Posterior Distraction First or Fronto-Orbital Advancement First for Severe Syndromic Craniosynostosis.

PURPOSE: Posterior calvarial vault expansion using distraction osteogenesis is performed for syndromic craniosynostosis as the first choice. This procedure allows far greater intracranial volume than fronto-orbital advancement (FOA). This study aimed to determine the most suitable timing of posterior distraction or FOA to sufficiently increase the intracranial volume and remodel the skull shape. PATIENTS AND METHODS: From 2014 to 2017, the authors performed posterior distraction in 13 patients with syndromic craniosynostosis. Data on premature suture fusion, age at first visit, age at surgery, skull thickness, and complications were collected. RESULTS: Five patients underwent posterior distraction at approximately 12 months of age and had no complications, including cerebrospinal fluid leakage or gull wing deformity. However, during the waiting period for the operation, the skull deformity continues to extend upward (turribrachycephaly). To prevent progress of the skull deformity, the authors performed the operation at approximately 6 months of age in 7 patients. However, in 3 of 7 patients whose lambdoid sutures were opening, gull wing deformity occurred. From these results, in a patient with severe Beare-Stevenson syndrome, the authors performed FOA first at 5 months of age, followed by posterior distraction at 12 months of age, and achieved favorable results. CONCLUSIONS: Treatment patterns are patient specific and should be tailored to premature suture fusion, specific skull deformity, and required intracranial volume of each patient.

Infantile Inflammatory Bowel Disease in a Three-Month-Old-Boy.

Very early-onset inflammatory bowel disease (VEO-IBD) and infantile IBD occur in children aged less than six years and less than two years, respectively. Since childhood-onset IBD seems to be a more aggressive and rapidly progressive disease than adult-onset IBD, it should therefore be diagnosed and treated immediately. Here, we report a case of infantile IBD in a three-month-old infant with clinical and biochemical manifestations. The diagnosis was confirmed with histopathological evidence. The patient had been treated successfully with both mesalazine and prednisolone and with mesalazine alone on follow-up.

Corticofugal projections to trigeminal motoneurons innervating antagonistic jaw muscles in rats as demonstrated by anterograde and retrograde tract tracing.

Little is known about the organization of corticofugal projections controlling antagonistic jaw muscles. To address this issue, we employed retrograde (Fluorogold; FG) and anterograde (biotinylated dextran amine; BDA) tracing techniques in rats. Three groups of premotoneurons were identified by injecting FG into the jaw-closing (JC) and -opening (JO) subdivisions of the trigeminal motor nucleus (Vmo). These were 1) the intertrigeminal region (Vint) and principal trigeminal sensory nucleus for JC nucleus; 2) the reticular region medial to JO nucleus (RmJO) for JO nucleus; and 3) the parabrachial (Pb) and supratrigeminal (Vsup) nuclei, reticular regions medial and ventral to JC nucleus, rostrodorsomedial oralis (Vor), and juxtatrigeminal region (Vjuxt) containing a mixture of premotoneurons to both the nuclei. Subsequently, FG was injected into the representative premotoneuron structures. The JC and JO premotoneurons received main afferents from the lateral and medial agranular fields of motor cortex (Agl and Agm), respectively, whereas afferents to the nuclei with both JC and JO premotoneurons arose from Agl also and from primary somatosensory cortex (S1). Finally, BDA was injected into each of the three cortical areas representing the premotoneuron structures to complement the FG data. The Agl and Agm projected to reticular regions around the Vmo, whereas the Pb, Vsup, Vor, and Vjuxt received input from Agl. The S1 projected to the trigeminal sensory nuclei as well as to the Pb, Vsup, and Vjuxt. These results suggest that corticofugal projections to Vmo via premotoneuron structures consist of multiple pathways, which influence distinct patterns of jaw movements.

Distribution of premotoneurons for jaw-closing and jaw-opening motor nucleus receiving contacts from axon terminals of primary somatosensory cortical neurons in rats.

To clarify features of direct projections from the primary somatosensory cortex (S1) to premotoneurons for the jaw-closing (JC) and jaw-opening (JO) components of the trigeminal motor nucleus, biotinylated dextranamine (BDA) and Fluorogold (FG) were used as the anterograde and retrograde tracers. The BDA and FG injections were made in the S1 and the JC or JO component, respectively, in rats. The distribution of FG-labeled JC and JO premotoneurons receiving contact(s) from BDA-labeled axon terminals of S1 neurons was quantitatively examined; the contacts were identified microscopically by using a X100 oil immersion objective. The largest and second largest numbers of JC and JO premotoneurons with contact(s) were found in the lateral reticular formation at the levels of the caudal pons and the medulla oblongata (cpmLRt) and trigeminal oral nucleus (Vo) bilaterally, and they comprised about 80% of the total premotoneurons with contact(s). The percentage of premotoneurons with contact(s) was higher in the Vo than in the cpmLRt for both JC and JO premotoneurons. Most of the JC or JO premotoneurons found in the nucleus of the solitary tract, inter- and supratrigeminal regions, mesencephalic trigeminal nucleus, parabrachial nucleus and reticular formation medial to the JO component of the trigeminal motor nucleus hardly received contact(s) from S1 neurons. This suggests that the contribution of S1 to the control of jaw movements is mediated via JC and JO premotoneurons located primarily in the cpmLRt and Vo areas of the brainstem.