Neurosurgical operative atlas 2nd ed pediatric neurosurgery

Neurosurgical Operative Atlas
Second Edition

Pediatric Neurosurgery

American Association of Neurosurgeons • Rolling Meadows, Illinois



Neurosurgical Operative Atlas
Second Edition

Pediatric Neurosurgery

James Tait Goodrich, MD, PhD, DSci (Honoris Causa)
Professor of Clinical Neurological Surgery, Pediatrics, Plastic and Reconstructive Surgery
Albert Einstein College of Medicine
Director, Division of Pediatric Neurosurgery
Center for Craniofacial Disorders
Children’s Hospital at Montefiore
Bronx, New York

Thieme
New York • Stuttgart
American Association of Neurosurgeons
Rolling Meadows, Illinois


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*The acronym AANS refers to both the American Association of Neurological Surgeons and the American Association of Neurosurgeons.
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Library of Congress Cataloging-in-Publication Data
Neurosurgical operative atlas. Pediatric neurosurgery / [edited by] James Tait Goodrich.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-58890-510-9 (alk. paper)
1. Nervous system—Surgery—Atlases. 2. Children—Surgery—Atlases. 3. Pediatric neurology—Atlases. I. Goodrich, James T.
[DNLM: 1. Nervous System Diseases—surgery—Atlases. 2. Child. 3. Infant. 4. Neurosurgical Procedures—methods—Atlases.
WL 17 P371 2008]
RD593.P3822 2008
618.92’8—dc22
2007048827
Copyright © 2008 by Thieme Medical Publishers, Inc., and the American Association of Neurosurgeons (AANS). This book, including all
parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright

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Important note: Medical knowledge is ever-changing. As new research and clinical experience broaden our knowledge, changes in
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reliable in their efforts to provide information that is complete and in accord with the standards accepted at the time of publication.
However, in view of the possibility of human error by the authors, editors, or publisher of the work herein or changes in medical
knowledge, neither the authors, editors, or publisher, nor any other party who has been involved in the preparation of this work,
warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or
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ISBN 978-1-58890-510-9


To Setti S. Rengachary, MD, and Robert H. Wilkins, MD
When the first edition of this remarkable atlas came out in early 1990s, it was an instant and powerful success in the
neurosurgical literature. Drs. Rengachary and Wilkins recognized the power of the illustrated text and in this case designed
a work that was clearly visual with the text being secondary. As neurosurgeons are visual animals, this was a successful
design. Drs. Rengachary and Wilkins’ contributions to neurosurgery have been enormous. It is a true pleasure to help bring
this remarkable atlas back in a second edition. However, it must be remembered that their original editorship led to this most
elegant and influential series of operative chapters. In acknowledgment of their insights, their educational leadership, and,
most importantly, their longstanding contributions to neurosurgery, I dedicate this work to these two scholars and superb
neurosurgeons.

v



Contents

Continuing Medical Education Credit Information and Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Continuing Medical Education Disclosure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Series Foreword Robert Maciunas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii
Foreword Richard D. Hayward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xix
Chapter 1

Fibrous Dysplasia Involving the Craniofacial Skeleton. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
James Tait Goodrich

Chapter 2

Chiari Malformations and Syringohydromyelia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Elizabeth C. Tyler-Kabara and W. Jerry Oakes

Chapter 3

Unilateral and Bicoronal Craniosynostosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Kant Y. K. Lin, John A. Jane Jr., and John A. Jane Sr.

Chapter 4

Transoral Surgery for Craniovertebral Junction Abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Arnold H. Menezes

Chapter 5

Malposition of the Orbits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
John A. Persing and Bianca I. Knoll

Chapter 6

Ventriculoatrial Shunting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
John Drygas and Stephen J. Haines

Chapter 7

Repair of “Growing” Skull Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Tadanori Tomita

Chapter 8

Occipital Encephaloceles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
William O. Bell

Chapter 9

Surgical Management of Pansynostosis (Craniosynostosis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
James Tait Goodrich and David L. Staffenberg

Chapter 10

Tethered Spinal Cord, Intramedullary Spinal Lipomas, and Lipomyelomeningoceles. . . . . . . . . . . . . . . . . . . . . . . . . 62
Elizabeth C. Tyler-Kabara and W. Jerry Oakes

Chapter 11

Encephaloceles of the Anterior Cranial Base. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Jonathan P. Miller and Alan R. Cohen

Chapter 12

Exorbitism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Constance M. Barone, David F. Jimenez, and James Tait Goodrich

Chapter 13

Depressed Skull Fracture in Infants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Marion L. Walker

Chapter 14

Orbital Hypertelorism and Orbital Dystopia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Constance M. Barone, David F. Jimenez, and James Tait Goodrich

vii


viii Contents
Chapter 15

Closure of the Myelomeningocele . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

David G. McLone

Chapter 16

Dandy-Walker Malformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Arthur E. Marlin and Sarah J. Gaskill

