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Samantha E. Hoffman, Rafael A. Vega, and Martina Stippler

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic disrupted the landscape of traditional neurosurgical subinternships, ramifications of which persist to this day. The outright cancellation of in-person subinternships in 2020 presented not only a challenge to both applicants and programs, but also an opportunity to establish an effective and efficient platform for virtual neurosurgical training. To address this need, the authors designed and trialed a novel virtual neurosurgical subinternship (Virtual Sub-I).

METHODS

The weeklong, case-based Virtual Sub-I program combined flipped-classroom and active learning approaches. Students worked in small groups to discuss neurosurgical cases. Faculty and residents offered personalized mentorship sessions to participants. Surveys were used to assess students’ experience with the authors’ subinternship program, consistent with level 1 of the Kirkpatrick model.

RESULTS

A total of 132 students applied from both international and American medical schools. The final cohort comprised 27 students, of whom 8 (30%) were female and 19 (70%) were male. Students characterized the subinternship as “interactive,” “educational,” and “engaging.” One hundred percent of survey respondents were “very likely” to recommend the Virtual Sub-I to their peers. Faculty involved in the Virtual Sub-I stated that the program allowed them to determine the fit of participating medical students for their neurosurgery residency program, and that information gathered from the Virtual Sub-I had the potential to influence their ranking decisions.

CONCLUSIONS

The Virtual Sub-I recapitulates the educational and interpersonal benefits of the traditional subinternship experience and can serve as a prototype for future virtual surgical education endeavors. Furthermore, the Virtual Sub-I presents a more equitable platform for introducing medical students across the undergraduate medical education spectrum to neurosurgical education and mentorship.

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Jamie Toms, David L. Boyer, Craig R. Kelman, and Rafael A. Vega

Traumatic spondylolisthesis is a known occurrence in trauma, but complete cord transection is relatively rare. Moreover, complete cord transection at a site distant from the traumatic spondylolisthesis without spondyloptosis is exceedingly rare. In this report, authors describe the first case of thoracic cord avulsion following a traumatic grade II lumbar spondylolisthesis. The unusual presentation of this case highlights the importance of further evaluating patients with neurological symptoms out of proportion with the injuries seen on initial imaging. Magnetic resonance imaging performed after initial imaging studies demonstrated T11 cord transection with the distal cord herniating into the lumbar paraspinal soft tissues, thus allowing for preoperative planning to prepare for a more significant intervention including complex dural repair and lumbar drain placement, in addition to instrumented fusion to stabilize the traumatic spondylolisthesis.

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Garrett N. Cyprus, Jefferson W. Overlin, Rafael A. Vega, Ann M. Ritter, and René Olivares-Navarrete

OBJECTIVE

Cranial suture patterning and development are highly regulated processes that are not entirely understood. While studies have investigated the differential gene expression for different sutures, little is known about gene expression changes during suture fusion. The aim of this study was to examine gene expression in patent, fusing, and fused regions along sagittal suture specimens in nonsyndromic craniosynostosis patients.

METHODS

Sagittal sutures were collected from 7 patients (average age 4.5 months) who underwent minimally invasive craniotomies at the Children’s Hospital of Richmond at VCU under IRB approval. The sutures were analyzed using micro-CT to evaluate patency. The areas were classified as open, fusing, or fused and were harvested, and mRNA was isolated. Gene expression for bone-related proteins, osteogenic and angiogenic factors, transforming growth factor–β (TGF-β) superfamily, and Wnt signaling was analyzed using quantitative polymerase chain reaction and compared with normal sutures collected from fetal demise tissue (control).

RESULTS

Micro-CT demonstrated that there are variable areas of closure along the length of the sagittal suture. When comparing control samples to surgical samples, there was a significant difference in genes for Wnt signaling, TGF-β, angiogenic and osteogenic factors, bone remodeling, and nuclear rigidity in mRNA isolated from the fusing and fused areas of the sagittal suture compared with patent areas (p < 0.05).

CONCLUSIONS

In nonsyndromic sagittal craniosynostosis, the affected suture has variable areas of being open, fusing, and fused. These specific areas have different mRNA expression. The results suggest that BMP-2, FGFR3, and several other signaling pathways play a significant role in the regulation of suture fusion as well as in the maintenance of patency in the normal suture.

