Lindy Washburn

All 17-year-old Josh Schultz could think about was the pain in his head. That, and hockey.

The right side of his face throbbed most of the time. It kept him up late at night. It woke him early in the morning.

The pain radiated outward - relentless, rhythmic. When it was bad, all he could hear was the blood pumping in his head. It pulsated from his right temple through the side of his face, moving with his heartbeat, sharp and piercing.

In hockey, a sport he'd played since age 3 with exceptional skill, he found himself afraid to go into corners, afraid of being checked hard into the boards. It hurt too much to get hit. Once, his coach stopped practice for a few minutes when Josh came out of a drill in immense pain and began screaming.

But Josh kept going. His club team was on its way to USA Hockey's national tournament; his high school team, the Indian Hills Braves, on their way to the state finals. Josh was their star defenseman. He was tough.

How tough, even his coach didn't realize. "I knew it was bad," coach Anthony Tabbacchino would later say of Josh's condition, "but I didn't know how bad it was until everything was over."

"Everything" for Josh would mean the discovery that the source of his pain was a tumor in his skull. It would mean neurosurgery, reconstruction, and recuperation - all made possible by a dream team of surgeons and technology that is revolutionizing brain surgery.

For a high school athlete, there is only one senior year. His parents and the doctors would try to save Josh's.

Josh's crisis began simply enough. He woke up one summer morning before his sophomore year complaining that his jaw felt off-kilter. His mother, Sandy Schultz, told him he'd probably just slept in the wrong position.

That odd feeling gradually morphed into straight-out pain. Within a year, they had visited orthodontists, pediatricians, and ear, nose and throat specialists. The orthodontist tightened the space between Josh's teeth. The ENTs prescribed multiple rounds of medication for swimmer's ear.

But things kept getting worse. Josh lost the hearing in his right ear. He had trouble smiling and chewing. The pain was nearly crippling. There was a bump at his right temple.

Sandy was the principal of a preschool, organized and capable; her husband, Rob, a human-resources executive. Josh was the youngest of their two boys - quiet and reserved, shining most on the ice. He was a master of the puck, bringing it down, setting up his team's power play.

When Josh couldn't sleep, Sandy stayed up with him. In the middle of the night, she would sit at her computer, searching the web for answers while Josh lay on the sofa nearby, enduring.

Mornings before school, she gave him two Ibuprofen with breakfast. The pills got him through six of nine periods. After they wore off, he stopped caring about anything. "I just sat there in pain," he said.

Finally, an ear specialist detected that Josh's hearing was blocked not by an inflamed ear canal, but by something solid - a mass. He ordered a CT scan. That, at last, provided a diagnosis.

The doctor thought it was fibrous dysplasia, an uncommon bone disorder in which scar tissue replaces normal bone, causing it to become weak and - depending on the location - leading to nerve pain and deformity.

But even with a diagnosis, Sandy didn't know what to do, how to help her son. The problem was the location of the mass: near Josh's brain in the base of his skull, close to the nerves that control facial sensation and expression and the ability to chew and swallow. The specialists, mindful that the problem could grow back, hesitated to operate. One suggested that he manage it long term with painkillers.

In the middle of one particularly bad night, Sandy thought, "Nobody can live on Ibuprofen the rest of their lives. This can't be his norm. He's 17."

So she kept searching online. That night, one neurosurgeon's name popped up several times - Joshua Bederson. He was chief of neurosurgery at Mount Sinai Health System in New York.

The next day, she made an appointment.

In the operating suite at Mount Sinai, Bederson, 60, has combined the technologies of two of his favorite pastimes, surgery and flying.

Much as a pilot navigates through fog with three-dimensional GPS, Bederson uses images showing brain tissue, blood supply, bone and nerves as he navigates through the brain. He is among the first neurosurgeons to bring this imaging directly into his field of vision while he operates.

Picture the movie, "Avatar," brought to life in brain surgery.

