Posterior calvarial vault expansion using distraction osteogenesis

Objectives  Management of raised intracranial pressure in syndromic multi-suture craniosynostosis by cranial vault expansion can be achieved by a number of techniques. We present our initial experience in treating this group of patients with posterior calvarial distraction. Materials and methods  Six patients underwent distraction osteogenesis of their posterior calvarial vault. Results  The mean period of distraction was 28 days. The mean consolidation period was 49 days. The mean distance of advancement was 24 mm. Five out of six patients completed their period of distraction and three of these cases also completed their period of consolidation. Significant calvarial expansion and improvement of head shape was achieved in all cases. Conclusions  Posterior calvarial distraction is a safe and more efficient method of calvarial expansion than conventional techniques. These are early promising results, and future modification of the distraction devices will be needed if the effective consolidation time is to be increased.     

Modified rotatory instruments for transphenoidal surgery: technical note

A series of modified gyratory bayonets instruments is described. They have the advantage to allow any adjustable position within a 360 degree rotation angle, during the various surgical steps of transphenoidal surgery, thus keeping the surgeon's hand always at the same position.     

Craniotomy using image-guided oscillating saw: technical note

OBJECTIVE: To describe a new craniotomic technique that eliminates burr holes and minimizes bone loss along the craniotomic line.PATIENTS AND METHODS: Fifty burr hole free craniotomies were performed in varied locations using an image-guided micro-oscillating saw. Care was taken to avoid cutting the inner cortical layer. Upon completing the micro-oscillating saw cut the inner table could then be gently fractured along the craniotomic line with a thin bladed osteotome. Simple silk sutures were used to resecure the bone flap.RESULTS: The craniotomic time required for this procedure ranged from 7 to 24 minutes (mean: 13 minutes). We observed no dural lacerations or signs of brain damage in any of these procedures. The use of image guidance allows a continuous measure of bone thickness along the craniotomic line. In all of the cases we report the cosmetic result was excellent.CONCLUSION: This alternative technique of craniotomy can be used in selected cases to achieve excellent cosmetic results which avoid the time and cost of complex reconstruction techniques.     

Fine needle aspiration biopsy for skull tumors: technical note and two demonstrative case reports.

Fine needle aspiration biopsy was performed in two case of infiltrating skull lesions. The role played by this relatively simple procedure in avoiding a major operation is discussed.     

Electroencephalographic changes using virtual reality program: technical note

The aim of the study was to describe the technique of an electroencephalographic (EEG) assessment using the Emotiv EPOC® during the performance of a virtual reality motor task and compare theta, alpha, beta and gamma power frequencies between left and right hemispheres. This is technical note in which 9 healthy young subjects were submitted to an evaluation with Emotiv EPOC® during the Nintendo® Wii ‘Basic Step’ virtual game using the Wii Balance Board (WBB) on a support 13 centimeters high. The Wilcoxon statistical test was applied and pairing between the cerebral hemispheres was performed. Participants had a mean age of 22.55 ± 2.78 years, 77.8% were right-handed, and 22.8% had no experience with the selected virtual game. According to dominancy (right handed n = 7; and left handed n = 2), it was observed that the right-handed individuals showed significantly greater difference in the right hemisphere in the EEG in front region (gamma power in channels AF4, p = 0.028 and F4, p = 0.043) and parietal region (theta and beta power in P8 channel, p = 0.043), while alpha power showed a greater activity in the left hemisphere (P7 channel, p = 0.043). Considering the inter-hemispheric analysis, it was observed that the right hemisphere presented a higher activation potential in the frontal lobe for gamma waves (p = 0.038 for AF3-AF4 channels), and in the temporal lobe for beta and alpha waves (p = 0.021). This study showed that the virtual environment can provide distinct cortical activation patterns considering an inter-hemispheric analysis, highlighting greater activation potential in the right hemisphere.     

Decompressive craniectomy: technical note

Quinn TM, Taylor JJ, Magarik JA, Vought E, Kindy MS, Ellegala DB. Decompressive craniectomy: technical note. Acta Neurol Scand: 2011: 123: 239–244.© 2010 John Wiley & Sons A/S. Decompressive craniectomy is a neurosurgical technique in which a portion of the skull is removed to reduce intracranial pressure. The rationale for this procedure is based on the Monro‐Kellie Doctrine; expanding the physical space confining edematous brain tissue after traumatic brain injury will reduce intracranial pressure. There is significant debate over the efficacy of decompressive craniectomy despite its sound rationale and historical significance. Considerable variation in the employment of decompressive craniectomy, particularly for secondary brain injury, explains the inconsistent results and mixed opinions of this potentially valuable technique. One way to address these concerns is to establish a consistent methodology for performing decompressive craniectomies. The purpose of this paper is to begin accomplishing this goal and to emphasize the critical points of the hemicraniectomy and bicoronal (Kjellberg type) craniectomy.     