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Charles F. Opalak, Rafael A. Vega, Jodi L. Koste, R. Scott Graham, and Alex B. Valadka

The Department of Neurosurgery at the Medical College of Virginia/Virginia Commonwealth University (VCU) celebrates its 100th anniversary in 2019. It was founded by C. C. Coleman, who directed the US Army School of Brain Surgery during World War I and was one of the original members of the Society of Neurological Surgeons. Coleman began a residency program that was among the first four such programs in the United States and that produced such prominent graduates as Frank Mayfield, Gayle Crutchfield, and John Meredith. Neurosurgery at VCU later became a division under the medical school’s surgery department. Division chairs included William Collins and Donald Becker. It was during the Becker years that VCU became a leading National Institutes of Health–funded neurotrauma research center. Harold Young oversaw the transition from division to department and expanded the practice base of the program. In 2015, Alex Valadka assumed leadership and established international collaborations for research and education. In its first 100 years, VCU Neurosurgery has distinguished itself as an innovator in clinical research and an incubator of compassionate and service-oriented physicians.

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Charles F. Opalak, Rafael A. Vega, Jodi L. Koste, R. Scott Graham, and Alex B. Valadka

The Department of Neurosurgery at the Medical College of Virginia/Virginia Commonwealth University (VCU) celebrates its 100th anniversary in 2019. It was founded by C. C. Coleman, who directed the US Army School of Brain Surgery during World War I and was one of the original members of the Society of Neurological Surgeons. Coleman began a residency program that was among the first four such programs in the United States and that produced such prominent graduates as Frank Mayfield, Gayle Crutchfield, and John Meredith. Neurosurgery at VCU later became a division under the medical school’s surgery department. Division chairs included William Collins and Donald Becker. It was during the Becker years that VCU became a leading National Institutes of Health–funded neurotrauma research center. Harold Young oversaw the transition from division to department and expanded the practice base of the program. In 2015, Alex Valadka assumed leadership and established international collaborations for research and education. In its first 100 years, VCU Neurosurgery has distinguished itself as an innovator in clinical research and an incubator of compassionate and service-oriented physicians.

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R. Scott Graham, Brian J. Samsell, Allison Proffer, Mark A. Moore, Rafael A. Vega, Joel M. Stary, and Bruce Mathern

OBJECT

Bone allografts used for interbody spinal fusion are often preserved through either freeze drying or lowtemperature freezing, each having disadvantages related to graft preparation time and material properties. In response, a glycerol preservation treatment has been developed to maintain the biomechanical properties of allografts at ambient temperatures, requiring no thawing or rehydration and minimal rinsing prior to implantation. The authors conducted a prospective randomized study to compare the clinical results of glycerol-preserved Cloward dowels and those of freezedried Cloward dowels in anterior cervical discectomy and fusion. The primary outcome measures were evidence of fusion and graft subsidence, and the secondary outcome measures included adverse events, pain, and neck disability scores.

METHODS

Of 106 patients, 53 (113 levels of surgery) were randomly assigned to the glycerol-preserved graft group and 53 (114 levels of surgery) to the freeze-dried graft group. Subsidence was assessed at 3 and 6 months after implantation. Evidence of fusion was evaluated radiographically at 6 months postimplantation. Subsidence was quantitatively assessed based on physical measurements obtained from radiographs by using calibrated comparators, whereas fusion was also evaluated visually. Surgeons were blinded to treatment type during visual and physical assessments of the patients and the radiographs.

RESULTS

No one in either group had evidence of complete nonunion according to radiographic evaluation at the 6-month follow-up. Average subsidence for all graft-treated levels was 2.11 mm for the glycerol-preserved group and 2.73 mm for the freeze-dried group at the 3-month follow-up and 2.13 and 2.83 mm at the 6-month follow-up, respectively. The 2 treatment groups were statistically equivalent (p = 0.2127 and 0.1705 for the 3- and 6-month follow-up, respectively). No differences were noted between the graft types in terms of adverse event incidence or severity.

CONCLUSIONS

Glycerol-preserved bone allografts exhibit fusion results and subsidence values similar to those of their freeze-dried counterparts, potentially more favorable biomechanical properties, and significantly shorter preparation times.

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Rafael A. Vega, Charles Opalak, Raymond J. Harshbarger, Jeffrey A. Fearon, Ann M. Ritter, John J. Collins, and Jennifer L. Rhodes

OBJECTIVE

This study examines a series of patients with hypophosphatemic rickets and craniosynostosis to characterize the clinical course and associated craniofacial anomalies.