Long before the day of surgery arrives, Bederson's operating team creates a simulation of the patient's head to plan the procedure. On the screen, they spin the virtual head around, try different approaches - through the nose, under the ear, from the top - to see what will be safest, quickest and most effective.

Bederson, professional surgeon and amateur pilot, flies - virtually - through his patient's brain.

Then, when the surgeon operates, these images are shown in transparent outline in the eyepiece of the operating microscope. That powerful instrument is suspended over the patient's bed and used during surgery. The "heads-up display" helps the surgeon find his way through skin and bone and other tissue to home in on the target.

He "sees" what lies beyond his drills and precision tools in the operating field, the way a pilot with a heads-up display on his windshield can "see" a mountain within the fog. "No-fly zones" - such as the carotid arteries - are flagged off limits.

"We are living in the future before we even know it," Bederson said. He'd used navigational aids to fly and land a plane, and wanted to see how the technology could be applied in the operating room.

Layered into this "GPS for the brain" is information from CT angiography scans, showing the bones, hard tissue and blood vessels, and MRI scans, showing soft tissue. He dials through the different layers as he operates.

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While each of these technologies has been available individually for a long time, Mount Sinai is the first to integrate them for both planning and performing surgeries, he said. And this is the wave of the future in surgery: patient simulations and even 3D printed versions of patient anatomy are leading to remarkable progress. Last month, Bederson taught a course about his work - "Advanced Use of Computer-Based Simulation Technologies for Intracranial Surgery" - at the annual scientific meeting of the American Association of Neurological Surgeons.

Sandy was so nervous when they drove in to see Bederson on Presidents Day of 2016 she left Josh's CT scan on the kitchen counter in Wyckoff. When she discovered her mistake in the parking garage on 98th Street, Josh was the calm one. He consoled her, and the staff was understanding. She went home and drove back with the scan.

When Bederson met Josh that day, he recalled, "you could see the deformity in his face."

Josh couldn't smile or open his mouth, the doctor said. "Right in front of his ear was a big mass. The side of his head was pushed out."

The doctor touched it with his fingers: "It was firm to the touch, like bone." And this was just the surface presentation, he knew; the mass extended inward as much as it did outward. More than anything, he was struck by Josh's overwhelming pain; he knew he had to operate to give the boy relief.

This is what Sandy remembers: "The first thing he was said was, 'We can fix that. And I don't see any malignancies.'"

Josh heard that, too. "That was good," said Josh. "That was nice to hear."

They scheduled the surgery after Josh's national hockey tournament and before his junior prom.

With their insurance, they could keep the focus on his care and recovery.

But there would be one more hiccup. As part of the work-up at an academic medical center, other neurosurgeons reviewed the case. Some were concerned that Josh's extreme pain might be evidence of a malignant tumor. They recommended an emergency biopsy.

So on the day the Indian Hills High School Braves played in the state hockey tournament semifinals, Josh was prepped for his biopsy, and didn't get to play. The bad news: his team was knocked out. The good news: the tumor wasn't malignant.

But the diagnosis now included something called osteoblastoma, a rare, non-cancerous bone tumor that destroys healthy bone and replaces it with abnormal bone material.

"He came home, healed and played hockey," said Sandy.

Josh was on the ice when the Skylands Kings, his club team, made it to the final eight in USA Hockey's national tournament at the end of March.

For Josh, hockey took his mind off everything - the tumor, the upcoming surgery, his pain. When he was playing, he didn't worry about any of it. Unless he got hit.

Surgery day: April 12, 2016. Three surgeons. Ten hours.

The plan was to go in and remove the tumor, reconstruct Josh's jaw and skull where the bone had been removed, and attempt to restore his hearing. Joining Bederson in the operating room were Dr. Eric M. Genden, chair of head and neck surgery at Mount Sinai, and Dr. Peter Weber, director of its Ear Institute.

For Josh, the lead-up had been rough -10 days with no Ibuprofen.

