological Surgery (initially of the AANS and later becoming joint with the CNS) were some of the earliest.5 It was during a neurosurgical meeting in Europe during which the formation of the European Society for Pediatric Neurosurgery was being discussed that the idea for an American society first took shape. Several thought leaders in American pediatric neurosurgery were in attendance, including Luis Schut, Fred Epstein, Harold Hoffman and Don Riegel, who planned the formation of an American society. In 1978, the American Society for Pediatric Neurosurgery (ASPN) was formed.6

The founding members of the ASPN wrote a constitution, which outlined the purpose of the organization and enumerated general criteria for membership. In brief, the purpose of the ASPN was to advance and develop the field by supporting research, providing leadership and voicing the interests of pediatric neurosurgery in academic, professional and public spheres.6 Membership criteria was not strictly defined, however the constitution required that candidates be proposed by an active member and sponsored by another prior to official consideration by the ASPN Membership Committee. Furthermore, two votes in opposition would prevent admission to the Society. Candidates were selected based on their clinical record in the field in addition to their research contributions and publications; however, most members agreed that the maxim “You know one when you see one” was the most important criterion when identifying pediatric neurosurgeon members.6

The American Board of Pediatric Neurosurgery(ABPNS) was formed in 1991, which began the process of formalizing pediatric neurosurgery as the first recognized neurosurgical subspecialty.6 Concurrently, the Accreditation Council for Pediatric Neurosurgical Fellowships (ACPNF) was formed to certify pediatric neurosurgical fellowship training programs. This was partially driven by the fact that the ABNS did not certify pediatric neurosurgical fellowships. The ASPN concurrently updated the requirements for candidate members, which included:

  • Completion of an approved fellowship;
  • Minimum five years of experience in the field;
  • At least five publications in the field of pediatric neurosurgery;
  • Case log requirements – either 75% of all operations in patients under 18 years old or 125 cases in patients less than two years old in the preceding two years.6

While the movement highlighted the benefits of subspecialization, opponents raised concerns of the negative consequences of segregating the field from general neurosurgical practice. The argument was raised that neurosurgical problems of infancy and childhood should not be the exclusive purview of neurosurgeons with fellowship training. Dr. Shilito argued that by restricting pediatric practice to only those with fellowship training, general neurosurgeons in communities removed from pediatric centers would not be able to provide for those pediatric patients without resources to travel to specialty centers or worse, not be able to treat pediatric neurosurgical emergencies.8 Proponents, including Dr. Anthony J. Raimondi, pointed out the evolution and needs of the field, stressing multidisciplinary care, the role of technology and the art of pediatric neurosurgery.9,10

With the formation of the ABPNS and ACPNF, the number of fellowship-trained pediatric neurosurgeons began to grow and the demand for a specialty journal skyrocketed. The body of knowledge is highlighted and represented in the oft-cited and continually updated reference currently on its 4th edition: “Principles and Practice of Pediatric Neurosurgery” by Drs. Albright, Adelson and Pollack. Ultimately, the Journal of Pediatric Neurosurgery was created in 2004 through the efforts of Dr. Jerry Oakes from the University of Alabama Birmingham as well as UVA’s Dr. John Jane Sr, who was the editor of the JNS at that time.7 Dr. James Rutka, current editor-in-chief of the JNS, contributed a significant amount to the literature regarding pediatric brain tumors, epilepsy and craniofacial anomalies, which was critical to the early days of the JNS: Pediatrics. With the formation of these organizations and the JNS: Pediatrics, the number of fellowship-trained pediatric neurosurgeons has steadily risen every year with 391 graduates of ACPNF-accredited pediatric neurosurgery fellowship programs from 1993-2018. Notably, the majority of fellowship-trained pediatric neurosurgeons trained since 1993 practice are in an academic setting (67.8%).11

Pediatric neurosurgery traces its origins back to Harvey Cushing and has developed from an area of special interest to the first neurosurgical subspecialty through the combined efforts of generations of neurosurgeons dedicated to the care of children. Pediatric neurosurgeons continue to grow the field and innovate to overcome the multitude of unique challenges their patients face. So, who are pediatric neurosurgeons? You know one when you see one.

References

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1. Lohani, S., & Cohen, A. R. (2013). Franc D. Ingraham and the genesis of pediatric neurosurgery. Journal of Neurosurgery: Pediatrics11(6), 727–733. doi: 10.3171/2013.3.peds12476

2. Page, L. K. (1991). History of pediatric neurosurgery in the United States and Canada. Childs Nervous System7(1), 53–55. doi: 10.1007/bf00263835

3. Cohen, A. R. (2014). Boston children’s hospital and the origin of pediatric neurosurgery. Childs Nervous System30(10), 1621–1624. doi: 10.1007/s00381-014-2535-z

4. Alexander, E. (1969). Donald Darrow Matson. Journal of Neurosurgery31(3), 249–252. doi: 10.3171/jns.1969.31.3.0249

5. Jea, A., Al-Otibi, M., Rutka, J. T., Drake, J. M., Dirks, P. B., Kulkarni, A. V., … Humphreys, R. P. (2007). The History Of Neurosurgery At The Hospital For Sick Children In Toronto. Neurosurgery61(3), 612–625. doi: 10.1227/01.neu.0000290910.32600.7e

6. Scott, M. (2018, January). The Formation of the American Society for Pediatric Neurosurgery. ASPN Annual Meeting. Retrieved from aspn.org/about-the-aspn/aspn-history

7. Walker, M. L. (2018, October 16). Pediatric Neurosurgery: The First Subspecialty. Neurosurgery Retrieved from https://www.neurosurgeryblog.org/2018/10/16/pediatric-neurosurgery-the-first-subspecialty

8. Shillito, J. (1997). An exclusive group of “pediatric neurosurgeons? – No! Childs Nervous System13(8-9), 474–475. doi: 10.1007/s003810050122

9. Raimondi, A. J. (1994). The evolution of pediatric neurosurgery as a speciality. Childs Nervous System10(6), 353–360. doi: 10.1007/bf00335124

10. Raimondi, A. J. (1992). The education and identification of a pediatric neurosurgeon. Childs Nervous System8(1), 4–7. doi: 10.1007/bf00316555

11. Nadel, J. L., Scott, R. M., Durham, S. R., & Maher, C. O. (2019). Recent trends in North American pediatric neurosurgical fellowship training. Journal of Neurosurgery: Pediatrics23(4), 517–522. doi: 10.3171/2018.10.peds18106

 

Further Reading

1. Albright, L. A., Pollack, I. F., & Adelson, D. P. (2015). Principles and practice of pediatric neurosurgery. NY, NY: Thieme Medical Publishers, Inc.

2. Cohen-Gadol, A. A., & Spencer, D. D. (2004). Inauguration of pediatric neurosurgery by Harvey W. Cushing: his contributions to the surgery of posterior fossa tumors in children. Journal of Neurosurgery: Pediatrics100(2), 225–231. doi: 10.3171/ped.2004.100.2.0225

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