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Team: University of Florida Pediatric Neurosurgery Craniosynostosis Treatment Center
Address:
UF Health Neuromedicine Hospital
1505 SW Archer Road, 1st Floor
Gainesville, FL 32608,
Phone: 352-273-6990 / 352-273-9000
Map:
Lance S. Governale, MD, FAANS, FAAP is the Chief of Pediatric Neurosurgery and the L.D. Hupp Associate Professor of Neurosurgery and Pediatrics. He joined the University of Florida’s Department of Neurological Surgery in 2017 after serving as a Pediatric Neurosurgeon at Nationwide Children’s Hospital in Columbus, Ohio and an Assistant Professor of Neurosurgery at the Ohio State University College of Medicine.
Dr. Governale obtained his Bachelor of Science in Physiology and Neurobiology from the University of Maryland, research training from the National Institutes of Health, and his Medical Degree from Harvard Medical School. He then stayed at Harvard to complete neurosurgical residency training at Brigham and Women’s Hospital and pediatric neurosurgical fellowship training at Children’s Hospital Boston.
Dr. Governale has the distinction of having received awards from his colleagues for excellence in research, teaching, and clinical care, including the Harvard Medical School Richardson Research Fellowship for MD Scientists and a nomination for the Harvard Medical School Faculty Prize for Excellence in Teaching. His research interests focus on clinical outcomes, quality improvement, and medical informatics; and he is a member of multiple professional societies including the American Association of Neurological Surgeons, the American Society of Pediatric Neurosurgeons, and the American Academy of Pediatrics.
Although he enjoys the full range of pediatric neurosurgery, Dr. Governale is especially interested in craniosynostosis, minimally invasive neurosurgery (including endoscopic treatment of hydrocephalus, craniosynostosis, pituitary disease, and skull base disease), brain / spinal cord tumors, tethered spinal cords, arachnoid cysts, and cavernous malformations. He is board certified by both the American Board of Neurological Surgery and the American Board of Pediatric Neurological Surgery.
The goals of craniosynostosis surgery are to unlock and reshape the bones. Historically, craniosynostosis has been treated using surgical methods that involve an incision from ear to ear and the removal, reshaping and reattachment of affected bones. However, at UF Health Shands Children’s Hospital, advances in technology are allowing us to conduct more of these procedures in a minimally invasive manner.
With traditional surgery, the procedure lasts approximately four hours and is performed in conjunction with a craniofacial plastic surgeon. A blood transfusion is often necessary. The child is typically observed overnight in the ICU and then an additional three days on the regular neurosurgical floor before discharge. Pronounced periorbital edema is normal, but generally resolves before discharge. To reduce surgical risk, this procedure is performed around the age of 6 months. Younger infants are very unlikely to experience increased intracranial pressure before then. Syndromic and multiple suture cases are more frequently treated using traditional surgical techniques. Because reshaping occurs at the time of surgery, no further interventions are required.
Minimally invasive surgery involves two small incisions and the removal of only the fused suture to unlock the bones. The surgery lasts approximately one hour and rarely requires a blood transfusion. Postoperatively, the child is observed overnight on the regular neurosurgical floor and is then discharged. Usually, there is no periorbital swelling. Minimally invasive surgery produces the most successful outcomes when performed on children before the age of 6 months. With minimally invasive techniques, reshaping occurs postoperatively with the assistance of either a cranial molding helmet or implanted custom springs.
The cranial molding helmet has a hard outer shell with moldable foam on the inside. It is worn 23 hours per day until the child’s first birthday. The helmet does not press the skull into shape but rather directs the growth of the skull into a more normal shape. Because the helmet relies on the high rate of skull growth in the first year of life, helmet-assisted surgery should be done between 10 to 14 weeks of age. The helmet requires frequent visits to an orthotist but no additional surgery.
Stainless steel cranial expander springs are implanted after the fused suture is resected. The springs are then removed three months later. The level of spring tension is selected based on the patient’s age, bone thickness and deformity severity. Spring-assisted surgery is performed between the ages of 3 to 6 months. The springs require a second surgery for removal but not the use of the helmet.
In some cases, when multiple sutures are fused, cranial distraction can be employed to create more intracranial volume. After the bones are unlocked, distractors are implanted spanning the bone cut At a rate of 1mm per day, the sides are separated by turning the screw that connects them using posts that project through the skin. After 30 days, distraction osteogenesis results in 3 cm of new bone. The posts are then removed and the skin is closed in the office .Three months later, the distractors are removed at a second surgery.
Marissa and Jon Yeatman gave birth to a healthy baby boy named Nathaniel on Feb. 9, 2018, in Tallahassee, Florida. He was their second child and made their daughter a big sister, a position she was eager to take on.
Three days after his birth, Marissa and Jon took their baby to the pediatrician for his newborn checkup, and the doctor noticed an abnormality in the shape of Nathaniel’s skull.
“The pediatrician took pretty much one look at him and said, ‘Let’s take some X-rays,’” Marissa said.
Though Nathaniel’s head only had a mildly pinched appearance, his abnormal head shape foreshadowed a much more serious problem. Nathaniel was diagnosed with sagittal craniosynostosis, a birth defect in which one of the fibrous joints between the bones of Nathaniel’s skull closed prematurely before his brain was fully formed.
