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UTHSCSA
DEAN’S MESSAGE
Advancing the standard of care
in neurosurgery
By Francisco González-Scarano, MD
The Department of Neurosurgery at the School of Medicine is mations: one causes a triangular shape, another an oblong shape,
expanding in size and scope, and also in its reach, changing the and yet another causes one side of the face/head to grow much
landscape of adult and pediatric patient care in innovative ways. larger and at a different angle than the other side. Multiple fusions
With a focus on minimally invasive approaches, the department, create other distortions and issues.
chaired by Dr. David Jimenez, now has one of the largest neuro-
surgery residency programs and is playing an expanding role in Dr. Jimenez began developing a minimally invasive technique
advancing the standard of care for a host of conditions. 17 years ago – including the design of special instruments – with
his partner and wife, Dr. Constance Barone, who is a plastic sur-
Our neurosurgeons operate at University Hospital, at St. Luke’s geon. They have been perfecting their approach ever since.
and North Central Baptist hospitals, and at the Veterans Admin- Known as an “endoscopic strip craniectomy,” this procedure has
istration Hospital. They also care for patients at the Cancer Ther- totally transformed the standard of care for children with cran-
apy & Research Center (CTRC). Many patients find out about iosynostosis.
our expertise because they are admitted to one of these hospitals,
but others seek out Dr. Jimenez and his team, especially for the The traditional approach is one of the few surgeries where
treatment of craniosynostosis. In fact, treatment of craniosynos- blood transfusions are always necessary as part of the preoperative
tosis is one of the areas in which our department has become the process. Because of the complexity of the standard surgery, the
destination for patients from around the world. The department’s child must be at least 6 months old, a time when the skull has al-
philosophy is to deliver maximum benefit with the minimum pos- ready thickened and will bleed profusely. Coupled with long sur-
sible disruption to the lives of the patients and their families. This gical times (four to eight hours), it is common to replace the
is how the neurosurgery team approaches all cases, and it has a child’s entire blood volume during a regular procedure; sometimes
profound impact in children with this condition. it is replaced twice.
PREMATURE FUSION ZIG-ZAG INCISIONS
Craniosynostosis is the result of the premature fusion of one or The key approach in the traditional surgery is to make large
more of the sutures of the skull. The National Institutes of Health zig-zag incisions in the scalp from ear to ear across the top of the
report that it occurs in about 4/10,000 births. Because the brain head. The skull is then removed and put back together in a more
grows so rapidly during the first few years of life, the skull must “normal” shape and must then be fixed back together with wires,
have open, expandable sutures. If these sutures are prematurely screws and other hardware. It is an extensive, complex operation
fused, the growing brain will create deformations in the skull. that commonly results in a hospital stay of three to five days, with
This condition results in a myriad of other complications that the first two or three in the ICU. There is a great deal of post-
often include learning and other development delays as well as operative swelling and pain. Typically there are multiple follow-
problems with vision, respiration, hearing and other neurological up procedures as well, in order to adjust, repair and reconfigure
functions. the skull. Children treated in the later stages (at 9 to 12 months
of age) often have a lifetime uncorrectable disfigurement.
Parents seek out Dr. Jimenez and bring their children from all
over the United States as well as from China, Japan, Germany, In contrast, the endoscopic procedure developed by Dr. Jimenez
Russia and the Middle East. As this article was being prepared, averages 57 minutes of operating time. There are no screws, wires
Dr. Jimenez received a CT scan of a newborn in Bogota, Colom- or other appliances used on the skull, and because it takes so little
bia. This child, only a few weeks old, had a very distinct protru- time, children as young as one or two days old can be operated
sion of one side of the forehead, causing asymmetry of the eye on. Unlike the traditional method, the scalp is not peeled back,
sockets. Fusion of different skull sutures causes different defor- only a small incision is made, and the fused suture of the skull is
removed relatively quickly -- leaving large spaces for the skull to
26 San Antonio Medicine • February 2015
