Pravin K. Patel

Neurodevelopment of children with single suture craniosynostosis: a review

IntroductionRates of neurocognitive risk range from 35–50% of school-aged children with isolated single suture craniosynostosis (SSC). It has been hypothesized that early surgical intervention to release suture fusion reduces risk for increased intracranial pressure (ICP) and the corresponding risk to neurodevelopment. However, studies assessing children with SSC have been inconsistent in finding an association between neurocognitive development, age of surgery, and ICP.ReviewSSC produces notable distortion of the cranial vault and underlying brain mass. Although a linear relationship between skull distortion, ICP, and neurocognitive deficits has generally been assumed, recent studies have postulated an interactive process between the skull and developing brain that results in neuroanatomical changes that are not limited to areas directly beneath the fused suture. The specific neuropsychological deficits identified in children with SSC including problems with attention and planning, processing speed, visual spatial skills, language, reading, and spelling may be related to the anatomic differences that persist after correction of suture fusion.ConclusionsAvailable literature on neurocognitive development of children with SSC is suggestive of mild but persistent neuropsychological deficits, which become more significant as cognitive demands increase at school age. Anatomical studies of children without SSC are beginning to identify particular groups of brain structures that if disrupted or malformed, may be associated with specific cognitive deficits. Controlled research investigating the relationship between persistent anatomical changes and neurocognitive functioning of school-aged children with SSC is needed.

The value of Jamshidi core needle bone biopsy in predicting postoperative Osteomyelitis in grade IV pressure ulcer patients

&NA; We present a retrospective review of 108 patients with spinal cord injury who underwent reconstruction of grade IV pressure ulcers between 1989 and 1994. Complications of reconstruction secondary to undetected osteomyelitis, namely, deep abscess and sinus tract formation, and their effect on hospital course after the flap reconstruction were quantitatively evaluated. Specifically, this study assesses whether the use of Jamshidi core needle bone biopsy allows for the accurate diagnosis, and therefore treatment, of osteomyelitis before pressure ulcer closure. Early diagnosis and treatment of osteomyelitis would presumably reduce the complication rate of reconstruction. The 108 patients in the study all underwent intraoperative Jamshidi core needle bone biopsy, and postoperative complications were evaluated by reviewers blinded to results of the biopsies. Of the 25 (23 percent) postoperative complications noted, 14 (13 percent) were attributed to underlying osteomyelitis. Patients with pressure ulcer complicated by osteomyelitis were hospitalized significantly longer than those with no osteomyelitis. On average, the former group stayed for 57 days and the latter 21 days (p < 0.001). All 14 patients who developed complications because of deep abscess and sinus tract formation had intraoperative Jamshidi core needle bone biopsy abnormality consistent with osteomyelitis (positive Jamshidi core needle bone biopsy results). The Jamshidi core needle bone biopsy compares favorably with other published modalities used to diagnose osteomyelitis, including white blood cell count, erythrocyte sedimentation rate, radiologic study, and bone biopsy culture. We propose an algorithm for the management of spinal cord injury patients with grade IV pressure ulcers. This algorithm incorporates the use of preoperative Jamshidi core needle bone biopsy to allow for the diagnosis and treatment of osteomyelitis before the flap reconstruction and to prevent complications of undiagnosed osteomyelitis after reconstruction.

Management of alveolar clefts

Treatment philosophies in the management of alveolar clefts have changed greatly over the years. Currently. the most widely accepted protocol is for repair using autologous cancellous bone from the iliac crest during the stage of mixed dentition. Preliminary data suggest that the appropriate age for surgical repair during the secondary phase can be decreased without evidence of limitation of facial growth. Further long-term studies are necessary to support this protocol, however. With a multidisciplinary approach between the various medical and dental specialties, it is now commonplace to achieve normal dentofacial aesthetics and function. The continued advances in medical and dental technology have further contributed to the excellent outcomes that are now achieved.

