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Fischer S, Unander-Scharin J, Bhatti-Söfteland M, Nysjö J, Maltese G, Lif H, Tarnow P, Enblad P, Kölby L, Nowinski D. Springs Produce Favorable Morphologic Outcomes Relative to H-Craniectomy According to a Two-Center Comparison of Matched Cases. Plast Reconstr Surg 2024; 154:317e-325e. [PMID: 39046901 DOI: 10.1097/prs.0000000000010761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Sagittal synostosis is the most common type of premature suture closure, and many surgical techniques are used to correct scaphocephalic skull shape. Given the rarity of direct comparisons of different surgical techniques for correcting craniosynostosis, this study compared outcomes of craniotomy combined with springs and H-craniectomy for nonsyndromic sagittal synostosis. METHODS Comparisons were performed using available preoperative and postoperative imaging and follow-up data from the 2 craniofacial national referral centers in Sweden, which perform 2 different surgical techniques: craniotomy combined with springs and H-craniectomy (the Renier technique). The study included 23 pairs of patients matched for sex, preoperative cephalic index, and age. Cephalic index, total intracranial volume (ICV), and partial ICV were measured before surgery and at 3 years of age, with volume measurements compared against those of preoperative and postoperative controls. Perioperative data included operation time, blood loss, volume of transfused blood, and length of hospital stay. RESULTS Craniotomy combined with springs resulted in less bleeding and lower transfusion rates than H-craniectomy. Although the spring technique requires 2 operations, the mean total operation time was similar for the methods. Of the 3 complications that occurred in the group treated with springs, 2 were spring-related. The compiled analysis of changes in cephalic index and partial volume distribution revealed that craniotomy combined with springs resulted in superior morphologic correction. CONCLUSION The findings showed that craniotomy combined with springs normalized cranial morphology to a greater extent than H-craniectomy based on changes in cephalic index and total and partial ICVs over time. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Sara Fischer
- From the Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Sahlgrenska University Hospital
| | | | - Madiha Bhatti-Söfteland
- From the Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Sahlgrenska University Hospital
| | - Johan Nysjö
- Department of Information Technology, Centre for Image Analysis
| | - Giovanni Maltese
- From the Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Sahlgrenska University Hospital
| | - Hanna Lif
- Department of Surgical Sciences, Plastic Surgery, Uppsala University Academic Hospital
| | - Peter Tarnow
- From the Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Sahlgrenska University Hospital
| | - Per Enblad
- Department of Medical Sciences, Neurosurgery, Uppsala University
| | - Lars Kölby
- From the Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Sahlgrenska University Hospital
| | - Daniel Nowinski
- Department of Surgical Sciences, Plastic Surgery, Uppsala University Academic Hospital
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Mellgren J, Maltese G, Tarnow P, Bhatti-Søfteland M, Kölby L, Säljö K. Spring-Assisted Surgery of Unilambdoid Craniosynostosis. J Craniofac Surg 2024; 35:00001665-990000000-01350. [PMID: 38353548 PMCID: PMC11045546 DOI: 10.1097/scs.0000000000010035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/03/2024] [Indexed: 04/28/2024] Open
Abstract
Craniosynostosis is traditionally treated with extensive cranial vault reconstructions (CVRs). Although less invasive techniques, such as endoscopic strip craniectomy with postoperative helmet therapy, have been successful, they also present difficulties. An alternative method is distraction osteogenesis using either manually controlled devices or specially designed springs. In this study, the authors provide the first comparison of spring-assisted surgery (SAS) with CVR for the treatment of unilambdoid synostosis (ULS). Fourteen consecutive patients (8 CVR and 6 SAS) treated for ULS at Sahlgrenska University Hospital between 2005 and 2018 were included. Skull shape and deviations were evaluated using previously defined measurement points on 3-dimensional computed tomography scans preoperatively, at spring removal, and at 3 years of age. Posterior and middle cranial fossa (PCF and MCF, respectively), skull-base cant, facial twist, and mastoid bulge (MB) were measured, and clinical data were obtained from chart reviews. The results indicated that at the 3-year follow-up, PCF, MCF, and MB improved in both groups, with no significant difference in outcome observed between methods. In the SAS group, duration of operation [61±27 min (mean±SD)] and perioperative bleeding (3.5±2.8 mL/kg body weight) were both significantly lower relative to the CVR group (P<0.05). These findings showed that both SAS and CVR resulted in similar improvements in treating ULS, although neither produced complete normalization of skull shape. The results suggest that early diagnosis and operation allow less extensive SAS to be performed without adversely affecting the results.
