Treatment of craniosynostosis

Impactful publishing: the Journal of Neurosurgery and its diamond anniversary (1944-2019)

With this landmark issue of the Journal of Neurosurgery (JNS), we celebrate the 75th anniversary of continuous publication of articles in neurosurgery. It is likely not a coincidence that the diamond anniversary of the JNS coincides precisely with the 150th anniversary of the birth of Harvey Cushing. It is possible that some events in life are inextricably and cosmically tied together, such as the birth of the founding father of our specialty, the society named after him that ultimately became the American Association of Neurological Surgeons (AANS), and the journal of this organization-the JNS.

Endoscopy-assisted wide-vertex craniectomy, “barrel-stave” osteotomies, and postoperative helmet molding therapy in the early management of sagittal suture craniosynostosis

Object

The purpose of this study was to assess the efficacy, safety, associated complications, and outcome in patients with sagittal suture craniosynostosis in whom endoscopy-assisted wide-vertex craniotomy and “barrel-stave” osteotomy were performed.

Methods

During a 4-year period, 59 patients with sagittal suture synostosis underwent endoscopy-assisted wide-vertex craniectomies, barrel stave–like osteotomies, and postoperatively were fitted with custom-made molding helmets. Data on operative time, blood loss, transfusion rates, hospital length of stay, complications, and hospital charges were collected prospectively. The mean patient age at the time of surgery was 3.7 months. The average blood loss was 31.8 ml; and only one patient required an intraoperative blood transfusion. Nine patients received transfusions of donor blood postoperatively. The mean operative time was 50 minutes, and all but three patients were discharged from the hospital the morning following surgery. There were no intraoperative complications. Normocephaly as well as normal cephalic indices were observed at latest follow up.

Conclusions

The authors conclude that early treatment of infants with sagittal suture craniosynostosis by using minimally invasive, endoscopy-assisted wide-vertex craniectomies provides excellent results and a significantly lower morbidity rate than traditional calvarial vault reconstructive procedures.

Total calvarial reconstruction for sagittal synostosis in older infants and children

Premature closure of the sagittal suture is the most common form of craniosynostosis, but this condition occasionally goes unrecognized until the child is too old to undergo procedures that depend upon continued calvarial growth for success. As the entire calvaria is affected and thus misshapen by sagittal synostosis, late correction involves total calvarial reconstruction. The extensive nature of this undertaking has precluded its utilization despite the presence of significant deformities. Adapting the techniques and experience gained from craniofacial surgery, the authors performed total calvarial reconstruction on nine children with sagittal synostosis and subsequent scaphocephaly diagnosed after the age of 1 year. In each case the goals of shortening the anteroposterior length, widening the biparietal diameter, and reducing frontal and occipital deformities were met. Morbidity consisted of acute blood loss, postoperative hyponatremia, and in one case a residual skull defect. The rationale for this procedure and the techniques utilized are discussed.

The frontoorbital advancement--on the use of 3D-CT and the miniplate osteosynthesis

Between 1987 and 1991 we performed a unilateral or bilateral frontoorbital advancement to correct trigono- or plagiocephaly in 10 children: Three-dimensional CT provides an exact basis for operation planning. Titanium miniplates allow an already primarily rather stable osteosynthesis. The best time for this intervention is the end of the third month of life.

Midline craniectomy for sagittal suture synostosis: comparative efficacy of two barriers to calvarial reclosure

This report quantitatively compares long-term head remolding achieved by two methods for retarding bone reunion after midline craniectomy for sagittal suture synostosis. In one group of six children the adjacent bone edges were overlayed with 1.0-cm-wide U-channel silicone strips, and in the other group, composed of seven patients, a considerably larger extent of the adjacent cranium was covered with silicone sheets. Mean percent change in the cephalic indices of the former group 18 months postoperatively was 9.1% +/- S.D. = 6.7, and of the latter group 23.7% +/- S.D. = 6.0 (p congruent to 0.01). These results indicate that the use of large silicone sheets lead to a significantly greater normalization of cranial proportions.

Keyhole craniectomy for correction of sagittal synostosis

A modification of the technique combining sagittal strip, circular occipital and biparietal wedge craniectomies (Albright's procedure) for the treatment of sagittal synostosis, with prominent occipital bossing, is described. "Keyhole," as opposed to wedge, parietal craniectomies allow improvement in the shape of the skull, beginning intraoperatively, while eliminating the outbending of the parietal bone that occurs at the apex of a wedge craniectomy.

