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Wu M, Barnett SL, Massenburg BB, Ng JJ, Romeo DJ, Taylor JA, Bartlett SP, Swanson JW. Early posterior vault distraction osteogenesis changes the syndromic craniosynostosis treatment paradigm: long-term outcomes of a 23-year cohort study. Childs Nerv Syst 2024; 40:2811-2823. [PMID: 38904767 PMCID: PMC11322207 DOI: 10.1007/s00381-024-06465-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 05/14/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Early surgical management of syndromic craniosynostosis varies widely between centers, with patients typically undergoing multiple intracranial procedures through childhood. This study evaluates the long-term impact of early posterior vault distraction osteogenesis (PVDO) versus conventional treatment paradigms on the number and timing of subsequent craniofacial procedures. METHODS We retrospectively analyzed the longitudinal operative patterns of patients with syndromic craniosynostosis treated from 2000 to 2023 with greater than five years of follow-up. Outcomes of patients who underwent early PVDO and conventional vault reconstruction were compared. RESULTS Fifty-five patients met the inclusion criteria (30 PVDO and 25 conventional). Age at initial vault surgery was similar between the PVDO and conventional cohorts (7.6 vs. 8.8 months), as were baseline craniometrics (p > 0.05). Multiple fronto-orbital advancement (FOA) procedures were performed in only 1/30 (3%) PVDO-treated patient versus 12/25 (48%) conventionally-treated patients (p < 0.001). Twelve (40%) PVDO-treated patients did not undergo FOA at all. Among patients with Apert and Crouzon syndromes, fewer PVDO-treated patients required FOA prior to midface surgery (33% vs. 92%, p = 0.004) or repeat FOA (6% vs. 50%, p = 0.005) compared to conventionally-treated patients. Among patients with Muenke and Saethre-Chotzen syndromes, a similar proportion of patients required FOA in the PVDO and conventional cohorts (91% vs. 100%, p = 0.353), though no PVDO-treated patients required repeat FOA (0% vs. 44%, p = 0.018). CONCLUSIONS Early PVDO is associated with a reduction in the high burden of both FOA and, critically, revisionary frontal procedures which are commonly seen in conventionally-treated patients with syndromic craniosynostosis.
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Affiliation(s)
- Meagan Wu
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA, USA
| | - Sarah L Barnett
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA, USA
| | - Benjamin B Massenburg
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA, USA
| | - Jinggang J Ng
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA, USA
| | - Dominic J Romeo
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA, USA
| | - Jesse A Taylor
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA, USA
| | - Scott P Bartlett
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA, USA
| | - Jordan W Swanson
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA, USA.
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Ng JJ, Saikali LM, Zapatero ZD, Massenburg BB, Wu M, Romeo DJ, Heuer GG, Bartlett SP, Taylor JA, Swanson JW, Lang SS. Vaulting further: cranial vault expansion for craniocerebral disproportion without primary craniosynostosis. Childs Nerv Syst 2024:10.1007/s00381-024-06517-2. [PMID: 38922367 DOI: 10.1007/s00381-024-06517-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 06/20/2024] [Indexed: 06/27/2024]
Abstract
PURPOSE Treatment of subjects with refractory idiopathic intracranial hypertension (IIH) or shunted hydrocephalus with chronic shunt complications is challenging. What is the role for cranial vault expansion, particularly utilizing posterior vault distraction osteogenesis (PVDO), in these cases? This study assesses medium-term efficacy of cranial vault expansion in this unique patient population. METHODS A retrospective review was conducted of patients who underwent cranial vault expansion from 2008 to 2023 at the Children's Hospital of Philadelphia. Subjects who did not have a diagnosis of primary craniosynostosis were included in the study. Demographic information, medical history, and perioperative details were collected from medical records. Primary outcomes were the rate of CSF diversion procedures and resolution of presenting signs and symptoms. Secondary outcomes were perioperative and 90-day complications and reoperation requirement. RESULTS Among 13 included subjects, nine (69.2%) patients had a primary diagnosis of shunted hydrocephalus and 4 (30.8%) patients had IIH. Twelve (92.3%) subjects underwent posterior vault distraction osteogenesis (PVDO) and one (7.7%) underwent posterior vault remodeling (PVR). All 4 patients with IIH demonstrated symptomatic improvement following PVDO, including resolution of headaches, vomiting, and/or papilledema. Among 9 patients with shunted hydrocephalus, CSF diversion requirement decreased from 2.7 ± 1.6 procedures per year preoperatively to 1.2 ± 1.8 per year following cranial vault expansion (p = 0.030). The mean postoperative follow-up was 4.1 ± 2.1 years and four (30.8%) patients experienced complications within 90 days of surgery, including infection (n = 2), CSF leak (n = 1), and elevated ICP requiring lumbar puncture (n = 1). Four (30.8%) patients underwent repeat cranial vault expansion for recurrence of ICP-related symptoms. At most recent follow-up, 7 of 9 patients with shunted hydrocephalus demonstrated symptomatic improvement. CONCLUSION Cranial vault expansion reduced intracranial hypertension-related symptomology as well as the rate of CSF diversion-related procedures in patients with refractory IIH and shunted hydrocephalus without craniosynostosis, and should be considered in those who have significant shunt morbidity.
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Affiliation(s)
- Jinggang J Ng
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Linda M Saikali
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zachary D Zapatero
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Plastic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Benjamin B Massenburg
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Meagan Wu
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dominic J Romeo
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gregory G Heuer
- Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Scott P Bartlett
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Plastic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Plastic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jordan W Swanson
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Plastic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Shih-Shan Lang
- Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
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