**6. Pediatrics**

*Trauma and Emergency Surgery - The Role of Damage Control Surgery*

Since most cells of the nervous system do not typically have a high turnover rate,

it would seem reasonable to assume that the nervous system is more resistant to radiation damage than other organs. However, this assumption does not account for the immediate molecular effects of radiation. Regardless of the rate of cell division, all cells will receive damage to membranes, organelles, and other structures within the cell. Cells that do not divide very frequently will have to endure these injuries for long periods of time, leading to eventual clinical manifestations. Damage to nearby vasculature also limits growth and healing of these structures, leading to pronounced long term effects. There are clear reports of radiation damage to the central nervous system sometimes long after the initial radiation exposure [35–38]. Patients who received radiosurgery or hypofractionation techniques are at risk of developing necrosis within six months of receiving therapy. Clinically, these developments can result in focal changes and change in behavior depending on the site of necrosis. Demyelinating syndromes, although rare, are also possible in the peripheral nerves and spinal cord. Often, neurotoxic symptoms are enhanced by chemotherapeutic agents, such as vinblastine, vincristine and cisplatin. Gathering a detailed physical exam, medical history and possible neurological referral may be required for definitive identification of these outcomes. Patients who received radiation therapy for pituitary adenomas or at sites near the optic structures are at risk for visual changes [36, 37]. This is because some structures, such as the lens and optic chasm, are sensitive to radiation exposure due to limited blood supply [15, 39, 40]. Patients treated for breast and head and neck cancers may rarely present with brachial plexopathy. Peripheral lymph nodes for these regions are often within the same field of treatment

as the brachial plexus, resulting in unintended exposure to this region [41].

The effect of radiation therapy on the endocrine glands varies depending on the gland affected. The timeline for the development of clinical sequelae varies, with some cases even being reported many years after the radiation exposure. The pituitary gland is relatively radiation sensitive and results in panhypopituitary syndrome, requiring supplementation of depleted hormones. Secondary malignancies from un-intentional radiation exposure, while rare, have been reported [42]. Patients who received previous head and neck radiation therapy who now present with headache, vision loss and/or hormonal abnormalities should be carefully examined for the development of pituitary adenomas. The thyroid gland is also sensitive to radiation therapy, resulting in hypothyroid syndromes. Patients who receive radiation therapy to the head and neck often receive surgery that involves dissection of the thyroid gland, exasperating thyroid function loss. The thyroid also has a relatively higher incidence of developing secondary malignancies. This finding has been identified not only in patients receiving radiation therapy, but also victims of the Chernobyl incident [5]. The same care must be given to the parathyroid glands, given the proximity to the thyroid gland, which can present with signs and symptoms of hypoparathyroidism. Radiation exposure to the endocrine pancreas and adrenal glands are less characterized and are thought to be more radiation resistant. However, there are a few cases of injury to these organs associated with radiation exposure [42].

The reproductive organs are highly sensitive to radiation damage, with early

exposure in pediatric patients leading to severe detriments like sterility and

**5.8 Nervous system**

**5.9 Endocrine**

**12**

**5.10 Reproductive**

Pediatric patients are unique in that many organs and tissues are still developing. As a result, the cells involved are particularly sensitive to radiation damage as the fully developed adult organ can become abnormal or dysfunctional. Pediatric patients who receive radiation therapy are known to have a higher risk of developing growth abnormalities, chronic diseases, secondary malignancies and premature death compared to sibling controls [43]. Children who were treated with radiotherapy in the pelvis for tumors such as rhabdomyosarcoma or germ cell tumors are at high risk for gonadal abnormalities. Given the rapid growth in the musculoskeletal system during puberty, exposure to the spine at an early age can cause drastic changes to the respiratory and cardiovascular system. Radiation exposure to any cartilage or bone not only presents the risk of bone necrosis, but also may affect the fully developed form of such tissue, sometimes resulting in stunted extremity length and increased frequency of fractures. Children treated for Wilms tumors are at high risk of renal abnormalities later in their lifetime to the remaining kidney, therefore attention to detail for renal health as these patients become adults is an important aspect of a survivorship plan. Exposure to the bowel and hepatic structures are known to adversely affect the growth and development of intraabdominal organs. These effects can affect nutritional intake, indirectly causing developmental issues as the child matures [14, 43, 44]. As these patients mature into adulthood, detailed review of a patient's radiation exposure history will play a pivotal role in survivorship plans.