Chapter 17

Surgical Management of Chiari I Malformations and Syringomyelia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Elizabeth C. Tyler-Kabara, Richard B. Morawetz, and W. Jerry Oakes

Chapter 18

Split Cord Malformations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Dachling Pang

Chapter 19

Tethered Cord Syndrome Secondary to Previous Repair of a Myelomeningocele . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Timothy A. Strait

Chapter 20

Sectioning of the Filum Terminale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Frederick B. Harris, Naina L. Gross, and Frederick A. Boop

Chapter 21

Diastematomyelia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142

Frederick B. Harris, Naina L. Gross, and Frederick A. Boop

Chapter 22

Lipomyelomeningoceles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Frederick B. Harris, Naina L. Gross, and Frederick A. Boop

Chapter 23

Untethering of the Spinal Cord after a Previous Myelomeningocele Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Frederick B. Harris, Naina L. Gross, and Frederick A. Boop

Chapter 24

Brain Abscesses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Darric E. Baty, Eli M. Baron, and Christopher M. Loftus

Chapter 25

Unilateral Coronal Synostosis (Plagiocephaly) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
James Tait Goodrich and David L. Staffenberg

Chapter 26

Moyamoya Syndrome in Children with Pial Synangiosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
R. Michael Scott and Edward R. Smith

Chapter 27

Selective Dorsal Rhizotomy for Spastic Cerebral Palsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

Tae Sung Park and James M. Johnston

Chapter 28

Treatment of Lambdoidal Synostosis with Calvarial Reconstructive Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
David F. Jimenez, Constance M. Barone, and James Tait Goodrich

Chapter 29

Early Treatment of Lambdoid Synostosis with Endoscopic-Assisted Craniectomy . . . . . . . . . . . . . . . . . . . . . . . . . . 190
David F. Jimenez and Constance M. Barone

Chapter 30

Posterior Plagiocephaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Richard G. Ellenbogen, Sudesh J. Ebenezer, and Richard Hopper

Chapter 31

Sagittal Synostosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Larry A. Sargent and Timothy A. Strait

Chapter 32

The Separation of Craniopagus Twins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Sami Khoshyomn and James T. Rutka

Chapter 33

Endoscopic Approaches to the Ventricular System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

David F. Jimenez

Chapter 34

Intraventricular Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Jonathan P. Miller and Alan R. Cohen

Chapter 35

Infected Ventriculoperitoneal Shunts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Keyne K. Thomas, Sohaib A. Kureshi, and Timothy M. George

Chapter 36

Combined Fronto-Orbital and Occipital Advancement for Total Calvarial Reconstruction . . . . . . . . . . . . . . . . . . . 241
Ian F. Pollack

Chapter 37

Lumbosacral Meningoceles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Ciaran J. Powers, Eric M. Gabriel, and Timothy M. George


Contents

ix

Chapter 38

Surgical Correction of Unilateral and Bilateral Coronal Synostoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256

Jack Chungkai Yu and Ann Marie Flannery

Chapter 39

Myelomeningoceles, Split Cord Malformations, and Filum Terminale Dysgenesis . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Robert F. Keating

Chapter 40

Lipomyelomeningoceles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
James Tait Goodrich

Chapter 41

Brain Stem Gliomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Darlene A. Lobel and Mark R. Lee

Chapter 42

Posterior Fossa Decompression without Dural Opening for the Treatment of Chiari I Malformation . . . . . . . . . 281
Jonathan D. Sherman, Jeffery J. Larson, and Kerry R. Crone

Chapter 43

Metopic Synostosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
Kant Y. K. Lin, John A. Jane Jr., and John A. Jane Sr.

Chapter 44

Total Cranial Vault Repair for Sagittal Craniosynostosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

John A. Jane Jr., Kant Y. K. Lin, Tord D. Alden, and John A. Jane Sr.

Chapter 45

Metopic Craniosynostosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
Paul C. Francel and Jayesh Panchal

Chapter 46

Unicoronal Synostosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
Jayesh Panchal and Paul C. Francel

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313



Continuing Medical Education Credit
Information and Objectives

◆ Objectives
Upon completion of this activity, the learner should be able to:
1. Describe the treatment and surgical management of pediatric neurosurgical disorders.
2. Demonstrate a full understanding of current neurosurgical operative techniques in pediatric neurosurgical disorders.
3. Discuss the operative management of complex pediatric neurosurgical disorders.

◆ Accreditation
This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council
for Continuing Medical Education through the American Association of Neurological Surgeons (AANS*). The AANS is accredited
by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

◆ Credit
The AANS designates this educational activity for a maximum of 15 AMA PRA Category 1 credits™. Physicians should only
claim credit commensurate with the extent of their participation in the activity.
The Home Study Examination is online on the AANS Web site at: www.aans.org/education/books/atlas3.asp
Estimated time to complete this activity varies by learner; activity equaled up to 15 Category 1 credits of CME.

