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Neurosurgical practice and its influence on postoperative paediatric cerebellar mutism syndrome-the Alder Hey
Natasha Aziz1, Barry Pizer2, Chris Parks1
1Department of Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
Insights
Modified surgical techniques and increased surgeon experience significantly reduced the incidence of postoperative cerebellar mutism syndrome (pCMS) following pediatric posterior fossa tumor (PFT) resection. These improvements were particularly notable in high-risk patients, suggesting modifiable surgical factors can mitigate this complication.
Area of Science:
- Pediatric Neurosurgery
- Surgical Oncology
- Neuro-oncology
Background:
- Postoperative cerebellar mutism syndrome (pCMS) is a known complication after pediatric posterior fossa tumor (PFT) resection.
- pCMS involves delayed-onset mutism and neurocognitive/motor deficits, potentially due to injury to cerebellar pathways.
- This study investigates the impact of surgical modifications and experience on pCMS incidence over 17 years.
Purpose of the Study:
- To evaluate the effectiveness of modified surgical techniques in reducing pCMS incidence.
- To assess the influence of surgeon experience on pCMS rates.
- To analyze pCMS incidence in relation to tumor location, type, and preoperative risk scores.
Main Methods:
- Retrospective review of 176 PFT resections in patients aged 0-18 years (2007-2023).
- Surgical modifications implemented from 2016 included reduced CUSA use, avoiding transvermian approaches, limited cerebellar retraction, and preoperative risk stratification (Rotterdam pCMS score).
- pCMS was classified as grade 1 (mutism) or grade 2 (reduced speech).
Main Results:
- Overall pCMS incidence was 17.6%, decreasing from 23.2% pre-2016 to 12.6% post-2016.
- Midline tumors showed higher pCMS rates (24%) than hemispheric tumors (10%), with a significant reduction post-modification (40% to 17%).
- High Rotterdam risk scores correlated with pCMS, but incidence in high-risk patients dropped from 65% to 29% post-2016; high-volume surgeons had lower pCMS rates.
Conclusions:
- Optimizing surgical technique, preoperative planning, and intraoperative strategies can reduce pCMS rates in pediatric PFT resections.
- Experience and tailored approaches appear to mitigate pCMS, especially in high-risk patient groups.
- Prospective multicenter studies are needed to validate these modifiable surgical risk factors.
Background:
Postoperative cerebellar mutism syndrome (pCMS) is a recognised complication following posterior fossa tumour (PFT) resection in children, marked by delayed-onset mutism or reduced speech with neurocognitive and motor deficits. Injury to proximal efferent cerebellar pathways is implicated. This study evaluates the impact of modified surgical techniques and experience on pCMS incidence over 17 years at a single tertiary centre.
Methods:
We retrospectively reviewed 176 PFT resections in 167 patients (age 0-18) from 2007 to 2023. Surgical modifications from 2016 aimed to reduce pCMS risk and included reduced CUSA use, avoidance of transvermian approaches, limited cerebellar retraction, and preoperative risk stratification via the Rotterdam pCMS score. pCMS was classified as grade 1 (mutism) or grade 2 (reduced speech).
Results:
Overall pCMS incidence was 17.6% (31/176). Rates declined from 23.2% pre-2016 to 12.6% post-2016 (p = 0.10). Midline tumours had higher pCMS rates (24%) than hemispheric (10%, p = 0.01). Among midline tumours, pCMS dropped from 40% to 17% post-modification (p = 0.02). Medulloblastomas had the highest pCMS rate (31.7%), followed by ependymomas (25.8%) and pilocytic astrocytomas (11.5%) (p = 0.02). High Rotterdam risk scores correlated with higher pCMS rates (p = 5 × 10⁻7), but incidence in high-risk patients fell from 65% to 29% after 2016 (p = 0.03). High-volume surgeons had lower pCMS rates (15% vs. 24%), with a notable reduction post-2016 (10% vs. 23%, p = 0.08).
Conclusion:
Our findings highlight that optimising surgical technique and experience, alongside tailored preoperative planning and intraoperative strategies, may reduce pCMS rates in paediatric PFT resections, particularly in high-risk groups, and supports the need for prospective multicentre studies to validate modifiable surgical risk factors.