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Affiliation(s)
- Jonas Mellgren
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg
- Department of Plastic Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Giovanni Maltese
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg
- Department of Plastic Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Peter Tarnow
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg
- Department of Plastic Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Madiha Bhatti-Søfteland
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg
- Department of Plastic Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Lars Kölby
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg
- Department of Plastic Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Karin Säljö
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg
- Department of Plastic Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
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Sanati-Mehrizy P, Hopper RA, Susarla SM. Discussion: Improved Facial and Skull-Base Symmetry following Osteotomy and Distraction of Unilateral Coronal Synostosis. Plast Reconstr Surg 2024; 153:457-460. [PMID: 38266138 DOI: 10.1097/prs.0000000000010778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Affiliation(s)
- Paymon Sanati-Mehrizy
- From the Craniofacial Center, Divisions of Plastic and Craniofacial Surgery and Oral and Maxillofacial Surgery, Seattle Children's Hospital
| | - Richard A Hopper
- From the Craniofacial Center, Divisions of Plastic and Craniofacial Surgery and Oral and Maxillofacial Surgery, Seattle Children's Hospital
| | - Srinivas M Susarla
- From the Craniofacial Center, Divisions of Plastic and Craniofacial Surgery and Oral and Maxillofacial Surgery, Seattle Children's Hospital
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Selvaggi G, Maltese G, Kölby L, Elander A, Tarnow P, Kljajić M. Ethical Considerations in Surgery for Single-suture Craniosynostosis. J Craniofac Surg 2023; 34:1922-1926. [PMID: 37552119 DOI: 10.1097/scs.0000000000009590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/19/2023] [Indexed: 08/09/2023] Open
Abstract
Singe-suture craniosynostosis (SSC) describes the premature fusion of one cranial suture, which restricts cranial growth and consequently results in unaffected regions presenting a compensatory expansion. Surgery can redistribute intracranial volume, reduce the risk of elevated intracranial pressure, and improve head shape, potentially leading to improved neurocognitive function and social acceptance. However, there is limited evidence that surgery for SSC improves neurocognitive function and social acceptance. Given the inherent surgical risks and uncertainty of outcomes, the conditions under which this surgery should be allowed remain uncertain. Here, we discuss ethical questions regarding the permissibility of surgery, value of neurocognitive function and social acceptance, research ethics associated with SSC, patient autonomy and parental roles, and the process of recommending surgery and obtaining consent. Because surgery for SSC has become a routine procedure, its practice now presents a relatively low risk of complications. Furthermore, having acquired an understanding of the risks associated with this surgery, such knowledge fulfils the principle of non-maleficence although not beneficence. Thus, we advocate that surgery should only be offered within Institutional Review Board-approved research projects. In these situations, decisions concerning enrollment in scientific research involves health care providers and parents or guardians of the child, with the former acting as gate-keepers upon recognition of a lack of coping skills on the part of the parent or guardian in dealing with unforeseen outcomes. To minimize associated surgical risks and maximize its benefits, there exists a moral obligation to refer patients only to highly specialized centers.