◆ Release/Termination Dates
Original Release Date: August 1, 2008
The CME termination date is: August 1, 2011

*The acronym AANS refers to both the American Association of Neurological Surgeons and the American Association of
Neurosurgeons.

xi


Continuing Medical Education Disclosure

The AANS controls the content and production of this CME activity and attempts to ensure the presentation of balanced,
objective information. In accordance with the Standards for Commercial Support established by the Accreditation Council for
Continuing Medical Education, speakers, paper presenters/authors, and staff (and the significant others of those mentioned)
are asked to disclose any relationship they or their co-authors have with commercial companies which may be related to the
content of their presentation.
Speakers, paper presenters/authors, and staff (and the significant others of those mentioned) who have disclosed a relationship* with commercial companies whose products may have a relevance to their presentation are listed below.

Author Name

Disclosure

Type of Relationship

Frederick A. Boop
Richard G. Ellenbogen
Paul C. Francel
Arthur E. Marlin
John A. Persing
Jonathan D. Sherman

Cyberonics
NIH/NCI
Medtronic
Medical Energy
W. Lorenz Group
Zimmer
TransOne

Paid for speech given at Grand Rounds 2/2007
Grant
Clinical research study grant
Consultant fee
Grant (no personal funds paid)
Consultant fee (signed agreement)
Honorarium—gave speech

Speakers, paper presenters/authors, and staff (and the significant others of those mentioned) who have reported they do not
have any relationships with commercial companies:
Author Name
Tord D. Alden
Eli M. Baron
Constance M. Barone

Darric Baty
William O. Bell
Alan R. Cohen
Kerry R. Crone
John Drygas
Sudesh J. Ebenezer
Ann Marie Flannery
Eric M. Gabriel
Sarah J. Gaskill
Timothy M. George

James Tait Goodrich
Naina L. Gross
Stephen J. Haines
Frederick B. Harris
Richard Hopper
John A. Jane Jr.
John A. Jane Sr.
David F. Jimenez
James M. Johnston
Robert F. Keating
Sami Khoshyomn
Bianca Knoll
Sohaib A. Kureshi

Jeffery J. Larson
Mark R. Lee
Kant Y. K. Lin
Darlene A. Lobel
Christopher M. Loftus

David G. McLone
Arnold H. Menezes
Jonathan P. Miller
Richard B. Morawetz
W. Jerry Oakes
Jayesh Panchal
Dachling Pang
Tae Sung Park

Ian F. Pollack
Ciaran J. Powers
James T. Rutka
Larry A. Sargent
R. Michael Scott
Edward R. Smith
David L. Staffenberg
Timothy A. Strait
Keyne K. Thomas
Tadanori Tomita
Elizabeth C. Tyler-Kabara
Marion L. Walker
Jack C. Yu

*Relationship refers to receipt of royalties, consultantship, funding by research grant, receiving honoraria for educational services
elsewhere, or any other relationship to a commercial company that provides sufficient reason for disclosure.

xii


Series Foreword

The Publications Committee of the American Association
of Neurological Surgeons began publishing the first edition
of the Neurosurgical Operative Atlas in 1991. To allow for
timely publication, coverage of six operations was published
at bimonthly intervals in looseleaf format in the order finished manuscripts were received. The completed series had
nine volumes and covered the entire spectrum of neurosurgery.
The goal was to publish a comprehensive reference that
included well-established neurosurgical procedures as
practiced in the United States and Canada by authors who
are respected in the field.
Working together, the AANS Publications Committee and
Thieme New York have organized the second edition of this
atlas series. The atlas’s main purpose remains the same, to
be a ready reference for well-established neurosurgical procedures for trainees and practitioners of neurosurgery worldwide. The new edition contains five volumes, covering neurooncology; spine and peripheral nerves; functional; pediatric;
and vascular neurosurgery. For each volume, one or more

lead editors with known expertise in the subject area were
selected. Each volume editor had complete freedom to add,
revise, or delete chapters. The number of chapters per volume
is approximately the same as the number of chapters in that
particular subject area found in the first edition.
Each chapter is designed to teach a specific surgical technique or approach. The illustrations of the techniques are a
vital part of the work, and the authors commissioned most
of the drawings in color. The text in each chapter covers the
case selection, the operative indications and contraindications, special points in the anesthetic technique, a step-bystep detailed description of the operation, and postoperative
complications. Detailed discussion of diagnostic techniques,
pathology, mechanisms of disease, histology, and medical
management are not included since they are logically outside the scope of a surgical atlas. Detailed tables, reference
lists, and statistical analysis of results are also not included

because they are readily available in standard texts.
We hope you find this reference of value in your practice
of neurosurgery.
Robert Maciunas, MD
Past Chair, AANS Publications Committee
Professor of Neurosurgery
University Hospitals of Cleveland
Cleveland, Ohio

