3-D skull technology a no-brainer in neurosurgical cases

It’s a good thing Rhett Bausmith was child No. 4.

It meant his mom, Crystal Bausmith, didn’t panic when she found out something was really wrong with her son. Bausmith recalls that they had no warning there were going to be problems. She was in labor for 10 hours.

“We knew it wasn’t right, but we weren’t quite sure what.”

After the birth, a neurologist came to consult with Crystal and Timothy Bausmith to explain what was wrong. Their son’s head was misshapen because he had craniosynostosis, a birth defect in which the bones in a baby’s skull join together too early. He would need to be referred to the Medical University of South Carolina.

MUSC's Ramin Eskandari, M.D., a pediatric neurosurgeon, and Jason Ulm, M.D., a plastic surgeon, joined forces to figure out the best way to help Rhett. Imaging showed his skull had not one, but two sutures (fibrous joints on babies' skulls that turn into bone) that had prematurely closed.

Often in these cases it’s just one suture that closes, but Rhett’s case was rare, Ulm says. The two sutures that had fused were affecting brain growth and the formation of Rhett’s face. Already one section of the skull that encases the eye, the orbital rim, had pulled back. Ulm discussed options with colleagues in Boston. “We usually don’t see something this severe.”

Bioprinting

Ulm and Eskandari requested MUSC’s bioprinting labs to take Rhett’s scans and make 3-D skulls. Ulm says only a handful of medical centers in the country are using bioprinting technology to create replicas of patients’ skulls to better plan surgical procedures. It also opens a new frontier in the training of residents and in creating a powerful tool to educate families about what can be very complex surgical cases.

Eskandari, a new father himself, says he understands how hard it is for parents to get bad news. In severe cases, it can be hard for families, who often are in shock, to understand the complexity of the surgery. “Even with Rhett, where you could see something really was wrong, it’s not until now, when there’s been a significant correction, where his mom says, ‘Oh my God, my baby was messed up.’”

It also lets him do a better job of obtaining informed consent, which prepares families for the upcoming treatment and its possible risks. “No matter how much you talk to a family about what you’re going to do as a surgeon, if you ask them even hours later, they have very little idea,” he says.

“Real-life visuals help with the process of getting better informed consent and lead to better questions from the patient or parent.”

Prepping for Surgery

The parents, especially when they heard how many cuts would need to be made into their son’s skull, had lots of questions.

Rhett, born May 1, 2015, was slotted for surgery that August. Ulm and Eskandari decided to do a two-stage repair. Doctors like to wait longer to do surgery to allow for more bone growth in the skull so there’s enough bone to perform reconstruction, but Rhett’s condition was progressing quickly. They needed to relieve pressure on his brain so they opted to go ahead with the first surgery.

Eskandari holds up the 3-D skull. “On this model, you can see where this side is open and this side has been fused. In this case when things fuse like this too early, as the brain is trying to grow and the skull tries to expand, the side that is fused can’t grow. As the brain continues to try to grow, everything gets pulled over to one side.”

Rhett’s eye had started to pull up – a condition called a harlequin eye – and a part of the forehead area was pushing forward. The first step was to take away bone from the sutures that had prematurely fused. “That’s when this comes really in handy,” he says, turning the 3-D model in his hand. “We used these to plan the cuts.”

Since Rhett’s brain needed room to expand, the surgeons also did a technique called a barrel stave osteotomy. “The barrel stave sort of describes it. You make slits in the bone – it’s like the Blooming Onion from Outback,” he said, explaining a crisscrossing of cuts in the skull.

“The cuts give it the extra ability to grow faster. By relieving the pressure from the bone by doing the barrel staves, it forces the brain to grow in the direction you want it to grow faster.”

Following surgery, the doctors also opted to do helmet therapy to really force growth in the directions they wanted. “He’s gotten a good correction,” says Eskandari. “His brain growth is significant in the early stages and the cuts and the helmet all worked together to get a good reconstruction.”

When Rhett is about 18 months old, they’ll perform a second surgery to remove the frontal bone and reconstruct the forehead and eye area. Because the orbits or eye sockets have really been affected, they will do an orbital osteotomy. Ulm, a father of three, is glad to see the progress Rhett already has made. It’s one of the parts of his job he enjoys the most.

“It’s amazing the difference you can make in kids and see the immediate and profound change that you can make in their appearance and development at that age.”

Training of the future

Ulm says he and Eskandari often work complicated cases such as this as a team. “We’re both young, fresh and eager to improve the methods by which we treat babies with these conditions to make surgery safer and more effective.”

Eskandari agrees, adding that Ulm is so laid back, it’s hard to get a rise out of him. “He’s so even keel and he’s so cerebral. He’s very meticulous and very thoughtful.”

Their differing backgrounds as a neurosurgeon and a plastic surgeon allow them different perspectives. They capitalize on each other’s expertise and both embrace using the new 3-D bioprinting technology, Eskandari says.