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Affiliation(s)
- Gennaro Selvaggi
- University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Department of Plastic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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Michaëlsson I, Skoglund T, Hallén T, Olsson R, Maltese G, Tarnow P, Bhatti-Søfteland M, Zetterberg H, Blennow K, Kölby L. Circulating Brain-Injury Markers After Surgery for Craniosynostosis. World Neurosurg 2023; 173:e593-e599. [PMID: 36863456 DOI: 10.1016/j.wneu.2023.02.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVE Historically, there have been few quantitative methods for effectively evaluating outcomes after surgery for craniosynostosis. In this prospective study, we assessed a novel approach for detecting possible postsurgery brain injury in patients with craniosynostosis. METHODS We included consecutive patients operated on for sagittal (pi-plasty or craniotomy combined with springs) or metopic (frontal remodeling) synostosis at the Craniofacial Unit at Sahlgrenska University Hospital, Gothenburg, Sweden, from January 2019 to September 2020. Plasma concentrations of the brain-injury biomarkers neurofilament light (NfL), glial fibrillary acidic protein (GFAP), and tau were measured immediately before induction of anesthesia, immediately before and after surgery, and on the first and the third postoperative days using single-molecule array assays. RESULTS Of the 74 patients included, 44 underwent craniotomy combined with springs for sagittal synostosis, 10 underwent pi-plasty for sagittal synostosis, and 20 underwent frontal remodeling for metopic synostosis. Compared with baseline, GFAP level showed a maximal significant increase at day 1 after frontal remodeling for metopic synostosis and pi-plasty (P = 0.0004 and P = 0.003, respectively). By contrast, craniotomy combined with springs for sagittal synostosis showed no increase in GFAP. For neurofilament light, we found a maximal significant increase at day 3 after surgery for all procedures, with significantly higher levels observed after frontal remodeling and pi-plasty compared with craniotomy combined with springs (P < 0.001). CONCLUSIONS These represent the first results showing significantly increased plasma levels of brain-injury biomarkers after surgery for craniosynostosis. Furthermore, we found that more extensive cranial vault procedures resulted in higher levels of these biomarkers relative to less extensive procedures.
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Affiliation(s)
- Isak Michaëlsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Thomas Skoglund
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Tobias Hallén
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Robert Olsson
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Giovanni Maltese
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Peter Tarnow
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Madiha Bhatti-Søfteland
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden; Department of Neurodegenerative Disease, UCL Institute of Neurology, London, United Kingdom; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; UK Dementia Research Institute at UCL, London, United Kingdom; Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Lars Kölby
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden.
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Two-Center Review of Posterior Vault Expansion following a Staged or Expectant Treatment of Crouzon and Apert Craniosynostosis. Plast Reconstr Surg 2023; 151:615-626. [PMID: 36730425 DOI: 10.1097/prs.0000000000009925] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The timing of posterior cranial expansion for the management of intracranial pressure can be "staged" by age and dysmorphology or "expectant" by pressure monitoring. The authors report shared outcome measures from one center performing posterior vault remodeling (PCVR) or distraction (PVDO) following a staged approach and another performing spring-assisted expansion (SAPVE) following an expectant protocol. METHODS Apert or Crouzon syndrome patients who underwent posterior expansion younger than 2 years were included. Perioperative outcomes and subsequent cranial operations were recorded up to last follow-up and intracranial volume changes measured and adjusted using growth curves. RESULTS Thirty-eight patients were included. Following the expectant protocol, Apert patients underwent SAPVE at a younger age (8 months) than Crouzon patients (16 months). The initial surgery time was shorter but total operative time, including device removal, was longer for PVDO (3 hours 52 minutes) and SAPVE (4 hours 34 minutes) than for PCVR (3 hours 24 minutes). Growth-adjusted volume increase was significant and comparable. Fourteen percent of PCVR, 33% of PVDO, and 11% of SAPVE cases had complications, but without long-term deficits. Following the staged approach, 5% underwent only PVDO, 85% had a staged posterior followed by anterior surgery, and 10% required a third expansion. Following the expectant approach, 42% of patients had only posterior expansion at last follow-up, 32% had a secondary cranial surgery, and 26% had a third cranial expansion. CONCLUSION Two approaches involving posterior vault expansion in young syndromic patients using three techniques resulted in comparable early volume expansion and complication profiles. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Introduction of Spring-Assisted Cranioplasty for Sagittal Craniosynostosis in a Craniofacial Service: A Report of Early Experience. J Craniofac Surg 2022; 34:899-903. [PMID: 36731050 DOI: 10.1097/scs.0000000000009065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 08/08/2022] [Indexed: 02/04/2023] Open
Abstract
Spring-assisted cranioplasty (SAC) for the treatment of craniosynostosis uses internal springs to produce dynamic changes in cranial shape over several months before its removal. The purpose of this study was to report the first Egyptian experiences with SAC in the treatment of children with sagittal synostosis and evaluate the preliminary outcome. A total of 17 consecutive patients with scaphocephaly underwent SAC with a midline osteotomy along the fused sagittal suture and insertion of 3 springs with bayonet-shaped ends across the opened suture. Operative time, blood transfusion requirements and length of ICU, total hospital stay, and complications graded according to Oxford protocol classification were recorded. Spring removal was performed once re-ossification of the cranial defect occurred. All patients successfully underwent SAC without significant complications. The mean age at surgery was 6.8 months. The mean time of the spring insertion surgery was 63 minutes (SD 9.7). Blood transfusion was needed in less than half of the patients (41.2%).The mean duration of hospital stay was 3.2 days. The mean timing of spring removal was 5.5 months (SD 0.4). The mean time of the second surgery (spring removal) was 22.8 minutes (SD 3.6). In conclusion, SAC can easily be incorporated into the treatment armamentarium of craniofacial surgeons. The technique offers a safe and minimally invasive option for the treatment of sagittal craniosynostosis with the benefit of limited dural undermining, minimal blood loss, operative time, anesthetic time, ICU stay, and hospital stay.
