BACKGROUND AND OBJECTIVES:Craniosynostosis can lead to progressive cranial and skull base deformities and can be associated with increased intracranial pressure (ICP), ophthalmological manifestations, behavioral changes, and developmental delay. Most published data on the incidence of elevated ICP include older children undergoing open surgical correction. Endoscopic-assisted release of fused sutures with postoperative helmet therapy is an established method for managing craniosynostosis presenting at an early age; however, the immediate effect of this approach on ICP in a young cohort has not been previously reported. METHODS:Prospective data on 52 children undergoing endoscopic-assisted release of stenosed cranial sutures were included. Individuals were excluded if they underwent open correction or had previous cranial surgery. Individuals underwent a standardized endoscopic approach for each suture type. ICP was measured using an intraparenchymal sensor both before creation of the neosuture and after complete release of the stenosed suture. An ICP reading of >10 mm Hg was considered elevated. RESULTS:The mean age was 5.3 months, range 1 to 32 months, and 94% was younger than 12 months. The mean opening pressure was 12.7 mm Hg, and the mean closing pressure was 2.9 mm Hg. Opening ICP ≥10 mm Hg was present in 58%, ≥15 mm Hg was present in 31%, and ≥20 mm Hg was present in 23%. No patient had an ICP above 10 mm Hg at closing. The mean percentage change in ICP among all craniosynostosis cases was a 64% decrease. Optic disk swelling was identified in 28 children preoperatively and improved in 22 children at follow-up. CONCLUSION:Elevated ICP may occur in infants with craniosynostosis at higher rates than previously reported. Endoscopic-assisted craniectomy has an immediate effect on lowering ICP and improving postoperative ophthalmological findings.

Posterior cranial vault distraction osteogenesis (PCVDO) is a relatively new paradigm in the treatment of syndromic craniosynostosis, having first been introduced in 2009. PCVDO directly addresses the underdeveloped cranial vault and appears to allow for a larger increase in intracranial volume when compared to traditional techniques. Although reported as safe in the literature, critical appraisal is still required as PCVDO is a relatively uncommon procedure that may require greater numbers to detect true complication rates. The overall reported incidence of serious complications in PCVDO to date is low. This presentation highlights a rare case of sagittal sinus obstruction following posterior cranial vault distraction and raises questions as to the safest technical considerations when planning the operation.

INTRODUCTION: The GOLD Laser utilizes an active medium comprised of InGaAsP (Indium-Gallium III-Arsenide Phosphide) and the chemical element Au(gold). It is a solid-state laser that operates in the 980nm-1000nm infrared light spectrum using Wavelength Conversion Technology (TM). METHODS: A total of 25 patients presenting with intracranial cysts and elevated intracranial pressure were treated with a GOLD laser using endoscopic techniques. There were 19 intraventricular cysts and 6 middle fossa arachnoid cysts. There were 13 males and 12 females. Ages ranged between 19 days and 12 years with a mean of 14.15 years. In all cases the laser was used to fenestrate the cyst wall. RESULTS: The study period extended between February 2018 and May 2021. Surgical time ranged between 1.2 and 2.6 hours with a mean of 1.6 hours. There were no mortalities. There were no infections or complications. In all cases the cyst walls were able to be successful fenestrated. There were no recurrences or cyst reclosure requiring reoperation except for one patient who had multiloculated hydrocephalus secondary to gram negative infection. Total Joules used ranged between 912 and 2237 with a mean of 1779 J. The laser was set between 2 and 10 watts. CONCLUSION: The GOLD laser is an excellent tool for fenestrating loculated intracranial cysts successfully. Energy delivery from the laser allows for wall fulguration and permanently keeping the fenestration open and minimizing recurrences. There are no complications associated with its use. Excellent hemostasis and control of bleeding was achieved in all cases.

Early endoscopic-assisted correction of unicoronal and metopic synostosis is an excellent, safe, cost-effective, and highly effective option for affected patients. Although open calvarial remodeling has a place in the armamentarium of the craniofacial team, the skull base changes seen in endoscopic-assisted techniques are unparalleled. The procedures are associated with low morbidity and no mortality. There is minimal blood loss, decreased operating time, significantly reduced blood transfusion rates, decreased hospitalization length, decreased cost, and less pain and swelling. Early diagnosis and referral for surgical evaluation are critical to obtaining these results.