Laminotomy: a technical note

In order to restore spinal integrity following posterior exposures of the spinal canal in children, we describe modifications of Raimondi's laminotomy technique. The use of a pneumatic dissecting tool with footplate to create a hinged osteoplastic laminotomy is described, as are techniques for secruing the laminotomy flap in place at the end of the procedure.     

Transpterygoid expanded endonasal approach in fibrous dysplasia of the skull base: case report and technical note

IntroductionExpanded endonasal approaches (EEA) are becoming a first-level technique for the treatment of skull base pathologies. In some cases, the endoscopic procedures make it possible to dissect structures manipulated with greater difficulty in the classic approaches. We report a full endoscopic transpterygoid EEA for the treatment of a fibrous dysplasia (FD) of the skull base. In addition, we reviewed the English literature available on FD and transpterygoid EEA, establishing an exact surgical technique and showing our intraoperative experience.Case reportA 42-year-old male with right sixth cranial nerve palsy. Cranial MRI and CT showed a central skull base lesion with diagnostic suspicion of FD. Patient underwent a full endoscopic transpterygoid EEA, achieving a wide skull base neurovascular decompression. Neuronavigation and the vidian canal landmark resulted mandatory during intraoperative procedure.DiscussionThe transpterygoid EEA is a safe technique consistently supported in the literature. It may reduce the morbidity associated to the classic transcranial approaches, since it permits maximum resection with minimum craniofacial distortion. The vidian hole and canal are the landmarks used to locate and avoid injury to the lacerum segment of the carotid injury. The surgical treatment indication in FD cases must be established in symptomatic patients.ConclusionTranspterygoid EEA for treatment of FD of the skull base is a safe and effective procedure, thanks to the guide that the vidian canal provides in finding the lacerum segment of the carotid artery.     

Third ventriculostomy through the lamina terminalis for intracranial pressure monitoring after aneurysm surgery: technical note

OBJECTIVE: A new ventriculostomy technique through the lamina terminalis is described. This technique is applied mainly during aneurysm surgery at the acute stage. METHOD: Thirteen patients were operated on intracranial aneurysms and, during the procedure, had the lamina terminalis fenestrated. A ventricular catheter was inserted into the third ventricule, left in place and connected to an external drainage system for further intracranial pressure (ICP) monitoring and/or cerebrospinal fluid (CSF) drainage. RESULTS: ICP readings and CSF drainage were obtained in all cases. No complication was recorded. CONCLUSION: Third ventriculostomy through the lamina terminalis is a simple and easy technique that can be used as an alternative to conventional ventriculostomy. This procedure can be indicated in cases where the ventricule is not reached by means of another technique, and when the decision to perform ventriculostomy is made at the end of aneurysm surgery.     

Corridor surgery: the current paradigm for skull base surgery

Introduction Clival chordomas are rare tumors, especially in the pediatric population. In this report, we present the case of a 3-year-old boy who was found to have a large posterior pharyngeal, clival, and posterior fossa tumor detected on a CT scan after a closed head injury. Discussion Further questioning revealed a history of ataxia and dysphagia. Imaging confirmed severe extrinsic brain stem compression. The tumor was resected in multiple stages utilizing a minimally invasive endoscopic endonasal technique along with open transfacetal, transcondylar approach through the carotid–vertebral window. The child suffered no permanent complications as a result of our treatment and his dysphagia significantly improved. Although a complete resection was not feasible due to vascular encasement by the tumor, extensive decompression was obtained with minimal morbidity. Conclusion We present this case to illustrate a new paradigm of skull base surgical approaches for large clival lesions in pediatric patients that allows aggressive resection with minimal morbidity.     

Primary Ewing's sarcoma of the skull: radical resection and immediate cranioplasty after chemotherapy. A technical note

Purpose

The current standard treatment of Ewing's sarcoma is chemotherapy followed by surgery, making an immediate cranial reconstruction in a one-step surgical procedure possible.