Functional prognosis of surgical treatment of craniosynostosis

Twenty-three cases of craniosynostosis were studied with regard to age at operation, symptoms, operative methods, and long-term results. Long-term results of 20 cases that were followed up for more than 1 year after surgery showed that mental retardation remained in 8 cases; a slight improvement in mental function was observed in only 2 cases. Of the 8 patients with mental retardation, 7 were operated on more than 6 months after birth, 7 showed striking digital impression on skull X-ray films and 5 were suffering from oxycephaly. Of the 8 patients with mental retardation, 5 had suffered from perinatal asphyxia or had seizures during delivery and subsequent past history. From these observations, factors affecting prognosis are: (1) age at operation; (2) the degree and duration of increased intracranial pressure; (3) the extent and degree of suture closures; (4) perinatal asphyxia and seizure disorders.

Roentgen stereophotogrammetric analysis of restricted periods of neurocranial suture immobilization in rabbits

The effect of temporary fusion of sutures on craniofacial growth was studied biometrically in 4-week-old male New Zealand White rabbits. Tantalum bone markers were implanted in the cranial vault, and the coronal suture immobilized with isobutyl-2-cyanoacrylate adhesive. Linear craniectomy was performed after 2 or 6 weeks of sutural growth restriction (four animals in each group). The animals were followed for approximately 17 weeks. Early craniectomy resulted in greatly increased coronal suture bone separation (175% of control growth rates in peers and 125% of maximal control rates). Growth after late craniectomy showed an age-dependent lower rate, but still the overshoot markedly surpassed controls (210% of control rates in peers and 65% of maximal control growth rates). Overall, both exhibited overcompensation in coronal suture growth. A rapid compensation of adjacent sutures to temporary growth restriction and a tendency toward spontaneous correction following release of growth inhibition were demonstrated. Thus, the total anteroposterior growth of the combined frontonasal and coronal sutures nearly equaled that of control animals. Following linear craniectomy, volumetric calvarial expansion increased considerably in both early and late groups, due to compensatory coronal suture growth, but probably due also to spatial bone rearrangements. Based upon the findings, the length of the suture immobilization period seems critical to longitudinal and volumetric growth as well as to subsequent compensatory activity after surgical correction.

Craniosynostosis

The authors review the embryopathology and clinical manifestations of craniosynostosis and analyze a series of 27 children. The operative procedure of linear craniectomy and immediate cranioplasty is described and evaluated. Since few children with craniosynostosis have neurological deficits that can be ascribed to the skull anomalies, surgery to prevent neurological complications is only rarely justified. However, it is often possible to ameliorate the cosmetic deformity in many of these patients if operative intervention is undertaken in early infancy.

Recurrent and multiple suture closures after craniectomy for craniosynostosis

✓ Six cases of craniosynostosis are reported in which recurrent and multiple closure of cranial sutures occurred after craniectomy and insertion of polyethylene film. In all patients there was closure of a second and sometimes a third suture as well as reclosure of the treated suture. In four children the second operations were done before the age of 18 months; none had increased intracranial pressure preoperatively and three who are living have normal intelligence. In two children, the second operations were not done until after the age of 3 years; both had increased intracranial pressure preoperatively, and both are now mentally retarded.

Crouzon's disease (craniofacial dysostosis). Modern diagnosis and treatment

✓ This article discusses the nature and treatment of Crouzon's disease and reproduces a translation of part of Crouzon's original description. Six typical patients with this disease are presented, and the reasons for surgical treatment emphasized.

Zenker's solution in the surgical treatment of craniosynostosis

✓ Tissue fixative (Zenker's solution) was applied to the outer layer of the cranial dura mater in 34 patients to delay regrowth of bone after craniectomy for craniosynostosis, and the results evaluated. Seizures, heretofore unrecorded as a complication, were noted postoperatively in two of 12 patients in whom the Zenker's solution was mixed with acetic acid. A time limit of 3 min for application of the solution to the dura mater and omission of acetic acid appeared to prevent permanent seizures in subsequent patients. Reoperation to maintain opened sutures has been necessary when the fixative was applied only to the bone edges and adjacent dura, indicating that the entire exposed dural surface must be covered. Cranioplasty to close large defects often became necessary at a later age when the solution containing acetic acid was applied longer than 3 min. With the modifications noted, the authors feel the technique is safe for use in cosmetic procedures.