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Comparisons of Intracranial Volume and Cephalic Index After Correction of Sagittal Craniosynostosis With Either Two or Three Springs. J Craniofac Surg 2021; 32:2636-2640. [PMID: 34238871 DOI: 10.1097/scs.0000000000007870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT In this retrospective study, the authors determined changes in intracranial volume (ICV) and cephalic index (CI) in patients with sagittal craniosynostosis and operated with craniotomy combined with either 2 or 3 springs. The authors included patients (n = 112) with complete follow-up that had undergone surgical correction for isolated sagittal craniosynostosis with craniotomy combined with springs between 2008 and 2017. All patients underwent computed tomography examination preoperative, at the time of spring extraction, and at 3 years of age. Intracranial volume was measured using a semiautomatic MATLAB program, and CI was calculated as the width/length of the skull. The authors found that craniotomy combined with 2 springs increased the ICV from a preoperative value of 792 ± 113 mL (mean ± standard deviation) to 1298 ± 181 mL at 3 years of age and increased the CI from 72.1 ± 4.1 to 74.6 ± 4.3, whereas craniotomy combined with 3 springs increased the ICV from 779 ± 128 mL to 1283 ± 136 mL and the CI from 70.7 ± 4.3 to 74.8 ± 3.7. The relative increase in ICV was 65 ± 21% in the two-spring group and 68 ± 34% in the three-spring group (P value = 0.559), and the relative increase in CI was 3.6 ± 3.3% in the two-spring group as compared with 6.0 ± 5.0% in the three-spring group (P = 0.004). These findings demonstrated that use of 3 springs resulted in additional absolute and relative CI-specific effects as compared with 2 springs during the time when the springs were in place, with this effect maintained at 3 years of age.
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Simplified Postoperative Care After Spring-assisted Strip Craniotomy for Sagittal Synostosis: A Prospective Before-and-After Study. J Craniofac Surg 2021; 32:1507-1510. [PMID: 33534314 DOI: 10.1097/scs.0000000000007498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Since the development of spring-assisted techniques for corrective craniofacial surgery, routine postoperative admission to intensive care units (ICUs) has been questioned. However, close monitoring is necessary if the continuous infusion of morphine is used as recommended for better pain relief. In this study, the authors evaluated a simplified postoperative protocol without continuous morphine infusion and no indwelling urinary catheter following spring-assisted surgery (SAS) for sagittal synostosis. Ten children were cared for according to a standard protocol with postoperative intravenous (i.v.) infusion of morphine and an indwelling urinary catheter, and 11 consecutive children were treated according to a simplified protocol with pain relief based on intermittent injections of morphine and clonidine [according to Face, Legs, Activity, Cry, Consolability (FLACC) scores >4] without the indwelling catheter. A Mann-Whitney U test was used for comparison of distributions between the two groups. The results revealed no differences between groups regarding the proportion of FLACC scores >4, total amount of administered i.v. morphine and clonidine, total volume of buffered glucose infused, time to first feeding on breast milk or substitute, or the length of stay. Despite the inherent limitations of our small observational study, the authors concluded that at our institution, it was possible to exclude a standard continuous i.v. infusion of morphine and an indwelling urinary catheter from our postoperative care protocol without decreasing the quality of pain relief in children submitted to SAS for sagittal synostosis. This finding supports downgrading the level of care from the ICU to a regular ward after limited immediate postoperative observation.
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