James Tait Goodrich

Single incision endoscope-assisted surgery for sagittal craniosynostosis

The authors have presented a paper on endoscopic assisted strip craniectomies with a Bnovel^ innovation of using a single incision. This paper provoked me to ask where are we going with the strip craniectomies. The request to provide an editorial on this paper arrived on my desk shortly after several meetings around the world in which I heard a number of various technical Bstrip^ modifications being offered for the treatment of craniosynostosis. I have to admit I have again become more confused and totally baffled at what the Bstrippers^ out there are doing in the sense of unification of a theme of surgical treatment. Why do I say this? Well, it has become quite clear that there is absolutely no consensus on what works and what does not in the technical challenges to Bendoscopically assisted^ surgery. As I have surveyed now, nearly a hundred national and international meetings, it has become very clear that there is no one way nor is there even close to one or two or three ways ormore to take a child’s head apart using a tool that is conceptually more important to the surgery than the thinking that goes into the operation. Some background on the strip craniectomy—introduced in the 1880s, discarded in late 1890s due to wrong treatments and highmortality—we have to thank Abraham Jacobi, MD, a pediatrician in NewYork for shutting down the surgical workshops of some evil surgeons for doing inappropriate craniectomies. Strippers came back again in the 1940s with Donald Matson and Frank Ingraham introducing again the strips but this time now adding silicone wrappers and metal clips to the craniectomy edges. This last technique is what I learned during my residency. It was a procedure that I quickly discarded, as the results were dismal and very unpredictable. I rapidly adopted the cranial vault remodeling techniques designed by Danny Marchac, Paul Tessier, Fernando OrtizMonestario, and others. I was also taught in the 1970s that a fused suture was a secondary phenomenon and not the primary problem. Thereby, just focusing on the suture was not only wrong but also leads two generations of surgeons to offer an ineffective surgical option. In the 1990s, neurosurgeons became focused on a Btool^ as the golden guidance that was to solve the earlier issues and bad outcomes. But a certain group was smart enough to realize that the strips did not work unless assisted with a 2000-year old technique of using an intentional cranial molding device affectionately known as an Borthotic molding helmet.^ What has left me so confused is I go to a meeting and discover that some people are not using helmets under the assumption that they are not necessary and yet continue to claim good results. Even more confusing is a group has now advocated that surgery is not even needed—just put on a helmet and the child will get better, no need to strip. A more important issue is the timing of helmet in how long it needs to stay on. The mavens in this business now comment that they have not been happy with some of their outcomes and hence are now leaving the helmets on for up to 18months. That leaves me to ask the obvious question. What was done with those children with the poorer outcomes? So at this point, if I was a young trainee, I would be quite confused as to what to do: use a helmet, for how long, or not use one at all. I have just returned from a postgraduate education course in Europe sponsored by the ESPN with an attendance of over 100 trainees, some quite senior. One of the sessions dealt with craniosynostosis and with arguments offered by the Bvaulters^ versus the Bstrippers.^ The vaulters were currently using * James Tait Goodrich James.Goodrich@Einstein.yu.edu

Prehistoric Skull Trepanation: Clearly a Worldwide Phenomenon

he surgical technique of making “a hole in the head” has clearly proven to be an ancient one. It seems that T neurosurgeons still remain the second oldest working profession, following only prostitution. What has become even more interesting, as shown in this paper, is how widespread the practice of skull trepanation has been around the world. It appears that most significant cultures dating well back before the Iron Age practiced the technique of trepanning, with what appear to be surprisingly good results, i.e., the patient survived. In this article, Drs. Lv and Wu present an interesting case report that details a case that originates from a Neolithic site in modern-day China dating to a period around 4300 to 2300 BC—clearly very early in the history of this surgical technique. The authors note that very few cases of trepanation from this region of the world have been reported in the English literature, so this report is a valuable addition and hopefully will lead to more detailed reports in the future.

Diffusion tensor imaging and ventricle volume quantification in patients with chronic shunt-treated hydrocephalus: a matched case-control study