xiii



Foreword

I came to pediatric neurosurgery after a nearly exclusively
adult neurosurgical training, and I confess to being a late
convert to pediatric neurosurgery as an almost autonomous
specialty. The surgical skills required to remove a medulloblastoma were no different, I thought, to those needed to excise a cerebellar metastasis (a far more frequently occurring
pathology), and as for all those shunts . . . !
And the conditions whose management fell within the
province of the pediatric neurosurgeon were all so rare . . .
I was wrong for several reasons, not least of which was to
regard pediatric neurosurgery too narrowly—as no more than
the deployment of particular operations. But I was right about
how uncommon (fortunately) in terms of their overall incidence
the conditions we deal with are. Pediatric neurosurgery is a specialty greedy for the resources it devours to treat comparatively
few patients, hydrocephalus aside. How should the expense of
managing a newborn with, say, Apert syndrome through infancy, childhood, and adolescence be balanced against returning
so many more adults to their former lifestyle after the replacement of a painful hip or knee? Or screening for such occult harbingers of morbidity as hypertension or glaucoma?

It does not take long for the fascination, indeed the privilege,
of working with children and their families to suppress such
thoughts, but nevertheless these remain questions to which
every pediatric neurosurgeon must have their own answer.
It has been said, and rightly so, that a society should be
judged by the way it treats its young and its old—those on
the vulnerable edges of life. James Goodrich, in assembling
the impressive list of internationally renowned experts who
make up the list of his contributors, has demonstrated only
too clearly the commitment of the North American pediatric
neurosurgical community to the care of its sick children.
Since the first edition of this book there has been further
acceptance and consolidation of pediatric neurosurgery as a
discipline that requires its own specialty training.
The conditions that are encountered in a pediatric neurosurgical practice vary markedly from those encountered in
an adult practice, as a glance at the titles of these chapters
with their emphasis upon a variety of congenital disorders
immediately reveals.

The days are long past, I hope, when a surgeon, as ambitious
as foolish, would wish to embark upon his or her first transoral
procedure with no more technical experience than having read
Arnold Menezes’s excellent chapter on this subject.
Then who—and what—is an Operative Atlas such as this
for? It is first and foremost a most valuable educational tool,
one that I would submit should be an essential companion for
pediatric neurosurgeons at all stages of their career.
Neurosurgical residents can read up on the procedures on
which they are about to assist; the increased understanding
of how and why these procedures are done will make them

not only more knowledgeable but all the more useful. Furthermore, when the surgery is over they can come back to
the atlas to find out exactly why and how some maneuver,
whose significance may have escaped them at the time, was
accomplished.
And not only the residents. Just as there exists no operation that cannot be improved (the final improvement being
to do away with the need for surgery altogether) so there is
no neurosurgeon whose training is finished; indeed, anyone
who makes such a claim about themselves has, whether
they recognize it or not, already retired.
What pediatric neurosurgeon, however long ago their residency ended, would not wish to discover how the experts
who have contributed to this volume deal with conditions as
frustrating as a lipomyelomeningocele or a brainstem glioma?
Or the management of a common nuisance such as a shunt
infection? Or something more critical, such as a total calvarial
remodelling for the older child with sagittal synostosis—surely
the limit to which “cosmetic” neurosurgery can be stretched?
I cannot imagine a pediatric neurosurgeon (in or postresidency) who will not be stimulated, intrigued, and (hopefully) sometimes provoked by what has been contributed
by the heady selection of experts James Goodrich has assembled here.
He is to be congratulated not only for bringing them together to produce this book but also for demonstrating so
clearly the commitment of the pediatric neurosurgical community of North America to its own continuing education
for the benefit of sick and disabled children worldwide.
Richard D. Hayward, FRCS
Professor, Pediatric Neurosurgery
Great Ormond Street Hospital for Children
London, United Kingdom

xv

Preface

O! Author, with what words will describe
with such perfection the whole configuration,
such as the sketch does here?
Leonardo da Vinci Quaderni d’Anatomia
Volume II, fol. 2r.
Christiania: Dybwad, 1911–1916.
O! reader, the same feeling that inspired Leonardo to restate the Vitruvian man and provide the perfect proportion
inspired the authors to provide this palimpsest atlas, now
in the second edition with pages now re-etched and redone. Surgical techniques have continued to evolve with
both new technologies and also newly designed surgical approaches. In the early part of the 16th century, Leonardo da Vinci planned a 120-volume text on anatomy
with mostly anatomic illustrations. Early on, Leonardo
recognized that the visual images were more important
in educating the individual; he has clearly remained the
master at that concept. In producing a second edition of
this work, we clearly wanted to keep the original design
with the illustrations being paramount and with text being
added clarification. In an effort to disseminate these surgical techniques, this atlas was formulated on the principle
that the visual image is most important; it must be clear,
precise, and bring forth the surgical design with precision.
In addition, the text design and presentation needs to be
straightforward and practical. The atlas-style format using
an operative narrative was selected in the belief that, like
Leonardo da Vinci, surgeons are more comfortable with
the “visual” image than the written word—though both
are provided! Starting with the first edition of this work,
we selected the chapters that dealt with pediatric subjects.
The original authors were asked to update and revise their
presentations as they felt necessary. In some cases extensive changes were made, and in others only some editing

