Pediatric neurosurgery emergencies: lessons from the operating room
A young child is brought into a hospital emergency department in regional Queensland after a fall from a backyard trampoline. Within minutes, a non-contrast CT scan shows a sizeable subdural collection with midline shift. The local paediatrician activates the retrieval service, and a few hours later a paediatric neurosurgical team is operating in a tertiary children's hospital. This scenario, common across Australia, shows how rapidly decisions must be made in paediatric neurosurgical emergencies, where minutes can determine whether a child walks out of hospital or not.
Operating on small brains and fragile spines demands a different mindset from adult neurosurgery. The margin for error is narrow, the physiology is volatile, and the families are under acute stress. The following case examples, drawn from the kinds of presentations seen regularly in Australian theatre suites, illustrate both the technical and the human side of the work. They also highlight why subspecialty training, robust retrieval networks, and continuous peer review remain essential to safe practice in this field.
Dr A.V. Thamburaj, the neurosurgeon behind this site, has spent decades in theatre and in teaching, and the About page outlines his training and ongoing clinical interests. The reflections that follow are offered in the spirit of open professional exchange, the kind that the site's discussion forum is designed to encourage.
Acute subdural haematoma in a toddler
The first case involves a 22-month-old girl transferred from a regional hospital three hours west of Sydney after a reported fall at home. She had been increasingly drowsy, with a bulging anterior fontanelle and a fixed downward gaze on arrival. Non-contrast CT demonstrated a mixed-density subdural collection with effacement of the basal cisterns and approximately six millimetres of midline shift. Within forty minutes of arrival in the tertiary paediatric emergency department, she was in theatre, with a coordinated team of neurosurgery, paediatric anaesthesia, and theatre nursing already prepared.
A bicoronal scalp flap, generous craniotomy, and evacuation of the haematoma was performed, with careful attention to haemostasis given the infant's small circulating volume. Anaesthesia was led by a paediatric fellow, with invasive monitoring and a pre-calculated transfusion plan in place before skin incision. The child made a steady recovery, returning to the ward within forty-eight hours with no new neurological deficit, and was feeding normally by the end of the week. Discussions with child protection services continued in parallel, recognising that non-accidental injury must always be considered in infants with subdural collections and retinal findings.
Such cases underscore the value of streamlined paediatric trauma pathways. In Australia, the integration between peripheral emergency departments, retrieval services such as the Royal Flying Doctor Service in remote regions, and tertiary paediatric neurosurgery centres, including Sydney Children's Hospital, the Royal Children's in Melbourne, and the Queensland Children's Hospital in Brisbane, has transformed outcomes over the past two decades. Time is brain, even at this age, and the system is built to move quickly with rehearsed transfer protocols.
Shunt malfunction in a child with hydrocephalus
The second case concerns a five-year-old boy with congenital hydrocephalus managed since infancy with a ventriculoperitoneal shunt. His mother, a registered nurse in a small town in the Pilbara region of Western Australia, recognised the early signs of shunt failure: early morning headache, vomiting, and a subtle change in his schoolwork over two days. She drove him to the nearest regional hospital, where a CT scan showed marked ventricular enlargement consistent with distal catheter obstruction, and within hours he was on a fixed-wing aircraft south to Perth Children's Hospital.
Children's shunts fail in predictable patterns, and the parents often recognise them before any clinician does. The boy was taken to theatre the same day for shunt exploration and revision of the distal catheter. Intraoperatively, the surgeon confirmed blockage with omental debris and replaced the abdominal portion, sending CSF for microscopy, culture, and cell count. He was observed closely for any sign of infection, which remains a feared complication of shunt surgery, particularly in remote-dwelling families where rapid readmission is logistically difficult. He went home on day three with a clear plan for outpatient review in his home town.
The broader lesson is that hydrocephalus and shunt malfunction account for a substantial share of emergency paediatric neurosurgical workload in Australia. The geography of the country means families may travel hundreds of kilometres for revision surgery, and a clear family-centred plan, including rapid phone advice lines, education about red-flag symptoms, and outpatient follow-up close to home, is an essential part of the care. A comparison of typical paediatric neurosurgical emergencies is provided below.
| Condition | Typical age | Common presentation | First-line imaging | Time to theatre |
|---|---|---|---|---|
| Acute subdural haematoma | Infants and toddlers | Drowsiness, bulging fontanelle, seizures | Non-contrast CT | Within 1–2 hours |
| Shunt malfunction | Any age, mostly under 5 | Headache, vomiting, lethargy | CT or rapid MRI | Within hours if obtunded |
| Posterior fossa tumour | 3–10 years | Morning headache, ataxia, papilloedema | MRI brain with contrast | Within 24–48 hours |
| Craniosynostosis | Infants under 1 year | Abnormal head shape, raised ICP signs | 3D CT skull | Elective, expedited if ICP rises |
| Spinal epidural abscess | Older children and adolescents | Back pain, fever, neurological deficit | MRI whole spine | Within 24 hours |
Posterior fossa tumour in a school-age child
The third case involves an eight-year-old presenting to her GP in suburban Adelaide with a four-week history of morning headaches, intermittent vomiting, and a new unsteadiness on the school sports field. Examination revealed truncal ataxia, a wide-based gait, and bilateral papilloedema on fundoscopy. Urgent MRI demonstrated a midline posterior fossa mass with associated hydrocephalus, later confirmed on histology as a medulloblastoma. She was referred directly to the on-call paediatric neurosurgical registrar at the Women's and Children's Hospital, bypassing the usual outpatient pathway.
