Supraorbital Rim Syndrome: Definition, Surgical Treatment, and Outcomes for Frontal Headache.

BACKGROUND: Supraorbital rim syndrome (SORS) is a novel term attributed to a composite of anatomically defined peripheral nerve entrapment sites of the supraorbital rim region. The SORS term establishes a more consistent nomenclature to describe the constellation of frontal peripheral nerve entrapment sites causing frontal headache pain. In this article, we describe the anatomical features of SORS and evidence to support its successful treatment using the transpalpebral approach that allows direct vision of these sites and the intraconal space. METHODS: A retrospective review of 276 patients who underwent nerve decompression or neurectomy procedures for frontal or occipital headache was performed. Of these, treatment of 96 patients involved frontal surgery, and 45 of these patients were pure SORS patients who underwent this specific frontal trigger site deactivation surgery only. All procedures involved direct surgical approach through the upper eyelid to address the nerves of the supraorbital rim at the bony rim and myofascial sites. RESULTS: Preoperative and postoperative data from the Migraine Disability Assessment Questionnaire were analyzed with paired t test. After surgical intervention, Migraine Disability Assessment Questionnaire scores decreased significantly at 12 months postoperatively (P < 0.0001). CONCLUSIONS: SORS describes the totality of compression sites both at the bony orbital rim and the corrugator myofascial unit for the supraorbital rim nerves. Proper diagnosis, full anatomical site knowledge, and complete decompression allow for consistent treatment. Furthermore, the direct, transpalpebral surgical approach provides significant benefit to allow complete decompression.

Chronic daily headaches secondary to greater auricular and lesser occipital neuromas following endolymphatic shunt surgery.

In head and neck surgery, peripheral sensory nerves are at risk for traumatic injury. These injuries are known to be peripheral triggers of chronic headaches if left untreated or unrecognised. We report the case of a patient that presented with a severe headache, nausea and emesis of 2 years duration following endolymphatic shunt placement for Meniere's disease. Nerve blockade suggested a peripheral trigger, and surgical exploration of the incision site revealed traumatic neuromas of the greater auricular and lesser occipital nerves. Subsequent nerve resection yielded complete symptomatic relief. This is the first case report of a peripherally triggered migraine headache due to the development of neuromas of the greater auricular and lesser occipital nerves, also representing a previously unreported complication of endolymphatic shunt placement. It is recommended that in patients presenting with intractable migraines and a history of head and neck surgery, diagnostic nerve blockage be used to assess for neuromas.

Primary reconstruction of alveolar clefts using recombinant human bone morphogenic protein-2: clinical and radiographic outcomes.

BACKGROUND: This novel method for primary alveolar cleft bony reconstruction avoids donor site morbidity and does not require close approximation of alveolar segments as necessitated by gingivoperiosteoplasty. The study aims to provide radiographic evidence of de novo synthesis of bone using recombinant human bone morphogenic protein-2 (rhBMP-2). METHODS: This institutional review board-approved class IV study retrospectively evaluated primary alveolar cleft patients from 2004 to 2006. Subjects chose an off-label application of rhBMP-2 impregnated on an absorbable collagen sponge carrier to reconstruct alveolar clefts, all greater than 3 mm in width. The surgical technique used for soft tissue closure, developmental field reassignment, is not a gingivoperiosteoplasty and is applicable to alveolar clefts of virtually any size. Developmental field reassignment produces a periosteal "pocket" containing mesenchymal stem cells sensitive to cytokines, such as BMP-2. Inductive conversion of mesenchymal stem cells to osteoblasts by BMP-2 is known as in situ osteogenesis (ISO). Seventeen cleft sites treated with ISO were evaluated at 6 months postoperative using low-dose spiral computed tomography with 1-mm cuts limited to the maxilla. Alveolar bone density (Hounsfield units) was assessed by 3 radiologists; trabecular bone was defined as Hounsfield units of more than 226. RESULTS: In 16 of 17 cleft sites, ISO produced trabecular bone that filled the implantation site both transversely and vertically. CONCLUSION: Stem cell stimulation using rhBMP-2/absorbable collagen sponge offers highly effective radiographic and clinical unification of the dental arch without donor site morbidity. Long-term follow-up studies for this initial cohort are under way to examine information on orthodontic relationships and cephalometrics using cone-beam computed tomography technology.

Repair of abdominal wall defects with bovine pericardium.

BACKGROUND: Ventral hernia repair with prosthetic mesh has recurrence rates up to 54% and is contraindicated in the setting of infection. The aim of this study was to provide our experience with acellular bovine pericardium (Veritas collagen matrix; Synovis Life Technologies, Inc., St. Paul, MN) in complex abdominal wall reconstruction where prosthetic mesh had failed or was contraindicated. Between 2005 and 2008, a retrospective review of a single general surgeon's practice identified patients reconstructed with acellular bovine pericardium. Thirty primary or recurrent ventral hernias were treated in 26 patients. All patients presented with either contaminated wounds or failure of a prosthetic mesh material. RESULTS: Hernia size ranged from 20 cm(2) to 600 cm(2) (mean 111 cm(2)). Seven patients had previous hernia repair with prosthetic mesh, and 16 patients had ongoing infection or gross contamination at the time of repair. The mean follow-up was 22 months. The hernia recurrence rate in our series was 19% with no fistula development. CONCLUSIONS: Acellular bovine pericardium's high strength, minimal infection rate, and low cost allow its use in the reconstruction of complex abdominal wall defects.