"There would be times where I would go upstairs to my bed and just moan," Josh said. But he was aiming for a goal - surgery - and he expected to come out of it pain-free. Whatever they wanted him to do, he would do.

The tumor was bigger than a golf ball, smaller than an orange, and very dense. Bederson approached it from above and behind Josh's right ear - making an incision like a reverse question mark on the right side of Josh's head.

He and Genden took apart the entire jaw joint to gain access to the tumor.

It had not penetrated the brain's temporal lobe, but it was close. The doctors took care to avoid bruising the brain tissue. Clots in the blood vessels could cause a stroke. The area was threaded with nerves - nerves that animate the face, provide hearing and sensation, move the tongue and enable chewing. They checked the nerve conductivity throughout the surgery.

Bederson worked to remove the skull base containing the tumor. Where it was hardest, he drilled with a diamond-tip bit whirring at 65,000 revolutions per minute, like an eraser for bone; in softer places, he dissected with a curette, a small hand tool used to scrape away tissue. And in areas dense with cartilage, he used an ultrasonic aspirator, a device that simultaneously fragments and sucks out the bone.

Next Genden took over. He carefully extracted a small piece of Josh's cranium, the bone in the upper skull, with which to rebuild his jaw. Because Josh is young, the implant had to contain clusters of cells that were still growing and reproducing, so the reconstructed bones would grow along with the rest of him. Otherwise, over time he might end up with an asymmetrical face.

A mother worries whether her son will survive, but her son worries about how he'll look.

The goal was a cure, but "You cannot hide your face," Genden said. Reconstructing it so Josh could eat and drink, smile and chat with ease for the rest of his life, with no trace of his travails, was critically important.

Genden filled in the gap in the cranium with titanium mesh and a bone putty that allows new bone to grow in.

Finally, the ear. Weber found the nerves intact, but the auditory canal was badly eroded by the tumor. Rather than reopen it and risk infection in the operative area, he decided to surgically close it.

From 8 a.m. to 6 p.m., Sandy and Rob sat in the same place in the second floor waiting area and did not move. The chief physician's assistant, Leslie Schlachter, sent Sandy email updates.

At 7:30 p.m., they went in to see him.

He was smiling. And pain free. Their relief was indescribable.

"The instant I woke up," Josh said. "I didn't need anything at all."

No painkillers. Nothing.

The doctors had warned that the first few days might be more painful than ever before. The nurses kept asking if he wanted something in his intravenous line. He wanted nothing.

Two days later, he went home.

Two weeks later, he went back to school.

He wasn't bothered by the red scar, the reverse question mark that soon was hidden beneath his blond hair. He thought it was pretty cool, in fact. He got used to not hearing with his right ear. He now has a miniature microphone to put in it that transmits auditory signals electronically to a tiny receiver in his left ear.

When he got home, he had six weeks until his junior prom; he looked normal for the pictures. And he had six weeks until he could return to the ice in non-contact practices. His head was still so swollen when he started that it barely fit in the helmet, he said. But it felt great to be skating again.

Twelve weeks after the operation, Bederson gave the all-clear to play hockey again. Sandy wasn't so sure. He had a tournament the very next weekend. Perhaps the doctor could recommend switching to tennis or golf, she suggested.

Josh played.

Sandy stayed home. His father took him to the game.

"Every time he goes back on the ice, it's a little bit of PTSD," she said.

Senior year was satisfying: six goals, 12 assists. Assistant captain of his high school team. First Team, All-County. First Team, All-League. Scouted by college coaches. Last month he played in a national high school showcase. Next year, he'll go to Union College.

"He's one of the best players on the ice every night, for either team," said Coach Tabbacchino. He's also, although the spectators don't know it, a miracle on ice.

For Josh, this ordeal has accomplished something else - something almost as miraculous as his surgery and recovery. At 18, he knows the value of health and the beauty of life.

"My life [since the surgery] has been completely normal," he said, "which sounds like oh, it's not that great. But it's really, it's amazing. ... Just the fact that I'm not in pain - how much better that makes my life, in every single way."