METHODS

A 20-year retrospective review identified patients with hypophosphatemic rickets and secondary craniosynostosis at 3 major craniofacial centers. Parameters examined included sex, age at diagnosis of head shape anomaly, affected sutures, etiology of rickets, presenting symptoms, number and type of surgical interventions, and associated diagnoses. A review of the literature was performed to optimize treatment recommendations.

RESULTS

Ten patients were identified (8 males, 2 females). Age at presentation ranged from 1 to 9 years. The most commonly affected suture was the sagittal (6/10 patients). Etiologies included antacid-induced rickets, autosomal dominant hypophosphatemic rickets, and X-linked hypophosphatemic (XLH) rickets. Nine patients had undergone at least 1 cranial vault remodeling (CVR) surgery. Three patients underwent subsequent surgeries in later years. Four patients underwent formal intracranial pressure (ICP) monitoring, 3 of which revealed elevated ICP. Three patients were diagnosed with a Chiari Type I malformation.

CONCLUSIONS

Secondary craniosynostosis develops postnatally due to metabolic or mechanical factors. The most common metabolic cause is hypophosphatemic rickets, which has a variety of etiologies. Head shape changes occur later and with a more heterogeneous presentation compared with that of primary craniosynostosis. CVR may be required to prevent or relieve elevated ICP and abnormalities of the cranial vault. Children with hypophosphatemic rickets who develop head shape abnormalities should be promptly referred to a craniofacial specialist.

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Rafael A. Vega, Camila Lyon, Jeannette F. Kierce, Gary W. Tye, Ann M. Ritter, and Jennifer L. Rhodes

Object

Children with craniosynostosis may require cranial vault remodeling to prevent or relieve elevated intracranial pressure and to correct the underlying craniofacial abnormalities. The procedure is typically associated with significant blood loss and high transfusion rates. The risks associated with transfusions are well documented and include transmission of infectious agents, bacterial contamination, acute hemolytic reactions, transfusion-related lung injury, and transfusion-related immune modulation. This study presents the Children's Hospital of Richmond (CHoR) protocol, which was developed to reduce the rate of blood transfusion in infants undergoing primary craniosynostosis repair.

Methods

A retrospective chart review of pediatric patients treated between January 2003 and Febuary 2012 was performed. The CHoR protocol was instituted in November 2008, with the following 3 components; 1) the use of preoperative erythropoietin and iron therapy, 2) the use of an intraoperative blood recycling device, and 3) acceptance of a lower level of hemoglobin as a trigger for transfusion (< 7 g/dl). Patients who underwent surgery prior to the protocol implementation served as controls.

Results

A total of 60 children were included in the study, 32 of whom were treated with the CHoR protocol. The control (C) and protocol (P) groups were comparable with respect to patient age (7 vs 8.4 months, p = 0.145). Recombinant erythropoietin effectively raised the mean preoperative hemoglobin level in the P group (12 vs 9.7 g/dl, p < 0.001). Although adoption of more aggressive surgical vault remodeling in 2008 resulted in a higher estimated blood loss (212 vs 114.5 ml, p = 0.004) and length of surgery (4 vs 2.8 hours, p < 0.001), transfusion was performed in significantly fewer cases in the P group (56% vs 96%, p < 0.001). The mean length of stay in the hospital was shorter for the P group (2.6 vs 3.4 days, p < 0.001).

Conclusions

A protocol that includes preoperative administration of recombinant erythropoietin, intraoperative autologous blood recycling, and accepting a lower transfusion trigger significantly decreased transfusion utilization (p < 0.001). A decreased length of stay (p < 0.001) was seen, although the authors did not investigate whether composite transfusion complication reductions led to better outcomes.

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Rafael A. Vega, Julie L. Chan, Tony I. Anene-Maidoh, Margaret M. Grimes, and John F. Reavey-Cantwell

Children experiencing severe neurological deficit due to acute ischemic stroke may benefit from endovascular intervention. The authors describe the use of mechanical thrombectomy in the treatment of embolic occlusion secondary to an atrial myxoma in a pediatric patient. This case involved an 11-year-old boy with a history notable for Raynaud syndrome and a distal extremity rash who presented to the emergency department with dense hemiparesis secondary to thromboembolic occlusion of the M1 segment of the middle cerebral artery. Following mechanical thrombectomy, the patient's pediatric National Institutes of Health Stroke Scale score improved from a 16 to a 7. In the setting of acute pediatric stroke due to atrial myxoma emboli, mechanical thrombectomy may be a first-line therapy.