was done. A number of the chapters are edited by several
surgical subspecialists, a common trend these days. Many
surgical procedures have clearly benefited from the skills
of several surgical subspecialties.
In recent years new materials, techniques, and equipment
have been offered to neurosurgeons for their operations. When
relevant, those contributions have been added. We specifically
asked the authors to avoid lengthy bibliographies and to be

practical in their presentations; we think the readership will
see that this is clearly evident throughout the volume. Where
appropriate, the authors have been asked to include imaging,
whether computed tomography, magnetic resonance imaging, or other radiologic studies. The format of the chapters has
been kept the same throughout in order that the presentation
remains clear and follows a consistent structure.
For our surgical colleagues outside of neurosurgery, a
careful review of this book will reveal useful surgical ideas
and techniques. The format is designed so that not only is
the concept provided and discussed, but the surgical technique is discussed step by step in an atlas format, detailing
each member of the surgical teams’ contributions. Standards, techniques, and styles are continuing to change so that
hopefully a third edition of this book will be necessary in
the not so distant future. Our founding neurosurgical father
Harvey Cushing put it best when he stated:
The knowledge which a man can use is the only real knowledge,
the only knowledge which has life and growth in it
and converts itself into practical power.
The rest hangs like dust about the brain
and dries like raindrops off the stones.
Harvey Cushing
Laboratories: Then and Now, 1922, p. 9

Acknowledgments
No book comes about without the efforts of a number of
people, and this book is certainly no exception.
We would like to start by thanking the editorial and
production teams at Thieme New York—as always an extremely talented and most pleasant group to work with—it
is clearly through their efforts that the published result is
so outstanding. At the top of the list of people are Brian
Scanlan, Tim Hiscock, Birgitta Brandenburg, Richard Rothschild, Dominik Pucek, and Ivy Ip. A special thanks to you
all for your individual contributions, which included skilled
editing, production, and design.
To Helen Lopez and Daniel Jimenez, a sincere thanks for
handling all the calls, mailing the bulky manuscripts, and
reminding us to be nice and to be on time.

xvii


xviii Preface
This book is about neurosurgery, and a fundamental part of
that team is our neurosurgical operating room nurses and technicians. To my operating room nurses and technicians, such an
essential part of my surgical team, special thanks for watchful
vigilance and your helpful advice and insight offered in the care
of patients. Hopefully this volume will be helpful to operating
room teams around in the world. Thanks to Mary Speranza,

Esther Ko-Uy, Katie Thompson, Charles Price, Loretta Caldwell,
Sylvan Fowles, Gabriel Ofurhie, Noel Greene, Danielle Dunne,
Cecille Edwards, Bindu Peter, and, finally, Charisse Terry—a most
remarkable and skilled team with which to work!

Finally, to all the authors who contributed to this book,
thanks for doing such a wonderful job in presenting some
very complex subjects.


Contributors

Tord D. Alden, MD
Assistant Professor
Department of Pediatric Neurosurgery
Feinberg School of Medicine
Northwestern University
Division of Neurosurgery
Children’s Memorial Hospital
Chicago, Illinois
Eli M. Baron, MD
Attending Neurosurgeon
Cedars-Sinai Institute for Spinal Disorders
Los Angeles, California
Constance M. Barone, MD, FACS
Division Head and Professor
University of Texas Health Science Center at San Antonio
Division of Plastic and Reconstructive Surgery
San Antonio, Texas
Darric E. Baty, MD
Resident
Department of Neurosurgery
Temple University School of Medicine
Temple University Hospital
Philadelphia, Pennsylvania

William O. Bell, MD, FACS
Neurosurgical Associates of the Carolinas
Winston-Salem, North Carolina
Frederick A. Boop, MD
Associate Professor of Neurosurgery
Chief, Pediatric Neurosurgery
Semmes-Murphey Clinic
LeBonheur Children’s Hospital
Memphis, Tennessee

Alan R. Cohen, MD
Division of Pediatric Neurosurgery
Rainbow Babies and Children Hospital
Cleveland, Ohio
Kerry R. Crone, MD
Professor of Neurosurgery and Pediatrics
Director, Pediatric Neurosurgery
Cincinnati Children’s Hospital Medical Center
Cincinnati, Ohio
John Drygas, MD, MS
Neuroscience and Spine Associates
Naples, Florida
Sudesh J. Ebenezer, MD, EdM
Department of Neurological Surgery
The University of Washington
Children’s Hospital and Regional Medical Center
Seattle, Washington
Richard G. Ellenbogen, MD, FACS
Professor and Chairman
Department of Neurological Surgery

