Occipital Plagiocephaly Research Articles

Evaluation of the Effects of Helmet Therapy on Head Deformities: A Systematic Review of Literature

Plagiocephaly is a common deformity of the skull. Various treatment approaches have been used for the subjects with head deformities, including use of helmet orthosis, repositioning, exercise, and only observation. The aim of this review was to check the efficiency of helmet therapy compared to other available approaches and also to check the effects of some parameters such as the duration of use, and age of the subjects on treatment of the subjects with this deformity. A search was done in some databases, including Google scholar, ISI Web of knowledge, PubMed, and Scopus. Some keywords such as plagiocephaly, posterior plagiocephaly, and occipital plagiocephaly were used in combination with positional modeling, helmet therapy, helmet orthosis, exercise, and observation. The quality of the studies was evaluated by use of Down and Black tool. Twenty-four studies were found on the mentioned keywords. The quality of the studies varied between 11 and 21. Although the efficiency of helmet therapy was more than other treatment approaches, the final outputs depend on optimal time and deformity criteria. This approach is effective, well tolerated with no morbidity. Moreover, it does not influence on the quality of life of the subjects. The efficiency of helmet therapy to correct head deformities is more than other available approaches. However, its effects depend on the age of the subjects at onset of treatment, duration of treatment, and severity of the deformity. Any side effects of this treatment method can be decreased by proper education of the subjects.

The functional manual therapy intervention in infants with non-synostotic plagiocephaly: a pilot study.

The aim of this study was to document the evolution of cranial asymmetries in infants with signs of nonsynostotic occipital plagiocephaly (NSOP) who underwent to many functional manual therapy treatments (in addition to the standard positioning recommendations); as well as to determine the feasibility of this methodology to conduct outcome research investigating the impact of this intervention for infants with NSOP. This is a pilot clinical standardization project using pre-post design in which 10 infants participated. Nine infants presented an initial Oblique Diameter Difference Index (ODDI) (over 104%), three an initial Ear Deviation Index (EDI) (over 4%), and three a Cranial Proportional Index (CPI) (over 90%). Infants received three functional manual therapy treatments for week during the first month of intervention and two for week during the second month. Plagiocephalometric measurements were administered at the first assessment preintervention (T0), after 30 days (±5) (T1) and at a third time after 60 days (±5) of treatment (T2). Nine out of ten participants showed a significant decrease in ODDI under 104% between T0 and T2 assessments. Five out of ten infants showed an EDI under 4%, and 3/10 showed a value about 0%. 3/10 maintained their CPI over 90% with a considerable decrease. These clinical findings support the hypothesis that functional manual therapy treatments contribute to the improvement of cranial asymmetries in infants younger than 6.5 months old presenting with NSOP.

The functional manual therapy intervention in infants with nonsynostotic plagiocephaly: a pilot study

The aim of this study was to document the evolution of cranial asymmetries in infants with signs of nonsynostotic occipital plagiocephaly (NSOP) who underwent to many functional manual therapy treatments (in addition to the standard positioning recommendations); as well as to determine the feasibility of this methodology to conduct outcome research investigating the impact of this intervention for infants with NSOP. This is a pilot clinical standardization project using pre-post design in which 10 infants participated. Nine infants presented an initial Oblique Diameter Difference Index (ODDI) (over 104%), three an initial Ear Deviation Index (EDI) (over 4%), and three a Cranial Proportional Index (CPI) (over 90%). Infants received three functional manual therapy treatments for week during the first month of intervention and two for week during the second month. Plagiocephalometric measurements were administered at the first assessment preintervention (T0), after 30 days (±5) (T1) and at a third time after 60 days (±5) of treatment (T2). Nine out of ten participants showed a significant decrease in ODDI under 104% between T0 and T2 assessments. Five out of ten infants showed an EDI under 4%, and 3/10 showed a value about 0%. 3/10 maintained their CPI over 90% with a considerable decrease. These clinical findings support the hypothesis that functional manual therapy treatments contribute to the improvement of cranial asymmetries in infants younger than 6.5 months old presenting with NSOP.

