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Pediatric Neurosurgery at UPMC Children’s: Minimally Invasive Endoscopic and Skull Base Surgery Have Applications Far Beyond Tumors

September 22, 2023

Michael McDowell, MD, leads skull base and pituitary neurosurgery efforts at UPMC Children’s Hospital of Pittsburgh. Dr. McDowell is one of only a handful of neurosurgeons in the United States to be dually fellowship-trained in pediatric neurosurgery and cranial base surgery. His residency training and fellowships in pediatric neurosurgery and cranial base surgery were all conducted at the University of Pittsburgh School of Medicine, UPMC, and UPMC Children's Hospital of Pittsburgh. He joined the faculty of the Division of Pediatric Neurosurgery in 2022 after completing his training and is a member of the renowned UPMC Center for Skull Base Surgery, which was the first skull base center to be established in North America and has pioneered both transcranial microscopic and endoscopic endonasal approaches to the skull base and brain.

The UPMC Center for Skull Base Surgery continues to lead the field of minimally invasive brain surgery after more than three decades by developing new techniques, tools, and approaches that have made it possible to access many tumors and lesions of the brain, regardless of size. Since 1997, more than 4,000 endonasal surgeries have been performed in adults and children, making UPMC one of the busiest centers in the world for the surgical treatment of tumors of the pituitary region and cranial base.

Dr. McDowell collaborates with other center members to provide comprehensive endoscopic and open skull base surgical care at UPMC Children's. In his surgical work, Dr. McDowell emphasizes cranio-cervical junction disease, including tumors, basilar invagination, and other causes of cranio-spinal instability requiring instrumentation. Dr. McDowell also brings research expertise in near-infrared spectroscopy (NIRS) as a noninvasive way of monitoring brain function and intracranial pressure. He recently received the 2021 Hydrocephalus Association Award for his groundbreaking work that may soon have wide-reaching applications for intracranial pressure disorders, including trauma, Chiari malformation, craniosynostosis, and hydrocephalus. A large-scale clinical trial is underway to validate this technology in children and adults with neurosurgical conditions.

"Because of UPMC and the University of Pittsburgh's decades-long pioneering work in cranial base surgery and techniques and training more skull base surgeons than any other program, we have been sought out nationally and internationally to treat complex pediatric cases," says Dr. McDowell. "Our experience with endoscopic endonasal surgery (EES) approaches to skull base and pituitary surgery in children is, perhaps, the largest in the world, and we employ these operative techniques for far more than just malignant tumor resection."

Making Extensive Use of Endoscopic Techniques for Brain Surgery

As Dr. McDowell explains, he and his colleagues at the UPMC Center for Skull Base Surgery, and collaborative colleagues from areas like pediatric otolaryngology, team up to take on numerous types of cases that are amenable – and at times more suitable – to endoscopic endonasal approaches.

As he elaborates, approaches through the skull base are options for a wide range of tumors – those existing within the skull base proper, but also those in adjacent areas or structures that allow for the minimally invasive approaches to be adopted. This includes near the bottom of the brain, as well as tumors located near the eye.

“But approaches through the skull base with endoscopic and endonasal techniques are not just for benign or malignant growths,” he says. “In some cases, we can use endoscopic skull base approaches for conditions like temporal lobe epilepsy where language function may be impaired by traditional surgery. And we routinely employ the techniques for spinal disorders like basilar invagination.”

Skull base approaches can also be employed for tumors affecting anterior aspects of the spine and neck due to the broad reach and angulation available with endoscopic skull base techniques. And, of course, tumors affecting the pituitary gland – adenomas, cysts, and other lesions or conditions.

“When dealing with pediatrics – children and their families – the incision-less nature of the surgery is highly desirable,” says Dr. McDowell.

Dr. McDowell also routinely collaborates on surgical cases with pediatric otolaryngology specialist Amanda Stapleton, MD. This comes into play with a number of conditions like juvenile nasal angiofibroma, nasal dermoids, and chordoma, among others.

