Complication profile of two surgical techniques, neurosurgical experience, and operative setting for pediatric external ventricular drainage implantation
External ventricular drain (EVD) insertion, a standard procedure for treating acute hydrocephalus, is also associated with significant risks. This retrospective study compares two surgical techniques routinely employed at our clinic and analyzes the influence of surgeon experience and the operative setting on complication rates in a pediatric population. The study population was divided into two cohorts based on the surgical procedures used to access the ventricular system: the BoltKit system (BS) or drain tunnelling (DT). Statistical analysis balanced age, sex, site and side of the drainage, neurosurgical experience, i.e. junior surgeons (JS) or senior surgeons (SS), and operating settings, i.e. intensive care unit (ICU) or operating room (OP), with complications such as cerebrospinal fluid infection, multiple insertion attempts (MIA), malpositioning, revision, and bleeding. This retrospective study included 101 patients (62 males, 39 females, mean age 7.1 years): 79 were treated with DT, and 22 with BS. Overall, 81 EVDs were placed frontal, 18 occipital, 68 at the right and 25 at the left side; 22 revisions (22%), 13 infections (13%), 11 MIA (11%), 10 malpositionings (10%), and 4 bleedings (4%) occurred. MIA, malpositionings, and revisions were significantly more frequent after BS than DT (p = 0.012, p = 0.038, p = 0.020). Revisions were also more common in ICU than OP insertions (p = 0.002) and in JS vs. SS (p = 0.018). Infections were significantly associated with frontal catheter placement (p = 0.018) but not with technique. In multivariable models, both DT and SS reduced the risk of MIA independently, while an ICU setting predicted the need for revision independently. In children, DT is associated with fewer complications than BS. Both surgical experience and the operative setting significantly influence outcome, highlighting the importance of careful technique selection and supervision in pediatric EVD placement.