Sagittal craniosynostosis is the most common type of synostosis. The chapter discusses in marked detail all of the necessary steps to successfully perform an endoscopic procedure. Topics depicted include patient positioning, incision locations, osteotomy creation, hemostasis management, and closing techniques. Multiple photographs present a detailed visual representation of the surgery.

KEY POINTS Early endoscopic-assisted surgery is associated with decreased blood loss, operating time, transfusion rates, hospital stay and costs, pain, and swelling when compared with open procedures. Endoscopic-assisted repair appears to correct downstream facial deformities. There are less reoperative cases necessary with endoscopic-assisted repair.

Craniosynostosis is a condition defined as the premature closure of one or more cranial sutures due to developmental (nonsyndromic) or genetic (syndromic) causes. This condition affects approximately 1 child in every 2000 live births. Calvarial growth follows Virchow’s law where calvarial growth is restricted in a plane perpendicular to a prematurely closed suture, whereas enhanced in a plane parallel to the suture. Structural abnormalities associated with craniosynostosis include dysmorphic cranial development with compensatory facial asymmetry.

Lambdoid craniosynostosis leads to significant deformational changes of the calvaria and cranial fossae. Surgery used to treat the condition typically consists of a calvarial vault remodeling (CVR) procedure whereby the entire occiput is removed and reshaped along with a bandeau advancement to give the patient a rounded occiput. As an option, this video presents the minimally invasive endoscopic craniectomy used at the author's institution, which was developed there and has been successfully used for 25 years. This procedure is simple and can be done rapidly, with minimal to no blood loss. The video details the key steps necessary to successfully perform the procedure. The video can be found here: https://vimeo.com/515746378.

In BriefThe long-term results of treating infants with metopic craniosynostosis by using endoscopic, minimally invasive techniques are reported. The impetus arose from the lack of consistent and favorable outcomes associated with calvarial vault remodeling techniques and from the very traumatic and invasive nature of these procedures. The results presented show excellent and consistent long-term outcomes that are superior to traditional methods and are associated with minimal trauma, blood loss, and anesthetic exposure, and with short surgical times.

To investigate the prognostic value of preoperative Nurick grade and time with symptoms for gait improvement and recovery in patients with ataxia secondary to cervical myelopathy.A retrospective chart review of all adult patients who underwent surgical decompression for cervical myelopathy between 1996 and 2013 was performed. Only adults with a Nurick grade of at least 2 or worse were included. Outcome measures included gait improvement and recovery.A total of 170 patients were identified. Gait improvement and gait recovery occurred in 57.7% and 45.9% of patients, respectively. Time to improvement occurred as early as 1 month up to 24 months postoperatively. A greater preoperative Nurick grade was associated with lower odds of gait improvement (odds ratio 0.74; 95% confidence interval 0.53–0.99, P = 0.048) and gait recovery (odds ratio 0.27; 95% confidence interval 0.17–0.43, P < 0.001). The proportion of patients with symptoms for 12 months or less that experienced gait improvement was 71.2%, compared with 36.4% for patients with symptoms for over 12 months (P < 0.001). Patients with symptoms for 12 months or less had a 59.6% gait recovery rate, compared to 24.2% in patients with symptoms for over 12 months (P < 0.001). Having symptoms for over 12 months was independently associated with lower odds of improvement and recovery.Patients with a greater preoperative Nurick grade and symptoms for more than 12 months may have significantly lower odds of experiencing gait improvement or gait recovery after surgery for cervical myelopathy. This study's conclusion favors early intervention in patients with cervical myelopathy.

Severe traumatic brain injury is associated with a multi-systemic response and changes in metabolic demand. Patients requiring intracranial pressure monitoring or cerebrospinal fluid diversion, often signifies a greater severity of injury. For this group, the association between RBC transfusion, transfusion thresholds, and clinical recovery is unknown. In this study, we studied the association between transfusion and clinical recovery for severe traumatic brain injury patients requiring external ventricular drain or intracranial pressure monitor placement.

