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Craniofacial deformity

John Persing, John A. Jane Jr., and John A. Jane Sr.

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Sagittal synostosis

John A. Jane Jr., Kant Y. Lin, and John A. Jane Sr.

Sagittal synostosis causes predictable malformations depending on the specific suture location that fuses. Anterior fusion causes frontal bossing, whereas posterior fusion causes an occipital knob. Complete sagittal synostosis results in deformity both anteriorly and posteriorly. Variants of each type exist and therefore surgical correction must be tailored to the individual patient. Examples of the different forms of sagittal synotsosis are discussed, and the various surgical techniques available are detailed.

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Editorial: International rotations and resident education

Robert M. Starke, John A. Jane Jr., Ashok R. Asthagiri, and John A. Jane Sr.

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Introduction: Craniosynostosis: modern treatment strategies

John A. Jane Jr., Mark D. Krieger, and John Persing

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Editorial. Endoscopic endonasal surgery for pediatric craniopharyngiomas

Davis G. Taylor and John A. Jane Jr.

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Severe cranial deformity following cerebrospinal fluid diversion in an adolescent with osteogenesis imperfecta

Winson S. Ho and John A. Jane Jr.

Osteogenesis imperfecta (OI) is an inherited connective tissue disorder that causes bone fragility and deformity. Neurological manifestations, including macrocephaly and hydrocephalus, have been reported. Increased vascular fragility or bleeding diathesis also predisposes OI patients to intracranial hemorrhage. The development of chronic subdural fluid collections or hydrocephalus may require CSF diversion. The authors report a previously unrecognized complication of CSF diversion in a patient with OI, that is, a delayed severe cranial deformity, presumably due to over-shunting. In addition to the cosmetic concern, the deformity caused severe headaches and tenderness. The patient underwent craniectomy and titanium mesh cranioplasty, which resulted in the complete resolution of symptoms. This report raises the possibility that over-shunting in patients with OI could predispose to the formation of cranial deformity requiring surgical intervention.

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Endoscopy in neurosurgery

Paolo Cappabianca, John A. Jane Jr., and Mark Souweidane

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A lesson in history: the evolution of endoscopic third ventriculostomy

Paul J. Schmitt and John A. Jane Jr.

The history of endoscopic third ventriculostomy (ETV) demonstrates the importance of studying neurosurgery's history. A story that began with numerous technological advancements started to fizzle as neurosurgeons were stymied by problems encountered during the infancy of the technology they were still developing. The new technique, although sound in theory, failed to deliver a realistic solution for managing hydrocephalus; it lost the battle to the valved shunt. Over the last 15–20 years, a clearer understanding of pathophysiological mechanisms underlying various forms of hydrocephalus, along with effective implementation of evidence-based practice, has allowed for optimization of patient selection and a remarkable improvement in ETV success rates. Neurosurgeons would be wise to take the lessons learned in modernizing the ETV procedure and reassure themselves that these lessons do not apply to other methods that are tempting to dismiss as antiquated or archaic.

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Resection of pituitary macroadenomas via the pseudocapsule along the posterior tumor margin: a cohort study and technical note

Davis G. Taylor, John A. Jane Jr., and Edward H. Oldfield

OBJECTIVE

Extracapsular resection of pituitary microadenomas improves remission rates, but the application of pseudocapsular techniques for macroadenomas has not been well described. In larger tumors, the extremely thin, compressed normal gland or its complete absence along the tumor’s anterior surface limits the application of the traditional pseudocapsular technique that can be used for microadenomas. However, in the authors’ experience, the interface between the pseudocapsule at the posterior margin of the adenoma and the compressed normal gland behind it is universally present, providing a surgical dissection plane. In mid-2010, the authors began using a new surgical technique to identify and use this interface for the resection of larger macroadenomas, a technique that can be used with the microscope or the endoscope.

METHODS

The authors performed a cohort study using prospectively collected preoperative imaging reports and operative details and retrospectively reviewed postoperative images and clinical follow-up of patients with a pituitary macroadenoma 20–40 mm in maximum diameter undergoing microscopic transsphenoidal resection. Since dissection of the tumor capsule only pertains to encapsulated tumor within the sella and not to tumor invading the cavernous sinus, assessment of tumor removal of noninvasive tumors emphasized the entire tumor, while that of invasive tumors emphasized the intrasellar component only. The incidence of residual tumor on postoperative imaging, new-onset endocrinopathy, and recovery of preoperative pituitary deficits was compared between patients who underwent surgery before (Group A) and after (Group B) implementation of the new technique.

RESULTS

There were 34 consecutive patients in Group A and 74 consecutive patients in Group B. Tumors in 18 (53%) Group A and 40 (54%) Group B patients had no evidence of cavernous sinus invasion on MRI. Use of the posterior pseudocapsule technique reduced the incidence of intrasellar residual tumor on postoperative MRI for tumors without cavernous sinus invasion (39% [Group A] vs 10%, p < 0.05) and in all tumors regardless of invasion (50% vs 18%, p < 0.005). The incidence of new endocrinopathy was less likely (25% vs 12%, p = 0.098) and the recovery of prior deficits more likely (13% vs 27%, p = 0.199) among patients treated using the pseudocapsule approach, although the differences are not statistically significant.

CONCLUSIONS

Use of the posterior pseudocapsule dissection plane can enhance the resection of pituitary macroadenomas.

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Acquired lumbar stenosis: topic review and a case series

John A. Jane Jr., Charles G. diPierro, Gregory A. Helm, Christopher I. Shaffrey, and John A. Jane Sr.

Stenosis of the central and lateral lumbar vertebral canal can be congenital or acquired; the latter is most often caused by a degenerative process. The associated neurogenic claudication and/or radiculopathic symptom complexes are thought to result from compression of the cauda equina and lumbosacral nerve roots by hypertrophy of or encroachment by any combination of the following: canal walls, ligamenta flava, intervertebral discs, posterior longitudinal ligament, or epidural fat.

The authors' technique for the treatment of lumbar stenosis involves extensive unilateral decompression with undercutting of the spinous process and obviates the need for instrumentation by using a contralateral autologous bone fusion. The results in a series of 29 patients in whom the procedure was performed suggest that this decompression method safely and successfully treats not only the radicular symptoms caused by lateral stenosis but also the neurogenic claudication symptoms associated with central stenosis. In addition, the procedure can preserve spinal stability without instrumentation by using contralateral autologous bone fusion along the laminae and spinous processes.