OBJECTIVE Pediatric intracranial abscesses are rare, life-threatening infections requiring prompt surgery and coordinated subspecialty care. Reports during COVID-19 described nationwide surges, but national operative trends and equity data remain sparse. Therefore, this study aimed to define decade-long trends in surgical management, outcomes, and racial disparities in children in the US who underwent intracranial abscess surgery, with an emphasis on pandemic-era changes. METHODS This was a retrospective, multicenter cohort study of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric (2013–2023) children undergoing surgery for intracranial abscess/empyema by neurosurgery and/or otolaryngology; outcomes were compared using nonparametric/exact tests (α = 0.05) in R. RESULTS Among 232 children (median age 11.9 years; 71.6% male), the annual operative volume rose 10-fold. The proportion of indexed operations performed by neurosurgery declined from 75% in 2013 to 7.5% in 2023, while the proportion performed by otolaryngology increased from 0% to 62.5% over the same period. Black children were less likely to undergo neurosurgery-only procedures than they were to undergo otolaryngology surgery with or without neurosurgery (4.3% vs 34.4%, p = 0.008). Black and Hispanic children had longer hospital stays than White children (12.5 and 11 days, respectively, vs 9 days; p = 0.026) and higher mortality (0.5%). Neurological complication rates (0.9%) were uniformly low. During COVID-19, patients were older (median age 12.5 vs 10.9 years, p = 0.014), had more extradural/subdural disease (47% vs 33%, p = 0.044), and had longer operations (median 203 vs 169 minutes, p = 0.020), while admission-to-incision time, readmission, and mortality rates were unchanged. CONCLUSIONS From 2013 to 2023, occurrences of pediatric intracranial abscess surgery increased dramatically, with a marked increase during the later study period (2020–2023), temporally overlapping with the COVID-19 pandemic, and peaking in 2022–2023. Over the same period, the specialty performing the indexed operation shifted progressively from neurosurgery to otolaryngology. Short-term outcomes remained favorable, but Black and Hispanic children experienced reduced neurosurgical access and longer hospitalization, underscoring the need to address structural determinants of pediatric neurosurgical equity.