Cerebrospinal fluid volume does not have etiological role in the incidence of positional skull deformities

BackgroundPositional skull deformities (PSD) are becoming a daily health concern for craniofacial surgeons. Several reports have indicated that cerebrospinal fluid (CSF) space increases on computed tomography (CT) scans of infants suffering from PSD, suggesting a potential causal link. Here, we describe a semi-automatic method to estimate total brain and CSF volumes quantitatively. We tested the potential correlation between total CSF volume and the occurrence of PSD. MethodsA single-center retrospective study was carried out using 79 CT scans of PSD and 60 CT scans of control subjects. The endocranium was segmented automatically using a three-dimensional deformable surface model, and the brain was segmented using a semi-automatic threshold-based method. Total CSF volume was estimated based on the difference between endocranial and brain volumes. ResultsAutomatic segmentation of the endocranium was possible in 75 CT scans. Semi-automatic brain and CSF volume evaluations were performed in 40 CT scans of infants with PSD (18 = occipital plagiocephaly, 11 = fronto-occipital plagiocephaly, and 11 = posterior brachycephaly) and in six control CT scans. Endocranial and total CSF volumes were not significantly different between patients with PSD and controls. The occipital plagiocephaly group had an enlarged brain volume compared with that in patients in the other groups. ConclusionsTotal CSF volume did not change in infants with PSD, and the results do not support a role for volume changes in CSF in the etiology of PSD. Macrocephaly in patients with occipital plagiocephaly may be a specific etiological factor compared with that in other PSDs.

Factors influencing outcomes of the treatment of positional plagiocephaly in infants: a 7-year experience.

OBJECTIVE Following institution of the Back to Sleep Campaign, the incidence of sudden infant death syndrome decreased while the prevalence of positional skull deformation increased dramatically. The management of positional deformity is controversial, and treatment recommendations and outcomes reporting are variable. The authors reviewed their institutional experience (2008-2014) with the treatment of positional plagiocephaly to explore factors associated with measured improvement. METHODS A retrospective chart review was conducted with risk factors and treatment for positional head shape deformity recorded. Univariate and multivariate analyses were used to assess the impact of these variables on the change in measured oblique diagonal difference (ODD) on head shape surface scanning pre- and posttreatment. RESULTS A total of 991 infants aged less than 1 year were evaluated for cranial positional deformity in a dedicated clinical program. The most common deformity was occipital plagiocephaly (69.5%), followed by occipital brachycephaly (18.4%) or a combination of both deformities (12.1%). Recommended treatment included repositioning (RP), physical therapy (PT) if indicated, or orthotic treatment with a customized cranial orthosis (CO) according to an age- and risk factor-dependent algorithm that the authors developed for this clinic. Of the 991 eligible patients, 884 returned for at least 1 follow-up appointment. A total of 552 patients were followed to completion of their treatment and had a full set of records for analysis: these patients had pre- and posttreatment 2D surface scanner evaluations. The average presenting age was 6.2 months (corrected for prematurity for treatment considerations). Of the 991 patients, 543 (54.8%) had RP or PT as first recommended treatment. Of these 543 patients, 137 (25.2%) transitioned to helmet therapy after the condition did not improve over 4-8 weeks. In the remaining cases, RP/PT had already failed before the patients were seen in this program, and the starting treatment recommendation was CO. At the end of treatment, the measured improvements in ODD were 36.7%, 33.5%, and 15.1% for patients receiving CO, RP/PT/CO, and RP/PT, respectively. Univariate analysis showed that sex, race, insurance, diagnosis, sleep position preference, torticollis history, and multiple gestation were not significantly associated with magnitude of ODD change during treatment. On multivariate analysis, corrected age at presentation and type of treatment received were significantly associated with magnitude of ODD change. Orthotic treatment corresponded with the largest ODD change, while the RP/PT group had the least change in ODD. Earlier age at presentation corresponded with larger ODD change. CONCLUSIONS Earlier age at presentation and type of treatment impact the degree of measured deformational head shape correction in positional plagiocephaly. This retrospective study suggests that treatment with a custom CO can result in more improvement in objective measurements of head shape.

