John A. Persing

Surgical approaches for the correction of metopic synostosis.

Premature closure of the metopic suture results in a deformity ranging from a minor variation to a severe cosmetic deformity. The three principal abnormalities comprising metopic synostosis are trigonocephaly secondary to the restriction of growth of both frontal bones, deficient lateral supraorbital rims, and hypotelorism. Seventeen of 18 patients evaluated for metopic synostosis had surgical correction of their anomalies. For a minor degree of prominence at the metopic suture, a bicoronal flap followed by shaping at the suture with a shaping burr was sufficient and yielded favorable cosmetic results. A more extensive procedure for cosmetic resolution of trigonocephaly and hypotelorism was required for those patients with more pronounced deformities. In patients with moderate to severe metopic synostosis, the following procedures were important in achieving excellent cosmetic results: a bicoronal subgaleal flap down to the supraorbital rims with preservation of continuity of pericranium with an intact periorbita; bifrontal craniotomy with complete removal of the metopic suture; dural plication in midline to achieve an immediate aesthetically pleasing contour; removal or remodeling of the supraorbital rims and nasion with replacement of the remodeled frontal bone anteriorly in order to rebuild the orbital rim and release the supraorbital bar from the anterior cranial base; and securement of the bifrontal bones anteriorly and laterally, but not posteriorly, to allow further anterior and lateral displacement of the supralateral orbital margin.

Use of the Philadelphia Collar as an Alternative to the Halo Vest in Patients with C-2, C-3 Fractures

We analyzed retrospectively 27 individuals with C-2, C-3 fractures, 8 of whom were treated with a Philadelphia collar rather than the more commonly used halo vest. Successful fusion without neurological deficit occurred in all cases whether treatment was by Philadelphia collar (n = 8), halo apparatus (n = 16), or prolonged bed rest (n = 3). There was an increase in subluxation in 3 patients in both the Philadelphia collar group and the halo apparatus group. However, 1 of the 3 in the collar group was uncooperative and discarded his collar during treatment. If he is excluded, the subluxation rate in the Philadelphia collar group is 27%; the rate in the halo group is 19%. The Philadelphia collar seems to be an acceptable means of stabilizing the neck in C-2, C-3 fractures, but one must consider the degree of cervical movement in the collar (as detected by dynamic x-ray films), patient reliability, and patient age. The presence of subluxation did not preclude successful fusion in either the Philadelphia collar or the halo vest groups.

Modified Prone Position for Cranial Remodeling Procedures in Children with Craniofacial Dysmorphism: A Technical Note

A new head position for use during operation on young children with cranial deformities is described. The position allows exposure of the entire calvarium from the supraorbital ridges to the posterior rim of the foramen magnum. It is a modification of the conventional prone position involving hyperextension of the neck. The authors have safely used this position to perform one-stage radical cranial remodeling procedures that previously required two stages. The advantages of this position and the methods for achieving it are discussed.

Multiple sclerosis and brain tumor: A diagnostic challenge

Multiple sclerosis may present as a lesion indistinguishable clinically and radiologically from brain tumor. A case of multiple sclerosis is reported with clinical and radiologic features of a brain tumor. A brain biopsy was later undertaken that provided pathological confirmation of the diagnosis of this demyelinating disease. This case report in conjunction with those in the literature indicate that conservative treatment with steroid therapy and serial computed tomography should establish the diagnosis of multiple sclerosis without the need for surgical intervention.

One-stage reduction cranioplasty for macrocephaly associated with advanced hydrocephalus.

A reduction cranioplasty in one stage was performed on a child with massive enlargement of the head secondary to advanced hydrocephalus. The authors discuss the techniques and advantages of a modified head position and a cross bar craniotomy for reduction cranioplasty.

Blepharospasm-oromandibular dystonia associated with a left cerebellopontine angle meningioma

Blepharospasm-oromandibular dystonia is characterized by the presence of spasms of the orbicularis oculi (blepharospasm) and of the lower facial or oromandibular muscles. A patient with this syndrome is presented in which a left cerebellopontine angle meningioma appeared to act as a triggering mechanism for the development of this disorder. On the basis of this report, we recommend that physicians search for this tumor in patients with this disorder.

Vascular lesions involving the cranial base: combined surgical and interventional radiologic approach.

Advantages and possible complications of combined surgical and interventional radiologic approach to vascular lesions involving the cranial base are presented in three case examples. The methodology and technology of endovascular embolization and occlusion techniques, selection of embolic materials, functional testing to prevent neurologic injury and surgical implications of these treatment modalities are discussed. Emphasis is placed on individualization of each combined approach relative to the aforementioned factors.