“Usually when you look at a newborn’s head on an X-ray, it looks like the skull is kind of shattered, but part of his looked like it was already formed and closed like an adult,” Marissa said.
Their pediatrician recommended Lance S. Governale, M.D., UF Health’s chief of pediatric neurosurgery who has a focus in craniosynostosis. The Yeatmans contacted him immediately, hoping to resolve the issue as quickly as possible.
Dr. Governale knew he needed to treat the problem early, so he scheduled the Yeatmans for an appointment close to their home at the UF Health Pediatric Specialties practice in Tallahassee.
“At that point, he was like new, new to the world,” Marissa said. “He was only about a month old. So, our options were kind of broadened, because we caught it so young.”
To gather more information, Dr. Governale obtained a special CT scan. CT scans involve some amount of radiation exposure, but at UF Health’s Gainesville and Tallahassee locations, Dr. Governale introduced ultra- low-dose CT scanning. These scans provide 3D views of the skull at a radiation dose similar to a few X-rays and much lower than standard CT scans.
After Nathaniel’s CT scan confirmed the condition, Dr. Governale laid out three different treatment options.
“The skull is made up of multiple different bones with sutures in between them,” Governale said. “Sutures allow the skull to grow. If they close early, it alters the head shape. In addition, suture closure can restrict skull growth while the brain is trying to grow leading to increased pressure.”
Craniosynostosis is typically treated surgically, due to the need to unlock the bones and reshape the skull. The traditional surgery, larger and more invasive, would probably require a blood transfusion and a longer hospital stay, but Dr. Governale was committed to offering minimally invasive options.
“One minimally invasive option consists of unlocking the bones through one or two small incisions with the assistance of an endoscope, and then using a helmet afterward to reshape the skull,” Governale said. “The downside is that the helmet has to be worn for 23 hours per day for upwards of nine months. It also requires regular visits to a helmet orthotist, who may not be located in the family’s region, like Tallahassee.”
Because of these issues, Dr. Governale and his pediatric craniofacial plastic surgery partner, Jessica A. Ching, M.D., introduced a second minimally invasive option to UF Health — cranial expander springs. With springs, a helmet is not required. UF Health Shands Children’s Hospital in Gainesville is the only site in Florida offering this newest treatment option.
Though she trusted the physician’s expertise, Marissa was relieved to feel as if she wasn’t forced into one specific treatment option for her baby boy. She felt that Dr. Governale let her have the final say.
“He was really good about not pushing one option over the others,” Marissa said. “He said if there was one option that was better than the other two, he wouldn’t offer the other two.”
That third, minimally invasive option for Nathaniel was the one that the nervous parents eventually chose.
In May of 2018, Nathaniel underwent craniosynostosis surgery with cranial expander spring implantation. Drs. Governale and Ching made one incision, used an endoscope to help open the sealed suture and then put in two cranial expander springs to reshape the skull. Three and a half months later, they went back in and took out the springs, completing the process — no helmet required.
A team approach is essential for treating craniosynostosis. The physicians work side-by-side to tailor the treatment to the patient and involve other specialists if needed, including ENT, oral surgery, dentistry, genetics, speech therapy, audiology, psychology and social work. Although Nathaniel did not need those additional specialists, he did have one more added benefit of Dr. Ching’s participation in the surgery — a beautiful closure with minimal scarring, something Marissa and Sean are very thankful for.
“She did an amazing job with all of his stitches and everything,” Marissa said. “The scar was actually, originally, a pretty odd U-shape. As his head is growing, it has started to stretch and look straighter. Already, you can’t see the incision that much.”
Today, Nathaniel is a healthy 1-year-old, and you can’t tell there was ever anything wrong with his skull.
“He had an excellent reshaping. His head looks normal now and is allowing his brain to grow,” Governale said. “We’ll be watching him, but hopefully, because he’s otherwise healthy, he won’t encounter additional issues.”
Nathaniel’s more focused on doing his favorite things, now that he doesn’t have to worry about surgeries or doctors’ visits. His big sister is his greatest source of entertainment.
“He loves his sister. Hands down, she’s the one that can make him smile the most,” Marissa said. “Any time she gives him attention and plays with him, he’s just so happy. They’re cute together.”
Nathaniel started walking recently and is very mobile. He loves eating and playing with a little lion rattle. The lion has been with him from the day he was born through every surgery after that.
Like that little rattle, Marissa and Jon have been there the whole way, too, and have learned a lot through their hardest moments with Nathaniel. Marissa offers advice to other parents who are about to undertake their own harrowing journey with craniosynostosis.
“I would say don’t panic,” Marissa said. “You’ll get through this. Honestly, the doctors know exactly what they’re doing. Trust them.”
She also encourages parents to trust their gut when it comes to health care decisions for their children.
“It’s very, very scary seeing your newborn baby go into surgery,” Marissa said. “It’s just very difficult. When Nate was waking up after his first surgery, he was very fussy. That whole day he was fussy: upset, disoriented, crying. I was second guessing our decision while trying to comfort him. Then, the next day, he woke up and smiled and was suddenly completely himself again. Don’t second guess yourself. You know what’s right for your family and your child. It’s crazy how resilient children are.”