She went to theatre within thirty-six hours for insertion of an external ventricular drain, followed the next day by a prone-position suboccipital craniotomy for tumour resection. Neurophysiological monitoring, including somatosensory evoked potentials and direct brainstem mapping, was used throughout. Surgery lasted over six hours, and a near-total resection was achieved with no new cranial nerve deficit. She then began a coordinated oncology pathway at the same hospital, including trial enrolment through a national children's cancer network, avoiding the need for interstate transfer.
Posterior fossa tumours remain the commonest solid paediatric malignancy, and their management sits at the intersection of emergency neurosurgery, oncology, and rehabilitation. Australian centres have contributed actively to international trials, and the multidisciplinary team meeting, held weekly in every major children's hospital, is where the surgical plan is ratified alongside radiotherapy, chemotherapy, neuropsychology, and school reintegration. Family accommodation, often through Ronald McDonald House or equivalent, is arranged early in the pathway to reduce the social cost of prolonged treatment.
Craniosynostosis correction in an infant
The fourth case departs slightly from the purely emergent category but illustrates how planned craniofacial surgery can rapidly intersect with urgent clinical decision-making. A four-month-old boy in regional Tasmania was noted by his maternal child health nurse to have a palpable ridge along his sagittal suture and a scaphocephalic head shape. CT with three-dimensional reconstruction confirmed sagittal synostosis with associated dolichocephaly. The family was referred to the state paediatric neurosurgery service, and an outpatient review was arranged for three months later.
A fronto-orbital advancement and remodelling procedure was planned for around nine months of age, but the family was reviewed regularly to monitor for raised intracranial pressure. At eight months, the boy developed new papilloedema on routine examination, and the surgery was brought forward by six weeks. He underwent a combined neurosurgical and craniofacial procedure, with blood products cross-matched in advance and a surgical time of approximately five hours. He was monitored in paediatric intensive care for forty-eight hours, with meticulous fluid balance and analgesia.
The case highlights the boundary between elective and urgent practice in paediatric neurosurgery. In Australia, craniosynostosis surgery is concentrated in a small number of paediatric centres, and the surgical decision is shared between neurosurgeons, craniofacial plastic surgeons, anaesthetists, and the family. Outcomes have improved with the centralisation of these procedures and the involvement of clinical psychologists throughout the pathway to support parents through what is often a deeply emotional experience.
Spinal cord compression in an adolescent
The final case involves a fourteen-year-old boy from a cattle property outside Alice Springs who developed rapid-onset weakness in his legs over forty-eight hours, with urinary retention and a fever. He had a recent history of a skin infection on his lower back. The Royal Flying Doctor Service was activated, and the boy was transferred to a tertiary paediatric centre, several hundred kilometres away. MRI on arrival demonstrated a thoracic epidural abscess extending from T6 to T9, with significant cord compression and intramedullary signal change on T2 sequences.
He went to theatre within four hours of arrival for emergency decompression and drainage via a posterior approach, with intraoperative neuromonitoring throughout. Microbiology grew Staphylococcus aureus sensitive to flucloxacillin, and he received targeted antibiotics for six weeks under the supervision of the infectious diseases team. The team coordinated intensive rehabilitation in partnership with a specialist spinal injury unit, supporting the family through social work and Aboriginal liaison officers. He regained the ability to walk with one stick and returned to school part-time by twelve weeks.
Spinal emergencies in children are rare but devastating, and the time-critical nature of cord compression means delays in retrieval or imaging can change the trajectory of a young life. The case also illustrates the extraordinary reach of Australian retrieval medicine, where teams routinely move patients across vast distances to reach the small number of centres equipped to perform such surgery. Discussions with rural general practitioners and Aboriginal health workers before discharge are an important part of ensuring a safe return home.
The five cases described here are representative rather than exhaustive. Paediatric neurosurgery emergencies span trauma, hydrocephalus, tumour, craniofacial, and spinal pathology, and each demands its own clinical pathway. Trainees preparing for subspecialty recognition, including those progressing through the Royal Australasian College of Surgeons' Surgical Education and Training program, will encounter all of these patterns during their paediatric rotations. Subspecialty exposure, supervised by senior consultants, remains essential to safe independent practice.
Readers are invited to share their own reflections, difficult cases, or questions in the comment thread on this site, or to register for the open peer discussion forum. The community exists to support learning, to reduce the isolation that can come with this demanding work, and to give voice to the small wins that often go unrecorded in formal case notes. For a more detailed look at how a practising neurosurgeon approaches these situations, including checklists and intraoperative photographs, explore the neurosurgeon's guide elsewhere on this site, and consider subscribing for future updates.