Surgical correction of lambdoid synostosis - New technique and first results.

Premature craniosynostosis of the lambdoid suture is rare. The use of differential diagnosis to rule out positional occipital plagiocephaly is crucial. Nevertheless, once diagnosed, lambdoid craniosynostosis requires corrective surgery to prevent intracranial harm and aesthetic stigma by significant dyscrania. Operative correction of the lambdoid fusion is often performed by suturectomy and helmet therapy, total occipital remodeling interventions, transposition of occipital bone flaps, or occipital advancement procedures either with or without distraction osteogenesis. We present a simple surgical maneuver to potentially correct the occipital and suboccipital constriction caused by unilateral lambdoid craniosynostosis. Three patients with true unilateral lambdoid synostosis underwent surgery. A straight-line skin incision was created, beginning at the caudal pole of the ipsilateral mastoideal bulge. The incision ran cranially and corresponded to the course of the lambdoid suture up to the posterior fontanel. The periosteum was incised and the contralateral (potent) lambdoid suture was identified at its origin. One burr-hole was created to separate the dura from the intern tabula. Afterwards, a square meander-shaped craniotomy was performed along the assumed course of the lambdoid suture. The squares were then forced apart to form the occipital and suboccipital area into a more rounded shape. The squares were fixed in those positions with resorbable plates or sutures. Pre- and postoperative three-dimensional (3D) photoscans were performed and analyzed with special software to follow the perioperative course of the cranial shape. This new approach minimized the operative time and degree of blood-loss, and rounding of the occipital area was accomplished with only one unilateral intervention. In terms of the available photogrammetric data of two of the patients, the cranial vault asymmetry index, posterior symmetry ratio, and posterior/anterior skull volume ratio were improved but not normalized completely. The measurement outcome, as determined by an automated analysis of the photoscans, however, indicated clear flaws with regard to repeatability. A unilateral approach using a square meander-shaped craniotomy and subsequent inclination may be a suitable surgical method for correcting assorted cases of lambdoid craniosynostosis. Transposition of the occipital bone flaps, subtotal craniectomies of the occipital area, and occipital advancements with or without distraction devices may not be essential in all cases of lambdoid synostosis. However, the reliability of the automated analysis of three-dimensional photoscans must be determined.

Apert Syndrome: Molecularly Confirmed C.758C>G (P.Pro253Arg) in FGFR2

Introduction A 5-day-old girl was referred to our clinic for evaluation of congenital malformations. She was identified with a pathogenic mutation c.758C>G (p.Pro253Arg) in FGFR2 gene using targeted exome sequencing. The de novo mutation was confirmed with Sanger sequencing in the patient and her parents. She showed occipital plagiocephaly with frontal bossing (Figure A and B). Skull frontal and lateral radiography revealed fusion of most of the sutures except coronal suture, with convolutional markings (Figure D and E). She had complete cleft palate (Figure C). Her fused bilateral hands showed type II syndactyly with complete syndactyly between the ring and the little fingers (Figure F1-F3). Both toes were simple syndactyly with side-to-side fusion of skin (Figure G1-G4).