Methods

We describe the technique used to repair a cranial defect after the resection of a primary Ewing's sarcoma of the skull in a one-step surgical procedure.

Results

Bone repair with a custom-made cranioplasty immediately after resection of a primary Ewing's sarcoma of the skull avoids deformities and late complications associated with reconstructive surgery after radiotherapy and not interfere with radiotherapy and neither with follow-up.

Conclusion

A one-step surgical procedure after chemotherapy for primary Ewing's sarcoma of the skull could be safer, less aggressive and more radical; avoiding deformities and late complications.     

Zygomatic arch cracking for cosmetic improvement: technical note

We describe a simple cracking method for removing the zygomatic arch. The drilling line of the zygomatic arch is partially drilled from the back, and the surface is left undrilled. The zygomatic arch is cracked during its removal in order to secure its position for later fixation. Dead bone spaces can be avoided by this method and the zygomatic arch can be replaced in its original position. By adding this procedure to the standard technique, this cracking method is a simple, safe and useful way to achieve better cosmetic results.     

双维控制牙槽骨牵ava张器的研制及动物实验研究

背景：牵张成骨增高牙槽嵴在基础研究及临床已有很多成功报道,双维控制垂直牙槽骨牵张器可有效防止单向直线牵张器行牙槽骨牵张发生轴向移位。目的：研制双维控制的牙槽骨牵张器,并通过动物实验观察其成骨效应。方法：选择杂种犬4只,拔除一侧下颌前磨牙形成萎缩牙槽骨模型。1个月后行骨切开放置双维牵张器,7 d后垂直牵张 (1 mm/d,共5 d)。完成垂直牵张后,利用双维牵张器颊向控制功能将移动骨块颊向牵出(大约2.4 mm),固定2个月后行大体观察及组织学检查。结果与结论：4只犬中2只黏膜伤口愈合良好,2只黏膜出现裂开,行二次缝合后愈合,牵张器固位良好,未出现松动、脱落。牵张骨块向垂直向及颊向的位移量满足实验目的要求,牙槽骨垂直向高度平均增加(5.0±0.2) mm,颊向宽度平均增加(2.4±0.3) mm。大体观察及组织学检查均证实牵张成骨的骨块新骨形成良好。说明双维控制垂直牙槽骨牵张器能较好的控制移动骨块垂直或颊向的移动方向,并且新骨形成良好。     

Transradial approach for selective cerebral angiography: technical note

Selective cerebral angiography is currently being performed using transfemoral and transbrachial approaches. However, these techniques require patients to tolerate a prolonged focal compression and sometimes cause serious complications such as pulmonary embolism. The authors describe a technique of transradial approach as a safer selective cerebral angiography. Between July 1997 and November 1998, 70 patients underwent selective cerebral angiography with a transradial approach using a 4-F catheter. The collateral blood supply to the hand from the ulnar artery was confirmed using Allen's test prior to the procedure. To prevent the mechanical spasm of the radial artery, an arterial introducer 20 cm long was used. The radial artery was successfully punctured and cannulated in all patients. Selective catheterization of the intended vessels was obtained in over 98% of the carotid angiography and over 95% of the vertebral angiography. No major vascular complications such as cerebral infarction, upper limb ischemia, significant local hematoma or pseudoaneurysm were experienced. The transradial approach is a less invasive and safer technique for selective cerebral angiography, and could be an alternative to transfemoral and transbrachial approaches.     

聚醚醚酮在颅骨缺损个体化重建手术中的应用

目的探讨新型颅骨修补材料——聚醚醚酮（PEEK）进行个体化颅骨重建手术的方法及效果。方法回顾性分析6例颅骨缺损需行重建手术病人的资料。先行头颅CT薄层扫描．数据采集后将其转化生成颅骨缺损区PEEK植入物模型图,经医生确认满意后交付生产。按常规方法显露颅骨缺损区,将PEEK植人物直接放置于缺损区表面,周边用钛连接片和钛钉固定。结果6例颅骨缺损病人均采用PEEK材料进行个体化颅骨重建手术,效果和外观均极为满意,未出现任何不良反应。结论PEEK是一种半晶体一热可塑材料,具有优异的抗高温性、耐化学性和抗疲劳性,具有极好的强度、硬度和韧性,即使被外力碰撞也不会出现局部凹陷或变形。PEEK材料进行个体化颅骨重建手术可达到极为满意的美学效果。缺点是制作过程较长,且价格昂贵．