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Christopher M. Bonfield and Douglas Kondziolka

Bill Masterton is the only man to die of injuries sustained in a National Hockey League (NHL) game. He remains the last fatality in any professional team sport involving a direct in-game injury in North America. While Masterton was originally thought to have suffered a fatal brain injury while being checked on the ice, later analysis of the case revealed evidence of second-impact syndrome and the effects of prior concussions. Masterton's death sparked both an immediate debate in the NHL on whether helmets should be compulsory and the NHL's first vote on mandatory helmet use. Although the subject of mandated helmet use met with resistance in the 10 years after Masterton's death, especially from hockey owners and coaches, the NHL finally legislated helmet use by all players entering the league beginning in the 1979–1980 season.

Several awards, including one recognizing the NHL player who best exemplifies the qualities of perseverance, sportsmanship, and dedication to hockey, have been created in memory of Masterton. However, his legacy extends far beyond the awards that bear his name. His death was the seminal event bringing head safety to the forefront of a game that was both unready and unwilling to accept change. An increase in mainstream media attention in recent years has led to unprecedented public awareness of brain injury and concussion in hockey and other sports. Advances in the diagnosis and treatment of head injury in sports have occurred recently, the impetus for which started over 45 years ago, when Bill Masterton died.

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Ann-Christine Duhaime

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Christopher M. Bonfield, D. Douglas Cochrane, Ash Singhal and Paul Steinbok

Sagittal craniosynostosis, the most common single suture craniosynostosis, is treated by numerous surgical techniques. Minimally invasive endoscopy-assisted procedures with postoperative helmeting are being used with reports of good cosmetic outcomes with decreased morbidity, shortened hospital stay, and less blood loss and transfusion. This procedure uses small skin incisions, which must be properly placed to provide safe access to the posterior sagittal and lambdoid sutures. However, the lambda is often hard to palpate through the skin due to the abnormal head shape. The authors describe their experience with the use of intraoperative, preincision ultrasound localization of the lambda in patients with scaphocephaly undergoing a minimally invasive procedure. This simple technique can also be applied to other operations where proper identification of the cranial sutures is necessary.

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Christopher M. Bonfield, Sandi Lam, Yimo Lin and Stephanie Greene

Object

Attention deficit hyperactivity disorder (ADHD) and traumatic brain injury (TBI) are significant independent public health concerns in the pediatric population. This study explores the impact of a premorbid diagnosis of ADHD on outcome following mild TBI.

Methods

The charts of all patients with a diagnosis of mild closed head injury (CHI) and ADHD who were admitted to Children's Hospital of Pittsburgh between January 2003 and December 2010 were retrospectively reviewed after institutional review board approval was granted. Patient demographics, initial Glasgow Coma Scale (GCS) score, hospital course, and King's Outcome Scale for Childhood Head Injury (KOSCHI) score were recorded. The results were compared with a sample of age-matched controls admitted with a diagnosis of CHI without ADHD.

Results

Forty-eight patients with mild CHI and ADHD, and 45 patients with mild CHI without ADHD were included in the statistical analysis. Mild TBI due to CHI was defined as an initial GCS score of 13–15. The ADHD group had a mean age of 12.2 years (range 6–17 years), and the control group had a mean age of 11.14 years (range 5–16 years). For patients with mild TBI who had ADHD, 25% were moderately disabled (KOSCHI Score 4b), and 56% had completely recovered (KOSCHI Score 5b) at follow-up. For patients with mild TBI without ADHD, 2% were moderately disabled and 84% had completely recovered at follow-up (p < 0.01). Patients with ADHD were statistically significantly more disabled after mild TBI than were control patients without ADHD, even when controlling for age, sex, initial GCS score, hospital length of stay, length of follow-up, mechanism of injury, and presence of other (extracranial) injury.

Conclusions

Patients who sustain mild TBIs in the setting of a premorbid diagnosis of ADHD are more likely to be moderately disabled by the injury than are patients without ADHD.

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Christopher M. Bonfield, Anand R. Kumar and Peter C. Gerszten

There is evidence that the neurosurgical procedure of cranioplasty is as ancient as its better-known counterpart, trephination. With origins in pre-Incan Peru, cranioplasty remains an important reconstructive procedure for modern craniofacial surgery teams to master. Solutions to the often challenging problem of repairing skull defects continue to evolve to improve patient outcomes. Throughout recorded history, advances in cranioplasty have paralleled major military conflicts due to survivorship after trephination or decompressive craniectomy. Primitive skull coverings used in Peru were later replaced during the Middle Ages by grafts obtained in animals and humans. Improved survivorship secondary to advances in anesthesia and battlefield medicine during the Crimean War and the American Civil War allowed the use of tantalum and acrylic cranioplasty to evolve during World Wars I and II. In the modern era of the Iraq and Afghanistan conflicts, greater survivorship after cranial injury due to improvements in protective armor, medical evacuation, and early “far-forward” neurosurgical treatment have occurred. Consequently, the last decade has seen great advancement in cranial defect reconstruction, including custom-fabricated alloplast implants and the emergence of regenerative cranial treatments such as distraction osteogenesis, protected bone regeneration, and free tissue transfers. Comprehensive rehabilitation after neurotrauma has emerged as the new standard of care.