소아 추나에 대한 국내·외 연구 동향

Abstract Domestic and Foreign Research Trend on the Pediatric Chuna Treatment Lee Jin Hwa․Han Jae Kyung․Kim Yun HeeDepartment of Pediatrics, College of Korean Medicine, Daejeon UniversityObjectivesThe purpose of this review is to investigate the domestic and foreign studies of pediatric Chuna treatment and propose the directions of future studies and clinical applications.MethodsWe searched for the study at RISS, KISS, DBPIA, Pubmed, CNKI by keywords, ‘추나’, ‘Osteopathic’, ‘Chiropractic’, ‘Manipulation’, ‘推拿’, ‘导引’, ‘按摩’, After 2010. Results1. Selected 3 domestic studies were categorized as 1 survey study and 2 case reports. Selected 41 foreign studies from Pubmed were categorized as 15 systemic reviews, 8 survey studies, 12 case reports and 6 control studies. Selected 82 foreign studies from CNKI were categorized as 10 systemic reviews, 22 case reports and 50 control studies.2. 2 clinical domestic studies researched on idiopathic Scoliosis. The foreign clinical studies from Pubmed are 18 cases, and those studies were categorized into Premature baby care (3), Infant colic (2), ADHD (2), Congenital talipes equinovarus (1), Somatic dysfuntion (1), Nonsynostotic occipital plagiocephaly (1), Conversion disorder (1), Lower back pain (1), Chronic bilateral dorsal foot pain and stiffness (1), plantar fasciitis (1), Migraine headaches (1), Cyclic vomiting syndrome (1), Acute otitis media (1) and Cerebral palsy (1). The other 72 foreign clinical studies were from CNKI, and they studied 39 different diseases. Systematically, they studied about digestive diseases (25), respiratory diseases (20), fever (6), musculoskeletal diseases (5), nervous system diseases (5), dermatology diseases (2) and other disease states. The Chuna treatment was used in variety of studies.3. 2 clinical domestic studies adopted techniques of Osteopathy Chuna. The foreign clinical studies from Pubmed adopted techniques of Osteopathic manipulation (10) and Chiropractic manipulation (8). The other foreign clinical studies from CNKI adopted techniques of Acupressure (69), Abdominal manipulation (23), Spinal manipulation (21), Thoracic manipulation (11), Traction manipulation (2), Muscular manipulation (2), Squeezing Sha manipulation (1), Spine correction (1), Joint manipulation (1) and Fascia manipulation (1).ConclusionsIn addition to musculoskeletal disorders, variety of pediatric diseases could be treated with Chuna treatment instead of acupuncture. Key words : Pediatric, Chuna, Osteopathic, Chiropractic, Manipulation

Positional plagiocephaly: experience with a passive orthotic mattress.

Positional plagiocephaly (deformational or occipital plagiocephaly) is the most common head-shape deformity, which is presented to specialist craniofacial units. The aim of management is to reduce pressure on the affected area in the expectation that brain growth will drive normalization of the head shape. Current management includes a variety of protocols based on repositioning advice or helmet orthotics. The aim of this study is to document changes in head shape associated with use of a passive orthotic mattress for the management of positional plagiocephaly of a series of 30 patients at Alder Hey Children's Hospital between April 2008 and June 2010. Cranial vault asymmetry was assessed before treatment and was classified into mild, moderate, or severe plagiocephaly. Follow-up demonstrated a significant improvement in cranial vault asymmetry in those treated with the passive orthotic mattress.

Major clinical features of synostotic occipital plagiocephaly: mechanisms of cranial deformations.

The clinical diagnosis of most common single-suture craniosynostosis is easily set, based on the stereotype of deformities and knowledge of the mechanisms of cranial deformations. However, synostosis of unilateral lambdoid suture, probably due to its lower incidence and similarity with other non-synostotic deformities affecting the posterior portion of the skull, makes its clinical diagnosis more difficult and imprecise. The aim of this study is to evaluate the most easily and accurate clinical characteristics to be recognized in the synostotic occipital plagiocephaly. This study consisted of clinical evaluation of eight patients with synostotic occipital plagiocephaly, whose diagnosis was further corroborated by computed tomography. We identified the following: unilateral occipital flattening in eight out of eight patients (100 %), bulging of ipsilateral mastoid process in eight out of eight (100 %), "edge effect" of ipsilateral lambdoid suture in eight out of eight (100 %), inferior deviation of the ear in eight out of eight (100 %), "Dumbo" ears in eight out of eight (100 %), horizontal slant of the bimastoid line in seven out of eight (87.5 %), tilt of the head viewed from behind in seven out of eight (87.5 %), trapezoidal contour of the skull in top view in six out of eight (75 %), contralateral parietal bossing in six out of eight (75 %), and bossing of the contralateral forehead three out of eight (37.5 %). The most important clinical features specific to the clinical diagnosis of synostotic occipital plagiocephaly, not present in the positional posterior plagiocephaly, were bulging of the ipsilateral mastoid process, edge effect of the synostotic lambdoid suture, tilt of the head, and slant of the bimastoid line viewed from behind, inferior deviation of the ear, and contralateral parietal bossing.

