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Punchak MA, Sarris C, Xu E, Flanders TM, Lang SS, Swanson JW, Taylor JA, Heuer GG. Craniosynostosis in primary metabolic bone disorders: a single-institution experience. Childs Nerv Syst 2023; 39:3583-3588. [PMID: 37420034 DOI: 10.1007/s00381-023-06059-z] [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: 03/15/2023] [Accepted: 06/24/2023] [Indexed: 07/09/2023]
Abstract
PURPOSE The incidence of metabolic bone diseases in pediatric neurosurgical patients is rare. We examined our institutional experience of metabolic bone diseases along with a review of the literature in an effort to understand management for this rare entity. METHODS Retrospective review of the electronic medical record database was performed to identify patients with primary metabolic bone disorders who underwent craniosynostosis surgery between 2011 and 2022 at a quaternary referral pediatric hospital. Literature review was conducted for primary metabolic bone disorders associated with craniosynostosis. RESULTS Ten patients were identified, 6 of whom were male. The most common bone disorders were hypophosphatemic rickets (n = 2) and pseudohypoparathyroidism (n = 2). The median age at diagnosis of metabolic bone disorder was 2.02 years (IQR: 0.11-4.26), 2.52 years (IQR: 1.24-3.14) at craniosynostosis diagnosis, and 2.65 years (IQR: 0.91-3.58) at the time of surgery. Sagittal suture was most commonly fused (n = 4), followed by multi-suture craniosynostosis (n = 3). Other imaging findings included Chiari (n = 1), hydrocephalus (n = 1), and concurrent Chiari and hydrocephalus (n = 1). All patients underwent surgery for craniosynostosis, with the most common operation being bifronto-orbital advancement (n = 4). A total of 5 patients underwent reoperation, 3 of which were planned second-stage surgeries and 2 of whom had craniosynostosis recurrence. CONCLUSIONS We advocate screening for suture abnormalities in children with primary metabolic bone disorders. While cranial vault remodeling is not associated with a high rate of postoperative complications in this patient cohort, craniosynostosis recurrences may occur, and parental counseling is recommended.
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Affiliation(s)
- Maria A Punchak
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, PA, 19146, USA.
| | - Christina Sarris
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emily Xu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tracy M Flanders
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, PA, 19146, USA
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shih-Shan Lang
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, PA, 19146, USA
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jordan W Swanson
- Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gregory G Heuer
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, PA, 19146, USA
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Kim EN, Leung KL, Wong A, McGregor J, Skolnick GB, Patel KB, Gosman AA. Management of Craniosynostosis in Lethal Perinatal Hypophosphatasia. J Craniofac Surg 2023; 34:2422-2425. [PMID: 37610006 DOI: 10.1097/scs.0000000000009641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/11/2023] [Indexed: 08/24/2023] Open
Abstract
Although perinatal lethal hypophosphatasia (HPP) was once a disease with a universally poor prognosis, it has now become a rare but treatable condition with the advent of enzyme replacement therapy with asfotase alfa. As a result, a greater population of patients with perinatal HPP are presenting with abnormal head shape and craniosynostosis. The authors present here 3 cases of perinatal lethal HPP, 1 treated with traditional open cranial vault remodeling and 2 treated utilizing distraction osteogenesis techniques. All patients demonstrated outcomes comparable to those previously reported with traditional observation or open cranial vault repair. Thorough consideration and discussion between the surgical team and patient's family is needed to determine a treatment plan that best addresses the goals of patient and family in light of recent advances in medical treatment in this rare patient population in which surgical interventions were previously nearly impossible. This article further supports the safety and efficacy of surgical intervention and explores the utility of distraction osteogenesis to address craniosynostosis in this patient population.