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Rebecca A. Reynolds, Lawrence B. Stack and Christopher M. Bonfield

Medical photographs are commonly employed to enhance education, research, and patient care throughout the neurosurgical discipline. Current mobile phone camera technology enables surgeons to quickly capture, document, and share a patient scenario with colleagues. Research demonstrates that patients generally view clinical photography favorably, and the practice has become an integral part of healthcare. Neurosurgeons in satellite locations often rely on residents to send photographs of diagnostic imaging studies, neurological examination findings, and postoperative wounds. Images are also frequently obtained for research purposes, teaching and learning operative techniques, lectures and presentations, comparing preoperative and postoperative outcomes, and patient education. However, image quality and technique are highly variable. Capturing and sharing photographs must be accompanied by an awareness of the legal ramifications of the Health Insurance Portability and Accountability Act (HIPAA). HIPAA compliance is straightforward when one is empowered with the knowledge of what constitutes a patient identifier in a photograph. Little has been published to describe means of improving the accuracy and educational value of medical photographs in neurosurgery. Therefore, in this paper, the authors present a brief discussion regarding four easily implemented photography skills every surgeon who uses his or her mobile phone for patient care should know: 1) provide context, 2) use appropriate lighting, 3) use appropriate dimensionality, and 4) manage distracting elements. Details of the HIPAA-related components of mobile phone photographs and patient-protected health information are also included.

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Julia Sharma, Christopher M. Bonfield, Ash Singhal, Juliette Hukin and Paul Steinbok

Craniopharyngioma is a benign, cystic suprasellar tumor that can be treated with intracystic chemotherapy. Interferon-α (IFN-α) has been gaining popularity as an intracystic treatment for craniopharyngioma because of its efficacy and supposed benign neurotoxicity profile. In this case report the authors describe a patient who, while receiving intracystic IFN-α, suffered a neurological event, which was believed to be related to drug leakage outside the cyst. This is the first report of a focal neurological deficit potentially attributable to intracystic IFN-α therapy, highlighting the fact that IFN-α may have neurotoxic effects on the central nervous system. Given this case and the results of a literature review, the authors suggest that a positive leak test is a relative contraindication to intracystic IFN-α treatment.

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Jonathan Dallas, Katherine D. Sborov, Bradley S. Guidry, Silky Chotai and Christopher M. Bonfield

OBJECTIVE

Many patients undergoing spinal fusion for neuromuscular scoliosis have preexisting neurosurgical implants, including ventricular shunts (VSs) for hydrocephalus and baclofen pumps (BPs) for spastic cerebral palsy. Recent studies have discussed a possible increase in implant complication rates following spinal fusion, but published data are inconclusive. The authors therefore, sought to investigate: 1) the rate of implant complications following fusion, 2) possible causes of these complications, and 3) factors that place patients at higher risk for implant-related complications.

METHODS

Cases involving pediatric patients with a preexisting VS or BP who underwent spinal fusion for scoliosis correction between 2005 and 2016 at a single tertiary children’s hospital were retrospectively analyzed. Patient demographics, implant characteristics, spinal fusion details, neurosurgical follow-up, and implant complications in the 180 days following fusion were recorded and analyzed.

RESULTS

Overall, 75 patients who underwent scoliosis correction had preexisting implants: 39 had BPs, 31 VSs, and 5 both. The patients’ mean age at fusion was 13.49 ± 2.78 years (range 3.62–18.81 years), and the mean time from the most recent previous implant surgery to fusion was 5.70 ± 4.65 years (range 0.10–17.3 years). The mean preoperative and postoperative Cobb angles were 62.4° ± 18.9° degrees (range 20.9°–109.0°) and 23.5° ± 13.3° degrees (range 2.00°–67.3°), respectively. No VS complications were identified. Two patients with BPs were found to have complications (unintentional cutting of their BP catheter during posterior spinal fusion) within 180 days postfusion. There were no recorded neurosurgical implant infections, failures, fractures, or dislodgements. Although 10 patients required at least 1 surgical procedure for irrigation and debridement of the spine wound following fusion, there were no abdominal or cranial implant wound infections requiring revision, and no implants required removal.

CONCLUSIONS

The results of this study suggest that spinal fusion for scoliosis correction does not increase the rates of complications involving previously placed neurosurgical implants. A large-scale, prospective, multicenter study is needed to fully explore and confirm this finding.

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Christopher M. Bonfield, Sanjay Naran, Oluwaseun A. Adetayo, Ian F. Pollack and Joseph E. Losee

Object

Head trauma is a common cause of morbidity and mortality in the pediatric population and often results in a skull fracture. Pediatric skull fractures are distinct from adult fractures. Pediatric fractures have a greater capacity to remodel, but the pediatric brain and craniofacial skeleton are still developing. Although pediatric head trauma has been extensively studied, there is sparse literature regarding skull fractures. The authors' aim was to investigate the characteristics, injuries, complications, and outcomes of the patients in whom surgical intervention was needed for skull fractures.