Value of high-resolution ultrasound in the differential diagnosis of scaphocephaly and occipital plagiocephaly

Secondary to the increase in deformational plagiocephaly a growing number of infants with cranial deformity present to craniofacial teams. Computed tomography (CT) is diagnostic, but uses ionizing radiation. The purpose of this study was to evaluate ultrasound as a screening test for the patency of cranial sutures in scaphocephaly and occipital plagiocephaly. The cranial sutures of 54 infants with this cranial deformity were assessed by ultrasound. Sutures were read as patent or fused if a hypoechoic gap could or could not be demonstrated between the hyperechoic clavarial bones, respectively. Seven children suffered from true craniosynostosis of either the sagittal or the lambdoid suture. In five cases the ultrasound findings were diagnostic for a fused suture, in two cases the results were inconclusive. Forty-seven infants presented with deformational plagiocephaly. Ultrasound examination demonstrated patent sutures in 45 cases and was inconclusive in two cases. Sonography of the cranial sutures is a good screening tool to distinguish fused from patent cranial sutures in scaphocephaly and occipital plagiocephaly and avoids the radiation exposure associated with CT examinations.

Deformaciones craneales posicionales: estudio clínico-epidemiológico

IntroductionCranial deformities have always existed, but it is only until recently that they provoked a greater interest. Several reports have demonstrated an increasing tendency for occipital plagiocephaly. This work presents an analysis of the clinical-epidemiological features of these deformities in our area. Patients and methodsThe medical records and neuroimaging studies of 158 children seen at our hospital due to a skull deformation were analyzed, paying special attention to risk factors. ResultsDuring the study period, an increase in the number of consultations for skull deformation of children was noted. The mean age for the patients at consultation was 9 months. There was a predominance of boys (68%) over girls. The deformities were: unilateral- (89.2%) or bilateral-posterior plagiocephaly (7.6%), and dolicochephaly (3.2%). In addition to the supine position for sleeping, there were several risk factors, among them pericerebral collections of cerebrospinal fluid found in 50% of children subjected to neuroimaging studies. Most children were managed conservatively, while 12 patients were given helmets, which led to an improvement in 136 cases. Discussion and conclusionsThe present findings agree with those in the current literature. A unique result of this study was the high rate of pericerebral fluid collections found in children assessed with neuroimaging methods. The increase in positional plagiocephaly seems to parallel the application of the recommendations for supine sleeping position established by the American Academy of Pediatrics for preventing the sudden infant death syndrome. The role played by Pediatricians in the detection, initial management and referral of these children is highlighted. Prevention measures seem to be more important than those regarding treatment.

Exploring the impact of osteopathic treatment on cranial asymmetries associated with nonsynostotic plagiocephaly in infants

Objectives To document the evolution of cranial asymmetries in infants with signs of nonsynostotic occipital plagiocephaly (NSOP) who were to undergo a course of four osteopathic treatments (in addition to the standard positioning recommendations) as well as to determine the feasibility of using this methodology to conduct a randomized clinical trial investigating the impact of osteopathic intervention for infants with NSOP. Design Pilot clinical standardization project using pre-post design in which 12 infants participated. Ten infants presented an initial Oblique Diameter Difference Index (ODDI) over 104% and five of them had an initial moderate to severe Cranial Vault Asymmetry (CVA) (over 12 mm). Interventions Infants received four osteopathic treatments at 2-week intervals. Main outcome measures Anthropometric, plagiocephalometric as well as qualitative measures were administered pre-intervention (T1), during the third treatment (T2) and two weeks after the fourth treatment (T3). Results Participants showed a significant decrease in CVA ( p = 0.02), Skull Base Asymmetry (SBA) ( p = 0.01), Trans-Cranial Vault Asymmetry (TCVA) ( p < 0.003) between the first and third evaluations. Conclusions These clinical findings support the hypothesis that osteopathic treatments contribute to the improvement of cranial asymmetries in infants younger than 6.5 months old presenting with NSOP characteristics.