OBJECTIVEThe object of this study was to use diffusion tensor imaging (DTI) and tract-based spatial statistics (TBSS) to characterize the long-term effects of hydrocephalus and shunting on white matter integrity and to investigate the relationship of ventricular size and alterations in white matter integrity with headache and quality-of-life outcome measures.METHODSPatients with shunt-treated hydrocephalus and age- and sex-matched healthy controls were recruited into the study and underwent anatomical and DTI imaging on a 3-T MRI scanner. All patients were clinically stable, had undergone CSF shunt placement before 2 years of age, and had a documented history of complaints of headaches. Outcome was scored based on the Headache Disability Inventory and the Hydrocephalus Outcome Questionnaire. Fractional anisotropy (FA) and other DTI-based measures (axial, radial, and mean diffusivity; AD, RD, and MD, respectively) were extracted in the corpus callosum and internal capsule with manual region-of-interest delineation and in other regions with TBSS. Paired t-tests, corrected with a 5% false discovery rate, were used to identify regions with significant differences between patients and controls. Within the patient group, linear regression models were used to investigate the relationship between FA or ventricular volume and outcome, as well as the effect of shunt-related covariates.RESULTSTwenty-one hydrocephalus patients and 21 matched controls completed the study, and their data were used in the final analysis. The authors found significantly lower FA for patients than for controls in 20 of the 48 regions, mostly posterior white matter structures, in periventricular as well as more distal tracts. Of these 20 regions, 17 demonstrated increased RD, while only 5 showed increased MD and 3 showed decreased AD. No areas of increased FA were observed. Higher FA in specific periventricular white matter tracts, tending toward FA in controls, was associated with increased ventricular size, as well as improved clinical outcome.CONCLUSIONSThe study shows that TBSS-based DTI is a sensitive technique for elucidating changes in white matter structures due to hydrocephalus and chronic CSF shunting and provides preliminary evidence that DTI may be a valuable tool for tailoring shunt procedures to monitor ventricular size following shunting and achieve optimal outcome, as well as for guiding the development of alternate therapies for hydrocephalus.

The Cushing-Dandy Conflict—Two Powerful Personalities That Were Best not to Collide!

he long-standing antagonism between Harvey Cushing and Walter Dandy remains still a most interesting subject T of discussion. Going through archival letters, previously unpublished, Patz et al. provided some quite provocative insights into the personalities of these two giants. Cushing’s history and contributions have been well documented by two historians— Michael Bliss and John F. Fulton—along with a smaller contribution by Elizabeth Thomson. I have read all three and learned a great deal about Harvey Cushing and having said that, I was totally unprepared for what appeared in this article. In reviewing these letters between Dandy and his parents one develops a most remarkable view of this neurosurgeon named Walter Dandy. It is totally astonishing to think that a young petulant house office with only 1 to 2 years of training would take a senior neurosurgeon’s patients to the operating room and remove tumors while he was away traveling. As Dandy notes in a letter to his mother “as you see the big men do not always do the best work ”—a bravado comment being made by a clinical assistant with just 1 year of training! In 1910e1912 neurosurgery was in its infancy with very few people around the world practicing this type of surgery. Yet here we find out that a young and impetuous student takes it upon his own devices to select complex cases and take these patients to the operating room and get surprisingly good results. Dandy goes onto note to hismother—“Geewon’t he (Cushing) be sore to think a young sprout is stealing his thunder. I won’t tell him much about themwhen he comes back I am not at all boastful. It is more the attitude of disdain towards him and the reproval of his self

Surgery of the Skull Base by 3 Pioneering 19th-Century Italian Surgeons—A Surgical Subspecialty That Has Been Around for a Long Time

eviewing the history of a subject and in particular reviewing surgical history often provides new enlightenR ment on how advanced in thinking were our surgical forefathers. When looking back at 19th-century surgical techniques, and in particular looking at the first half of the 19th century, it was clearly quite challenging to have been a surgical patient about to undergo a “speedy” and extremely painful surgery. Surgical anesthesia and “painless” surgery only came about in the mid-1840s and then notwidely adopted until the late 1850s.When reviewing the careers of the 3 surgeons, T. Vanzetti, D. Giordano, and F. Durante, only the last 2 had surgical anesthesia, that is, “painless surgery” available, Vanzetti did not. For a surgeon to even begin to think of doing extensive skull base surgery, this individual would need to be able to provide the patient with a “painless state” and this state would need to be maintained throughout the surgery. For the surgeon of the 21st century, these concepts of painless surgery are not even an issue but in the 19th century this was not the case. Themedications used, for example, ether and chloroform, were often hard to control, leading to death during the surgery from overdosing in a number of cases. This perspective is extremely important to keep in mind, simply becausesurgeonswereundertaking somevery complex surgeries and in particular also developing complex surgical approaches to the skull base.

Searching for the seat of the soul and its surgical corridors with a perspective on James L. Poppen, René Descartes, and their contributions.

ené Descartes (1596e1650) was a philosopher and mathematician, along with being a scholar of the R sciences and the mind. It was Descartes who concluded that all was open to doubt with the exception of consciousness and existence, which led him to believe “I think, therefore I am.” The search for the “seat of the soul” has been an ancient endeavor and enchanted many authors and investigators over the previous four millennia. An ever-evolving concept in the history of the religion has been the view that there is within us humans a special place within which the seat of the rational soul resides.