“Our approach, and I think our outcomes back this up, has been to work together in teams to achieve optimal outcomes," says Dr. McDowell. "I think it's a lot safer for the patient to have a team of surgeons collaborating on things like angiofibromas where you may have a lot of bleeding and a small patient with lower blood volume. It also never hurts to have two experts putting their heads together on a given problem. One might see or think of something important that a single surgeon would be more likely to miss."

Expanding Neurosurgical Services to the Harrisburg Area

In early 2024, Dr. McDowell plans to begin performing general neurosurgical procedures at UPMC Pinnacle in Harrisburg, Pa. This work will expand surgical options for patients in the region while avoiding the need for longer-distance travel for expert subspecialty surgical care – travel and time away from home that can often be highly burdensome for children and their families.

"Access to the kind of expertise and subspecialty care that UPMC Children's and the UPMC Center for Skull Base Surgery offers – when it is far from home – can be a barrier for many patients and families," says Dr. McDowell. "My hope is that by traveling to Harrisburg and conducting surgery locally, we will remove one of those barriers for local families facing difficult diagnoses and long-term care needs."

Large Pediatric Skull Base Chordoma Experience

UPMC Children’s and the UPMC Cranial Base Center have significant experience with rare skull base chordomas, and in 2020, published findings on cases conducted over a 15-year period in which endoscopic endonasal approaches were employed. This is the largest single-center publication to date on the surgical treatment of pediatric chordomas.

Research Highlight - Endoscopic Endonasal Surgery in Early Childhood: Safety and Efficacy

In 2021, Dr. McDowell and colleagues published the results of a study examining the safety and efficacy of EES in very young children. Historically, this procedure has seen limited use in very young children due to the intricacies of the developing pediatric skull base and inherent anatomic complexities. However, Dr. McDowell has found that in his practice endoscopic surgery can be routinely performed even in children under the age of 2.

Dr. McDowell and colleagues’ analysis of cases conducted at UPMC aimed to determine the safety and effectiveness of EES in children below the age of 7. The retrospective cohort study reviewed patients who underwent EES between 2002 and 2019. Of the 36 patients included in the analysis, the average age at the time of the first surgery was 4 years, and the entire cohort was comprised of 11 different skull base pathologies.

“Our study represents the largest single-center analysis of EES in young children conducted to date,” explains Dr. McDowell.

One of the study’s important findings was around the use of nasoseptal flaps. These flaps have recently been used for skull base reconstruction in young children, and although earlier studies hinted at potential wound healing challenges, the latest results are encouraging. Postoperative complications like cerebrospinal fluid leaks have decreased over time, indicating advancements and efficacy of surgical techniques. The study also underscores the need for vigilance — specific pathologies, such as craniopharyngiomas, still present recurrence and associated challenges. It also highlights the importance of being treated by a pediatric neurosurgeon who has had extensive experience not only in performing the surgeries but ensuring that the surgical wound will heal safely.

Another past concern has been the long-term impact of EES on the craniofacial growth of young children. The study's findings are positive, as early indications showed postoperative measurements remaining within the typical or expected range.

Understanding the outcomes and potential of EES in young patients is pivotal because it can help guide decision-making, potentially offering a promising surgical avenue for children in need while ensuring safety and optimal long-term outcomes with low risk of major complications or adverse postsurgical events.

Patient Referrals and Consultations

To consult on a patient or make a referral, please call the Division of Pediatric Neurosurgery at UPMC Children’s Hospital of Pittsburgh at 412-692-5090.

Further Reading

Article References

McDowell M, Chiang M, Abou-Al-Shaar H, Zenonos GA, Wang EW, Snyderman CH, Gardner P. Applications of Endoscopic Endonasal Surgery in Early Childhood: A Case Series. Pediatr Neurosurg. 2021; 56(6): 519-528. Epub 2021 Sep 10.

McDowell MM, Zwagerman NT, Wang EW, Snyderman CH, Tyler-Kabara EC, Gardner PA. Long-Term Outcomes in the Treatment of Pediatric Skull Base Chordomas in the Endoscopic Endonasal Era. J Neurosurg Pediatr. 2020 Nov 20; 27(2): 170-179.

Additional Selection of Recent Published Studies from Dr. McDowell and Colleagues on Endoscopic/Skull Base Surgery