Occipitofrontal Switching for Simultaneous Correction of Synostotic Frontal and Occipital Plagiocephaly: A Novel Surgical Technique

Plagiocephaly has traditionally been corrected by unilateral or bilateral frontal bone advancement or rotation using bone-molding forceps and distraction devices. Complete symmetrical correction of deformed frontal bones is considered almost impossible because the curvature of each frontal bone varies. We evaluated the feasibility of measuring the optimal curvature of frontal and occipital bones using a plaster skull model and applying these measurements to "switch" them for simultaneous correction of frontal and occipital plagiocephaly. A 2-year-old girl suffering from unifrontal flattening visited our clinic. Unilateral coronal synostosis was observed. The 3-D rapid prototype model and skull replica method using thin paper clay were used for preplanned virtual surgery. The triangular bone was harvested from the contralateral bulging side of the occipital bone ("occipitofrontal switching") for the best optimal curvature in the affected frontal bone. Another triangular bone was harvested from the ipsilateral flattened side of the frontal bone, and bones were switched with each other. Further bending of the frontal or occipital segment was not necessary for optimal curvature. Symmetrical correction was made by switching the triangular bone of the frontal area with that of the contralateral occipital area. Revision has not been necessary, and infection was not observed at 1-year follow-up. Our novel technique of preplanning surgery using a 3-D plaster model for simultaneous correction of frontal and occipital plagiocephaly is effective and time-saving.

Delayed Etiologic Diagnosis of Meningitis in an Extremely Low Birth Weight Newborn

Delayed Etiologic Diagnosis of Meningitis in an Extremely Low Birth Weight Newborn

Surgical treatment of isolated and syndromic craniosynostosis: Results and complications in 283 consecutive cases

Objective. To review the results and complications of the surgical treatment of craniosynostosis in 283 consecutive patients treated between 1999 and 2007. Patients and methods. Our series consisted of 330 procedures performed in 283 patients diagnosed with scaphocephaly (n=155), trigonocephaly (n=50), anterior plagiocephaly (n=28), occipital plagiocephaly (n=1), non-syndromic multi-suture synostosis (n=20), and with diverse craniofacial syndromes (n=32; 11 Crouzon, 11 Apert, 7 Pfeiffer, 2 Saethre-Chotzen, and 2 clover-leaf skull). We used the classification of Whitaker et al. to evaluate the surgical results. Complications of each technique and time of patients� hospitalization were also recorded. The surgeries were classified in 12 different types according to the techniques used. Type I comprised endoscopic assisted osteotomies for sagittal synostosis (42 cases). Type II included sagittal suturectomy and expanding osteotomies (46 cases). Type III encompassed procedures similar to type II but that included frontal dismantling or frontal osteotomies in scaphocephaly (59 cases). Type IV referred to complete cranial vault remodelling (holocranial dismantling) in scaphocephaly (13 cases). Type V belonged to fronto-orbital remodelling without fronto-orbital bandeau in trigonocephaly (50 cases). Type VI included fronto-orbital remodelling without fronto-orbital bandeau in plagiocephaly (14 cases). In Type VII cases of plagiocephaly with frontoorbital remodelling and fronto-orbital bandeau were comprised (14 cases). Type VIII consisted of occipital advancement in posterior plagiocephaly (1 case). Type IX included standard bilateral fronto-orbital advancement with expanding osteotomies (30 cases). Type X was used in multi-suture craniosynostosis (15 cases) and consisted of holocranial dismantling (complete cranial vault remodelling). Type XI included occipital and suboccipital craniectomies in multiple suture craniosynostosis (10 cases) and Type XII instances of fronto-orbital distraction (26 cases). Results. The mortality rate of the series was 2 out of 283 cases (0.7%). These 2 patients died one year after surgery. All complications were resolved without permanent deficit. Mean age at surgery was 6.75 months. According to Whitaker et al�s classification, 191 patients were classified into Category I (67.49%), 51 into Category II (18.02%), 30 into Category III (10.6%) and 14 into Category IV (4.90%). Regarding to craniofacial conformation, 85.5 % of patients were considered as a good result and 15.5% of patients as a poor result. Of the patients with poor results, 6.36% were craniofacial syndromes, 2.12% had anterior plagiocephaly and 1.76% belonged to non-syndromic craniosynostosis. The most frequent complication was postoperative hyperthermia of undetermined origin (13.43% of the cases), followed by infection (7.5%), subcutaneous haematoma (5.3%), dural tears (5%), and CSF leakage (2.5%). The number of complications was higher in the group of re-operated patients (12.8% of all). In this subset of reoperations, infection accounted for 62.5%, dural tears for 93% and CSF leaks for 75% of the total. In regard to the surgical procedures, endoscopic assisted osteotomies presented the lowest rate of complications, followed by standard fronto-orbital advancement in multiple synostosis, trigonocephaly and plagiocephaly. The highest number of complications occurred in complete cranial vault remodelling (holocranial dismantling) in scaphocephaly and multiple synostoses and after the use of internal osteogenic distractors. Of note, are two cases of iatrogenic basal encephalocele that occurred after combined fronto-facial distraction. Conclusions. The best results were obtained in patients with isolated craniosynostosis and the worst in cases with syndromic and multi-suture craniosynostosis. The rate and severity of complications were related to the type of surgical procedure and was higher among patients undergoing re-operations. The mean time of hospitalization was also modified by these factors. Finally, we report our considerations for the management of craniosynostosis taking into account each specific tech- nique and the age at surgery, complication rates and the results of the whole series.