Actinobacillus actinomycetemcomitans: a new cause for granuloma of the parotid gland and buccal space.

A case of chronic granuloma of the buccal space and parotid gland is described which was caused by the unusual organism Actinobacillus actinomycetemcomitans. A review of the literature describing its pathogenesis and other clinical presentations is offered.

The Structural Implications of a Unilateral Facial Skeletal Cleft: A Three-Dimensional Finite Element Model Approach

Objective: For children born with a unilateral facial skeletal cleft, oral motor function is impaired and skeletal development and growth are asymmetrical with regard to the midsagittal plane. This study was designed to verify that a unilateral skeletal cleft and its dimensions (i.e., depth and width) affect the severity of the asymmetric stress and strain distribution within the maxilla. Methods: A three-dimensional finite element model of a normal maxilla was developed from pediatric, subject-specific computerized tomography scan data. A clefting pattern then was introduced to simulate varying degrees of deformity in geometry, with the bone properties and boundary conditions held constant. The asymmetric index was introduced to quantify the asymmetrical stress and strain distribution within the maxilla with regard to the midsagittal plane. Results: The unilateral skeletal cleft led to a nonuniform, asymmetric stress and strain distribution within the maxilla: intensified on the noncleft side and weakened on the cleft side. As the depth of the unilateral cleft increased, the stress and strain distribution became increasingly asymmetric as measured by the asymmetric index. In contrast, the width of the cleft had minimal effect on the asymmetrical stress and strain distribution. Interpretation/conclusion: These results implied that a child born with a unilateral cleft would be expected to have an asymmetric skeletal development between the noncleft and the cleft sides as a consequence of an asymmetric functional loading pattern.

Osteoblast-directed osteoclast metabolism from patients with premature coronal synostosis

&NA; Osteoclasts were harvested from explants of five patients with premature unilateral coronal synostosis and plated on devitalized bovine bone wafers. The planar surface areas of resorption lacunae were quantitated by means of light microscopy and a digital imaging system. Osteoclasts isolated from involved regions of premature synostosis exhibited enhanced resorption when compared with osteoclasts isolated from noninvolved cranial bone in the same patients (p < 0.05). When the involved osteoclasts were exposed to conditioned media from noninvolved osteoblasts, the in vitro metabolism was reduced consistent with noninvolved osteoclasts. The results suggest there may be a primary cellular defect and that there appears to be a complex coupling between osteoblast and osteoclast function that may lead to sutural synostosis.

Statistical shape analysis of metopic craniosynostosis: a preliminary study.

This preliminary study was conducted to explore different analytical shape methods for use in evaluating children born with cranial vault deformities. Twenty skull outlines from patients with metopic craniosynostosis were ascribed landmarks. Scale, location, and rotational factors were removed using Procrustes analysis. A single index of severity from 0-5, with 5 being the most severe, was developed using Procrustes distance in shape space. Skull 20 had the highest score in our data set. Principal component analysis was performed to determine areas of large shape variability. Principal component 1 and 2 accounted for 86 % of the shape variability which was attributed to early closure of the metopic suture. Procrustes analysis used in combination with Procrustes distance and principal component analysis are powerful tools for the evaluation of cranial vault deformities and can be used to objectively categorize the severity of the skull deformity and outcome from surgical reconstructive surgery

Supraorbital fractures in children

Children are at an increased risk of supraorbital roof fractures because of the relative prominence of the cranium compared with the face and the lack of frontal sinus pneumatization. With growth and development of the face and frontal sinus, orbital fracture patterns in older children approach those seen in adults. Computerized tomography (CT) is indispensable in defining the anatomic deformity and evaluation of associated intracranial injury. Management of supraorbital and roof fractures should be individualized based on the degree of anatomic displacement, involvement of intracranial and frontal sinus fractures, and ocular globe position and motility. Displaced fractures require surgical intervention. Nondisplaced fractures must be followed closely for late development of encephalocele, vertical orbital dystopia, pulsatile exophthalmos, and meningitis.