Methods

The authors performed a retrospective review of patients presenting to the emergency department of a pediatric Level I trauma center between 2000 and 2005 with skull fractures. Patient demographics, mechanism of injury, associated injuries, fracture bone involvement, surgical intervention, complications, and outcomes were analyzed. Groups treated nonoperatively, for skull fracture repair, and for traumatic brain injury were compared.

Results

A total of 897 patients with a skull fracture were analyzed. Most patients (n = 772, 86.1%) were treated nonoperatively (Non-Op group). Fifty-eight patients (6.5%) underwent repair of the fracture (Repair group) and 67 (7.5%) required intervention for treatment of traumatic brain injury (TBI group). The Non-Op group was significantly younger, and the TBI group had a lower initial Glasgow Coma Scale (GCS) score. A fall (51.2%) was the most common mechanism of injury in the Non-Op group, whereas a motor vehicle crash (23.9%) and being hit in the head with an object (48.2%) were most prevalent in the TBI and Repair groups, respectively. Associated injuries were seen in all 3 groups, with brain injury (hematoma) being the most common. Frontal bone fracture was seen most in the Repair and TBI groups, and the parietal bone was the most frequent bone fractured in the Non-Op group. Patients in the TBI group were much more likely to have 2 or 3 skull bones fractured. In the Repair group, 36.2% had a complication (38.0% intervention related and 62.0% trauma related), but no patient had a worsening of their neurological status. In the TBI group, 48.7% of the patients suffered a complication, the vast majority (90.6%) of which were related to the trauma.

Conclusions

The majority of pediatric skull fractures can be managed conservatively. Of those requiring surgical intervention, fewer than half of the surgeries are performed solely for skull fracture repair only. Patients hit in the head with an object or involved in a motor vehicle crash are more likely to need surgical intervention either to repair the skull fracture or for TBI management, respectively. Frontal bone fractures are more likely to necessitate repair, and those patients treated for TBI have a greater incidence of 2 or 3 bones involved in the fracture. Complications occurred but most were related to underlying trauma, not the surgery. No patients who underwent intervention for repair of their skull fracture only had a worsening of their neurological status.

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Zachary J. Tempel, Gurpreet S. Gandhoke, Christopher M. Bonfield, David O. Okonkwo and Adam S. Kanter

Object

A hybrid approach of minimally invasive lateral lumbar interbody fusion (LLIF) followed by supplementary open posterior segmental instrumented fusion (PSIF) has shown promising early results in the treatment of adult degenerative scoliosis. Studies assessing the impact of this combined approach on correction of segmental and regional coronal angulation, sagittal realignment, maximum Cobb angle, restoration of lumbar lordosis, and clinical outcomes are needed. The authors report their results of this approach for correction of adult degenerative scoliosis.

Methods

Twenty-six patients underwent combined LLIF and PSIF in a staged fashion. The patient population consisted of 21 women and 5 men. Ages ranged from 40 to 77 years old. Radiographic measurements including coronal angulation, pelvic incidence, lumbar lordosis, and sagittal vertical axis were taken preoperatively and 1 year postoperatively in all patients. Concurrently, the visual analog score (VAS) for back and leg pain, the Oswestry Disability Index (ODI), and Short Form-36 (SF-36) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were used to assess clinical outcomes in 19 patients.

Results

At 1-year follow-up, all patients who underwent combined LLIF and PSIF achieved statistically significant mean improvement in regional coronal angles (from 14.9° to 5.8°, p < 0.01) and segmental coronal angulation at all operative levels (p < 0.01). The maximum Cobb angle was significantly reduced postoperatively (from 41.1° to 15.1°, p < 0.05) and was maintained at follow-up (12.0°, p < 0.05). The mean lumbar lordosis–pelvic incidence mismatch was significantly improved postoperatively (from 15.0° to 6.92°, p < 0.05). Although regional lumbar lordosis improved (from 43.0° to 48.8°), it failed to reach statistical significance (p = 0.06). The mean sagittal vertical axis was significantly improved postoperatively (from 59.5 mm to 34.2 mm, p < 0.01). The following scores improved significantly after surgery: VAS for back pain (from 7.5 to 4.3, p < 0.01) and leg pain (from 5.8 to 3.1, p < 0.01), ODI (from 48 to 38, p < 0.01), and PCS (from 27.5 to 35.0, p = 0.01); the MCS score did not improve significantly (from 43.2 to 45.5, p = 0.37). There were 3 major and 10 minor complications.

Conclusions

A hybrid approach of minimally invasive LLIF and open PSIF is an effective means of achieving correction of both coronal and sagittal deformity, resulting in improvement of quality of life in patients with adult degenerative scoliosis.