University of Washington School of Medicine
Neurological Surgeon
Children’s Hospital and Regional Medical Center
Seattle, Washington
Ann Marie Flannery, MD, FACS, FAAP
Reinert Chair in Pediatric Neurosurgery
Department of Surgery
Saint Louis University School of Medicine
Cardinal Glennon Children’s Hospital
St. Louis, Missouri
Paul C. Francel, MD, PhD
Oklahoma Sports Science and Orthopedics
Oklahoma City, Oklahoma

xix


xx Contributors
Eric M. Gabriel, MD
St. Vincent’s Medical Center
Jacksonville, FLorida
Sarah J. Gaskill, MD, FAAP, FACS
Associate Professor
Department of Neurosurgery
University of South Florida
Tampa, Florida
Center for Pediatric Neurosurgery and
Neuroscience
All Children’s Hospital
St. Petersburg, Florida

Timothy M. George, MD, FAAP, FACS
Chief of Service
Dell Children’s Medical Center of Texas
Austin, Texas
James Tait Goodrich, MD, PhD, DSci
(Honoris Causa)
Professor of Clinical Neurological Surgery,
Pediatrics, Plastic and Reconstructive Surgery
Albert Einstein College of Medicine
Director, Division of Pediatric Neurosurgery
Center for Craniofacial Disorders
Children’s Hospital at Montefiore
Bronx, New York
Naina L. Gross, MD
Department of Neurosurgery
Oklahoma University
Oklahoma City, Oklahoma
Stephen J. Haines, MD
Professor and Head
Department of Neurosurgery
University of Minnesota
Minneapolis, Minnesota
Frederick B. Harris, MD, MS
Division of Neurosurgery
St. Mary’s Duluth Clinic
Duluth, Minnesota
Richard Hopper, MD
Surgical Director
Craniofacial Center
Children’s Hospital & Regional Medical Center

Seattle, Washington

John A. Jane Jr., MD
Assistant Professor of Neurosurgery and
Pediatrics
Department of Neurosurgery
University of Virginia Health System
Charlottesville, Virginia
John A. Jane Sr., MD, PhD
Professor and Chairman
Department of Neurosurgery
University of Virginia
Charlottesville, Virginia
David F. Jimenez, MD
Professor and Chairman
Department of Neurosurgery
University of Texas Health Science Center at San Antonio
San Antonio, Texas
James M. Johnston, MD
Department of Neurosurgery
Washington University School of Medicine
St. Louis Children’s Hospital
St. Louis, Missouri
Robert F. Keating, MD
Associate Professor of Neurological Department of Surgery
and Pediatrics
George Washington University School of Medicine
Division of Pediatric Neurosurgery
Children’s National Medical Center
Washington, DC

Sami Khoshyomn, MD
Pediatric Neurosurgery Fellow
Hospital for Sick Children
Toronto, Ontario
Canada
Bianca I. Knoll
Chief Resident
Department of Plastic Surgery
Yale University School of Medicine
Division of Plastic Surgery
Yale-New Haven Hospital
New Haven, Connecticut
Sohaib A. Kureshi, MD
Neurosurgical Medical Clinic
Chula Vista, California
Jeffrey J. Larson, MD
Neurosurgeon
Coeur d’ Alene Spine and Brain, PLLC
Coeur d’Alene, Idaho


Contributors
Mark R. Lee, MD
Chairman, Department of Neurosurgery
Medical College of Georgia
Augusta, Georgia
Kant Y. K. Lin, MD
Professor
Department of Plastic Surgery
University of Virginia School of Medicine

Charlottesville, Virginia
Darlene A. Lobel, MD
Chief Resident
Department of Neurosurgery
Medical College of Georgia
Augusta, Georiga
Christopher M. Loftus, MD, DHC (Hon.), FACS
Professor and Chairman
Department of Neurosurgery
Assistant Dean for International Affiliations
Temple University School of Medicine
Philadelphia, Pennsylvania
Arthur E. Marlin, MD, MHA
Professor
Department of Neurosurgery
University of South Florida
Division of Pediatric Neurosurgery
All Children’s Hospital
Tampa, Florida
David G. McLone, MD
Professor
Department of Pediatric Neurosurgery
Feinberg School of Medicine
Northwestern University
Children’s Memorial Hospital
Chicago, Illinois
Arnold H. Menezes, MD, FACS, FAAP
Professor and Vice Chairman
Department of Neurosurgery
University of Iowa Carver College of Medicine Department

of Neurosurgery
University of Iowa Hospitals and Clinics
Iowa City, Iowa
Jonathan P. Miller, MD
Department of Neurosurgery
University Hospitals and Health System
Cleveland, Ohio
Richard B. Morawetz, MD
Division of Neurosurgery
UAB Hospital
Birmingham, Alabama

xxi

W. Jerry Oakes, MD
Dan L. Hendly, Professor
Department Surgery
Division of Neurosurgery
University of Alabama at Birmingham School of Medicine
Pediatric Neurosurgery
Children’s Hospital
Birmingham, Alabama
Jayesh Panchal, MD, MBA, FRCS
Genesis Plastic Surgery and Medical Spa
Edmond, Oklahoma
Dachling Pang, MD, FRCS(C), FACS
Professor of Pediatric Neurosurgery
University of California
Davis Chief, Regional Centre of Pediatric Neurosurgery
Kaiser Permanente Hospital, Northern California