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Affiliation(s)
- Erinn N Kim
- Division of Plastic Surgery, University of California San Diego, San Diego, CA
| | - Karen L Leung
- Division of Plastic Surgery, University of California San Diego, San Diego, CA
| | - Alvin Wong
- Division of Plastic Surgery, Virginia Commonwealth University, Richmond, VA
| | - Jyoti McGregor
- Section of Plastic Surgery, University of Mannitoba, Winnipeg, MB, Canada
| | - Gary B Skolnick
- Division of Plastic Surgery, Washington University, St. Louis, MO
| | - Kamlesh B Patel
- Division of Plastic Surgery, Washington University, St. Louis, MO
| | - Amanda A Gosman
- Division of Plastic Surgery, University of California San Diego, San Diego, CA
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Roth DM, Piña JO, MacPherson M, Budden C, Graf D. Physiology and Clinical Manifestations of Pathologic Cranial Suture Widening. Cleft Palate Craniofac J 2023:10556656231178438. [PMID: 37271984 DOI: 10.1177/10556656231178438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
Cranial sutures are complex structures integrating mechanical forces with osteogenesis which are often affected in craniofacial syndromes. While premature fusion is frequently described, rare pathological widening of cranial sutures is a comparatively understudied phenomenon. This narrative review aims to bring to light the biologically variable underlying causes of widened sutures and persistent fontanelles leading to a common outcome. The authors herein present four syndromes, selected from a literature review, and their identified biological mechanisms in the context of altered suture physiology, exploring the roles of progenitor cell differentiation, extracellular matrix production, mineralization, and bone resorption. This article illustrates the gaps in understanding of complex craniofacial disorders, and the potential for further unification of genetics, cellular biology, and clinical pillars of health science research to improve treatment outcomes for patients.
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Affiliation(s)
- Daniela M Roth
- School of Dentistry, University of Alberta, Edmonton, Canada
| | - Jeremie Oliver Piña
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | | | - Curtis Budden
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Daniel Graf
- School of Dentistry, University of Alberta, Edmonton, Canada
- Department of Medical Genetics, University of Alberta, Edmonton, Canada
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Sklirou E, Alodaib AN, Dobrowolski SF, Mohsen AWA, Vockley J. Physiological Perspectives on the Use of Triheptanoin as Anaplerotic Therapy for Long Chain Fatty Acid Oxidation Disorders. Front Genet 2021; 11:598760. [PMID: 33584796 PMCID: PMC7875087 DOI: 10.3389/fgene.2020.598760] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/27/2020] [Indexed: 12/15/2022] Open
Abstract
Inborn errors of mitochondrial fatty acid oxidation (FAO) comprise the most common group of disorders identified through expanded newborn screening mandated in all 50 states in the United States, affecting 1:10,000 newborns. While some of the morbidity in FAO disorders (FAODs) can be reduced if identified through screening, a significant gap remains between the ability to diagnose these disorders and the ability to treat them. At least 25 enzymes and specific transport proteins are responsible for carrying out the steps of mitochondrial fatty acid metabolism, with at least 22 associated genetic disorders. Common symptoms in long chain FAODs (LC-FAODs) in the first week of life include cardiac arrhythmias, hypoglycemia, and sudden death. Symptoms later in infancy and early childhood may relate to the liver or cardiac or skeletal muscle dysfunction, and include fasting or stress-related hypoketotic hypoglycemia or Reye-like syndrome, conduction abnormalities, arrhythmias, dilated or hypertrophic cardiomyopathy, and muscle weakness or fasting- and exercise-induced rhabdomyolysis. In adolescent or adult-onset disease, muscular symptoms, including rhabdomyolysis, and cardiomyopathy predominate. Unfortunately, progress in developing better therapeutic strategies has been slow and incremental. Supplementation with medium chain triglyceride (MCT; most often a mixture of C8–12 fatty acids containing triglycerides) oil provides a fat source that can be utilized by patients with long chain defects, but does not eliminate symptoms. Three mitochondrial metabolic pathways are required for efficient energy production in eukaryotic cells: oxidative phosphorylation (OXPHOS), FAO, and the tricarboxylic (TCA) cycle, also called the Krebs cycle. Cell and mouse studies have identified a deficiency in TCA cycle intermediates in LC-FAODs, thought to be due to a depletion of odd chain carbon compounds in patients treated with a predominantly MCT fat source. Triheptanoin (triheptanoyl glycerol; UX007, Ultragenyx Pharmaceuticals) is chemically composed of three heptanoate (seven carbon fatty acid) molecules linked to glycerol through ester bonds that has the potential to replete TCA cycle intermediates through production of both acetyl-CoA and propionyl-CoA through medium chain FAO. Compassionate use, retrospective, and recently completed prospective studies demonstrate significant reduction of hypoglycemic events and improved cardiac function in LC-FAOD patients, but a less dramatic effect on muscle symptoms.
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Affiliation(s)
- Evgenia Sklirou
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ahmad N Alodaib
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Newborn Screening and Biochemical Genetics Lab, Department of Genetics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Steven F Dobrowolski
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Al-Walid A Mohsen
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jerry Vockley
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States.,Center for Rare Disease Therapy, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
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