Drug-resistant epilepsy (DRE) has a strongly negative impact on quality of life, as well as the development of pediatric patients. Surgical treatments have evolved over time, including more invasive craniotomies for resection or disconnection. More recently, neuromodulation techniques have been employed as a less invasive option for patients. Responsive neurostimulation (RNS) is the first closed-loop technology that allows for both treatment and device data collection, which allows for an internal assessment of the efficacy of treatment. This novel technology has been approved in adults and has been used off label in pediatrics. This review seeks to describe this technology, its history, and future directions.

OBJECTIVE: Intraventricular baclofen (IVB) administration is used for the treatment of secondary dystonia associated with cerebral palsy (CP), but it has not been reported as a first-line infusion technique for spasticity. In this study, the authors report outcomes of patients with mixed or isolated spasticity treated with IVB administration. METHODS: A retrospective analysis was performed of consecutive patients treated with IVB between 2019 and 2023. Demographics, baseline clinical variables, and complications data were collected. The primary outcome of the study was the change in spasticity and dystonia as measured by the modified Ashworth Scale (MAS) and Barry-Albright Dystonia Scale (BADS) scores, respectively. Wilcoxon rank-sum tests were performed to compare the change in the pre- and postoperative scores. RESULTS: Fifteen patients were implanted with IVB pumps for spasticity related to CP between 2019 and 2023. The median change in the MAS score was 2 (interquartile range [IQR] = 1) and the median change in the BADS score was 1 (IQR = 2). The Wilcoxon rank-sum test revealed a statistically significant change in both scores following IVB pump placement (BADS z = 2.90, p = 0.003; MAS z = 3.2, p = 0.001). Three patients (20%) experienced minor perioperative complications, all of which were self-limiting and none required additional surgery. CONCLUSIONS: This study reported on 15 cases of mixed or isolated spasticity and showed a relative improvement in the MAS and BADS scores after IVB pump placement. These results provide evidence that IVB can be a safe and effective treatment for spasticity-related CP in addition to dystonia. IVB may be advantageous when an intraventricular route of baclofen administration is preferred.

OBJECTIVE: The Subaxial Cervical Spine Injury Classification (SLIC) score has not been previously validated for a pediatric population. The authors compared the SLIC treatment recommendations for pediatric subaxial cervical spine trauma with real-world pediatric spine surgery practice. METHODS: A retrospective cohort study at a pediatric level 1 trauma center was conducted in patients < 18 years of age evaluated for trauma from 2012 to 2021. An SLIC score was calculated for each patient, and the subsequent recommendations were compared with actual treatment delivered. Percentage misclassification, sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and area under the receiver operating characteristic (ROC) curve (AUC) were calculated. RESULTS: Two hundred forty-three pediatric patients with trauma were included. Twenty-five patients (10.3%) underwent surgery and 218 were managed conservatively. The median SLIC score was 2 (interquartile range = 2). Sixteen patients (6.6%) had an SLIC score of 4, for which either conservative or surgical treatment is recommended; 27 children had an SLIC score ≥ 5, indicating a recommendation for surgical treatment; and 200 children had an SLIC score ≤ 3, indicating a recommendation for conservative treatment. Of the 243 patients, 227 received treatment consistent with SLIC score recommendations (p < 0.001). SLIC sensitivity in determining surgically treated patients was 79.2% and the specificity for accurately determining who underwent conservative treatment was 96.1%. The PPV was 70.3% and the NPV was 97.5%. There was a 5.7% misclassification rate (n = 13) using SLIC. Among patients for whom surgical treatment would be recommended by the SLIC, 29.6% (n = 8) did not undergo surgery; similarly, 2.5% (n = 5) of patients for whom conservative management would be recommended by the SLIC had surgery. The ROC curve for determining treatment received demonstrated excellent discriminative ability, with an AUC of 0.96 (OR 3.12, p < 0.001). Sensitivity decreased when the cohort was split by age (< 10 and ≥ 10 years old) to 0.5 and 0.82, respectively; specificity remained high at 0.98 and 0.94. CONCLUSIONS: The SLIC scoring system recommended similar treatment when compared with the actual treatment delivered for traumatic subaxial cervical spine injuries in children, with a low misclassification rate and a specificity of 96%. These findings demonstrate that the SLIC can be useful in guiding treatment for pediatric patients with subaxial cervical spine injuries. Further investigation into the score in young children (< 10 years) using a multicenter cohort is warranted.

Cerebral palsy (CP) affects 1.5–2.5 per 1,000 live births and manifests as diverse movement disorders including spasticity, dystonia, and mixed phenotypes that significantly impact motor function and quality of life. This review examines surgical and neuromodulatory interventions for medically refractory CP-associated movement disorders. Selective dorsal rhizotomy (SDR) offers a novel treatment option for spastic diplegia in ambulatory children (GMFCS II-III), with combined dorsal-ventral rhizotomy showing promise for mixed presentations. Peripheral neurectomies provide targeted focal spasticity management with sustained improvements in muscle tone and walking speed. Intrathecal baclofen (ITB) effectively reduces spasticity and dystonia through programmable drug delivery, though infection rates and potential scoliosis progression require monitoring. Deep brain stimulation (DBS) targeting the globus pallidus internus demonstrates efficacy for dystonia-predominant CP, with younger patients showing greater improvement. Emerging cerebellar DBS approaches show early promise for spasticity and mixed presentations. Spinal cord stimulation (SCS) may benefit select patients with spasticity or painful dystonia, though evidence remains limited. Focused ultrasound represents a novel noninvasive ablative option currently under investigation. Treatment selection requires multidisciplinary evaluation considering movement disorder phenotype, functional goals, patient age, and family factors. As understanding of CP pathophysiology advances, mechanism-based, individualized treatment algorithms will increasingly optimize functional outcomes for this heterogeneous patient population.