Recurrent giant cell tumor (GCT) of the cervical spine represents a significant therapeutic challenge. We present a case of 16-year-old boy with widespread cervical recurrence of GCT 1 year after radical tumor resection via C2 spondylectomy. Computed tomography and magnetic resonance imaging of the cervical spine showed massive recurrence of the tumor with soft tumor mass compressing the spinal cord, osteolytic lesion of the right C1 lateral mass, and complete osteolytic destruction of the C3 vertebral body. The tumor was extending ventrally involving the carotid artery (Fig. 1). Radical surgical reintervention not being conceivable, parallel to conventional external beam radiation therapy (54 Gy in 30 fractions), the patient was started on intravenous monthly 4-mg zoledronic acid treatment for 1 year. At 30-month follow-up after the initiation of zoledronic acid therapy, the patient was asymptomatic, resumed school, and started driving. Imaging studies showed ossification of the tumor, no hardware loosening, and good cervical spine alignment with sufficient space available for the spinal cord (Fig. 2). We suggest that anti-osteoclast therapy should be considered as first-line treatment for GCTs of the spine, especially for those cases where complete tumor resection is not possible. Surgery should be reserved for decompression and stabilization in patients with progressive neurological deficit and spinal instability [ 1 Balke M. Campanacci L. Gebert C. Picci P. Gibbons M. Taylor R. et al. Bisphosphonate treatment of aggressive primary, recurrent and metastatic giant cell tumor of bone. BMC Cancer. 2010; 10: 462 Crossref PubMed Scopus (108) Google Scholar , 2 Mattei T.A. Ramos E. Rehman A.A. Shaw A. Patel S.R. Mendel E. Sustained long-term complete regression of a giant cell tumor of the spine after treatment with denosumab. Spine J. 2014; 14: e15-e21 Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar , 3 Gille O. Oliviera B.A. Guerin P. Lepreux S. Richez C. Vital J.M. Regression of giant cell tumor of the cervical spine with bisphosphonate as single therapy. Spine. 2012; 37: E396-E399 Crossref PubMed Scopus (28) Google Scholar ].

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INTRODUCTION: Posttraumatic stress disorder (PTSD) is one of the hallmark conditions of soldiers returning from Operations Iraqi Freedom and Enduring Freedom, with as many as 20% of soldiers affected. Approximately 30% of patients do not respond to conventional treatment, resulting in a significant unmet treatment need. Amygdalar activity is increased in fear learning and PTSD, leading our group and others to hypothesize that amygdalar stimulation may attenuate PTSD-related symptoms. Prior studies showed decreased avoidance behavior with right amygdalar stimulation in a foot-shock paradigm. However, the underlying molecular mechanisms remain incompletely understood. Human and animal studies indicate an anxiolytic function for the neurotransmitter Neuropeptide Y (NPY) in PTSD patients and models of PTSD. We hypothesized that amygdalar stimulation would attenuate behavioral effects in the predator scent model of PTSD and that effects would be mediated by NPY. METHODS: Lewis rats (10-12 weeks) underwent exposure to feline urine. One week later, baseline behavioral testing on the elevated plus maze confirmed increased anxiety-related behavior. One day after testing, rats were stereotactically implanted with bilateral stimulating electrodes in the basolateral amygdalae. After 1 week of recovery, rats were stimulated 4 hours/day for 7 days (300 mA, 120-μs pulse width, 160 Hz), and then were retested. After euthanization, immunohistochemistry for amygdalar NPY, C-fos, and DAPI was performed. RESULTS: Bilateral stimulation resulted in increased mean time in the open arm of the elevated plus maze (87 ± 16.8 vs 32 ± 9.7 sec, P < .05, n = 4), indicating decreased anxiety, while rats undergoing sham stimulation showed no change (Figure 1). Immunohistochemistry showed increased NPY peptide levels in the amygdalae of stimulated rats (Figure 2). CONCLUSION: Bilateral amygdalae stimulation attenuated anxiety-like behavior in the predator scent model of PTSD, and treatment was correlated with increased amygdalar NPY. Amygdalar stimulation may alleviate PTSD symptoms, and these data provide the first evidence of a possible underlying molecular mechanism.