Oakland, California
Tae Sung Park, MD
Shi H. Huang Professor of Neurosurgery
Department of Neurosurgery
Washington University in St. Louis–School of Medicine
Division of Neurosurgery
St. Louis Children’s Hospital
St. Louis, Missouri
John A. Persing, MD
Professor and Chief
Department of Plastic Surgery
Yale University School of Medicine
Division of Plastic Surgery
Yale–New Haven Hospital
New Haven, Connecticut
Ian F. Pollack, MD, FACS, FAAP
Professor
Department of Neurosurgery
University of Pittsburgh School of Medicine
Chief of Pediatric Neurosurgery
Children’s Hospital of Pittsburgh
Pittsburgh, Pennsylvania
Ciaran J. Powers, MD, PhD
Department of Surgery, Division of
Neurosurgery
Duke University
Division of Neurosurgery
Durham, North Carolina
James T. Rutka, MD, PhD, FRCS(C), FACS, FAAP
Professor and Chairman

Department of Neurosurgery
University of Toronto
Division of Neurosurgery
The Hospital for Sick Children
Toronto, Ontario
Canada


xxii Contributors
Larry A. Sargent, MD
Professor and Chair
Department of Plastic Surgery
UT College of Medicine–Chattanooga Unit
Chattanooga, Tennessee

Keyne K. Thomas, MD
Pediatric Neurosurgery Service
Division of Neurosurgery
Duke University Medical Center
Durham, North Carolina

R. Michael Scott, MD
Neurosurgeon-in-Chief
Department of Neurosurgery
The Children’s Hospital
Boston, Massachusetts

Tadanori Tomita, MD
The Yaeger Professor of Pediatric Neurosurgery
Professor of Neurosurgery

Feinberg School of Medicine
Northwestern University
Chairman, Division of Pediatric Neurosurgery
Children’s Memorial Hospital
Chicago, Illinois

Jonathan D. Sherman, MD
Mountain Neurosurgical and Spine Center, PA
Asheville, North Carolina
Edward R. Smith, MD
Assistant Professor
Department of Neurosurgery
Harvard Medical School
Attending Neurosurgeon
The Children’s Hospital, Boston
Boston, Massachusetts
David L. Staffenberg, MD
Associate Professor
Department of Clinical Plastic Surgery, Neurological
Surgery, and Pediatrics
Albert Einstein College of Medicine, Yeshiva University
Montefiore Medical Center, Children’s Hospital at
Montefiore
Bronx, New York
Timothy A. Strait, MD
Clinical Assistant Professor of Surgery
Department of Surgery
University of Tennessee College of Medicine–
Chattanooga Unit
The Neurosurgical Group of Chattanooga

Chattanooga, Tennessee

Elizabeth C. Tyler-Kabara, MD, PhD
Assistant Professor
Department of Neurological Surgery
University of Pittsburgh School of Medicine
Division of Pediatric Neurosurgery
Children’s Hospital of Pittsburgh
Pittsburgh, Pennsylvania
Marion L. Walker, MD
Professor
Department of Neurosurgery
University of Utah School of Medicine
Division of Pediatric Neurosurgery
Primary Children’s Medical Center
Salt Lake City, Utah
Jack Chungkai Yu, MD, DMD, MS Ed
Department of Surgery
Section of Plastic and Reconstructive Surgery
Medical College of Georgia
Augusta, Georgia


1
Fibrous Dysplasia Involving the Craniofacial
Skeleton
James Tait Goodrich
This chapter will deal with fibrous dysplasia of the craniofacial complex, in particular those regions involving the
forehead, orbital rim, lateral and medial orbital walls, the
orbital roof, and the optic foramen. The discussion will involve the “worst case scenario,” assuming that, if the surgeon can handle this type of case, the simpler cases will be

easier to treat.
Fibrous dysplasia can involve the calvaria and any of the
upper facial bones. Its etiology is unknown, but the pathology involves a replacement of normal bone with a fibroosseous matrix. The surgical principle involves removing
all of the dysplastic bone (or as much as possible) and replacing it with normal calvarial bone harvested from other
parts of the head. Fibrous dysplasia can be of a simple type
called monostotic, where only one bone unit is involved,
or polyostotic, where two or more bones are involved. In
this chapter we will deal with the more complicated polyostotic type.
The most common presenting complaints in fibrous dysplasia of the craniofacial complex are proptosis (Fig. 1–1),
diplopia and headaches, and in severe cases, progressive

blindness due to optic nerve compression; fortunately,
blindness is an extremely rare outcome.
An x-ray film of the skull will show a sclerotic mass expanding the calvarial and orbital bones. The radiologist typically describes a “ground glass” appearance. There will also be
sclerosis or even a cystic appearance to the bone. It is not uncommon to see complete obliteration of the frontal and nasal
sinuses. The proptosis is secondary to the orbital fibrous dysplasia compressing the globe and forcing the eye forward. As a
result of this, an early presenting complaint can be diplopia.
The principle behind the surgical treatment of fibrous
dysplasia of the craniofacial complex is threefold: (1) relief
of optic nerve compression (decompression of the nerve
should be considered though is not always essential); (2)
removal of all dysplastic bone if possible, as any residual can
form a new dysplastic center; and (3) use of the patient’s
own bone for grafts to achieve a satisfactory cosmetic result
is preferred. We now avoid the use of any foreign implantable materials such as methylmethacrylate, wire mesh, or
metal fixation plates, particularly in children, due to high
risk of migration and infection.

10.1055/978-1-60406-039-3c001_

B

A
Figure 1–1 (A) Frontal view and (B) superior view of a patient with
orbital proptosis secondary to fibrous dysplasia. Typical proptosis is
evident and fibrous dysplasia involving the right orbital unit including

rim, lateral, and medial walls. As a result, the eye is pushed forward
and downward. Interestingly, the only visual symptom was double vision: The visual acuity was normal.

1

14535_C01.indd 1

4/23/08 3:13:33 PM


2 Pediatric Neurosurgery
At the Craniofacial Center of the Children’s Hospital at
Montefiore we now do as much as possible of the reconstruction with “normal” calvarial bone, that is, bone not involved with fibrous dysplasia. We have found this considerably lessens the risk of resorption, which occasionally occurs
with rib grafts placed in the craniofacial region. The use of
ribs, particularly in the forehead region, can sometimes lead
to an unacceptable “washboard” appearance. Another advantage of using calvarial bone is the reduction in operative
exposure. This technique also avoids the complications that
can occur with rib harvesting, such as pneumothorax and
chest wall pain.

Preoperative Preparation
Evaluation
All patients should have radiographic studies of the skull

in the routine views to document the extent of dysplastic
involvement of the skull and surrounding orbital and nasal structures. Computed tomography scanning with bone
windows in the axial and coronal views along with threedimensional reformatting are obtained for the operative
planning. We have not found magnetic resonance imaging
to be helpful, so we do not use it routinely.
If the optic nerve is compressed, we routinely do visual
acuity and visual field testing to have baseline values. Damage to the optic apparatus and to the nerves supplying the
extraocular muscles are the most significant complications
to be avoided. Subtle damage may already have occurred
preoperatively, and it is essential to document this prior to
any surgical intervention. In recent years our ophthalmologic colleagues now feel it is no longer always necessary to
decompress the optic nerve, even in cases of severe radiological compression. Some surgical teams now feel the risk
of removing the dysplastic bone is too great in causing direct
injury to the nerve. As a result of these recent discussions
we no longer just routinely decompress the optic nerve. The
exception is a rapid and clear progression of visual loss due
to an overgrowth of dysplastic bone.
We routinely start an anti-staphylococcal antibiotic at the
time of anesthetic induction in the operating room. Because
the surgical manipulations are extradural, we do not routinely use anticonvulsant medications.

pressure line. An arterial line is highly recommended for
monitoring blood gases, hematocrit, electrolytes, etc., during the procedures. We request an osmotic diuresis, usually
with mannitol (0.5 mg/kg) at the time of anesthetic induction. A spinal drainage system for cerebrospinal fluid (CSF)
removal can sometimes also be helpful for brain relaxation.
These relaxation measures can be key in getting a relaxed
frontal lobe for retraction when working back toward the
optic foramens.
We do not routinely use steroids in these types of cases;
the exception is if there is evidence of brain or optic nerve

edema during the case.

Operative Procedure
Positioning
The patient is placed in the supine position with the head
resting on a cerebellar (horseshoe) headrest (Fig. 1–2). The
head is placed in a slightly extended, brow-up position.
Rigid fixation devices such as a Mayfield clamp are specifically avoided, as the surgical team will need to move

Preparation
Fibrous dysplastic bone can be, and usually is, highly vascular. As a result, the blood loss in these procedures can be
significant. We routinely plan for a blood loss of 2 to 3 units.
If the family wishes, we arrange for pedigree blood donations from family members 1 week in advance. The patient
can also donate his/her own blood prior to surgery. If available, a “cell saver” unit can rescue up to 50% of the patient’s
lost blood volume. Because of the risk of extensive blood
loss, all patients require at least two large-bore intravenous
lines of 16 gauge or larger. If there is any history of cardiac or
pulmonary problems, we routinely put in a central venous

14535_C01.indd 2

10.1055/978-1-60406-039-3c001_f002
Figure 1–2 Schematic showing the location of the surgical and anesthesia teams.

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