Complications in the surgical treatment of craniosynostosis and craniofacial syndromes: apropos of 306 transcranial procedures

To review the complications in the surgical treatment of craniosynostosis in 306 consecutive transcranial procedures between June 1999 and June 2007. Surgical series consist of 306 procedures done in 268 patients: 155 scaphocephalies, 50 trigonocephalies, 28 anterior plagiocephalies, one occipital plagiocephaly, 20 non-syndromic multisutural synostosis and 32 craniofacial syndromes (11 Crouzon, 12 Apert, seven Pfeiffer and two Saethre-Chotzen) Complications and time of hospitalisation were reckoned. Surgical procedures were classified in 12 different types according to the technique: Type I: frontal-orbital distraction (26 cases); Type II: endoscopic assisted osteotomies in sagittal synostosis (39 cases); Type III: sagittal suturectomy and expansive osteotomies (44 cases); Type IV: same as type III, but including frontal dismantling or frontal osteotomies in scaphocephalies (59 cases); Type V: complete cranial vault remodelling (holocranial dismantling) in scaphocephalies (13 cases); Type VI: frontal-orbital remodelling without frontal-orbital bandeau in trigonocephaly (50 cases); Type VII: frontal-orbital remodelling without frontal-orbital bandeau in plagiocephaly (14 cases); Type VIII: frontal-orbital remodelling with frontal-orbital bandeau in plagiocephaly (14 cases); Type IX: Occipital advancement in posterior plagiocephaly (one case); Type X: Standard bilateral front-orbital advancement with expansive osteotomies (28 cases); Type XI: holocranial dismantling (complete cranial vault remodelling) in multisutural craniosynostosis (12 cases); Type XII: occipital and suboccipital craniectomies in multiple suture craniosynostosis (six cases). There was no mortality and all complications resolved without permanent deficit. Mean age at surgery was 6.75 months. Most frequent complication was non-filiated postoperative hyperthermia (13.17% of the cases) followed by infection (8.10%), subcutaneous haematoma (6.08%), dural tears (5.06%) and cerebrospinal fluid (CSF) leakage (2.7%). Number and type of complications was higher among the group of reoperated patients (12.8% of all): 62.5% of all the series infections, 93% of all dural tears and 75% of all CSF leaks. In relation to surgical procedures, endoscopic assisted osteotomies reported the lowest rate of complications, followed by standard frontal-orbital advancement in multiple synostosis, trigonocephalies and plagiocephalies. Highest number of complications was related to complete cranial vault remodelling (holocranial dismantling) in scaphocephalies and multiple synostoses and after the use of internal osteogenic distractors. Special consideration deserves two cases of iatrogenic basal encephaloceles after combined frontal-facial distraction. Finally, we establish considerations based on the complications related to every specific technique. Percentage and severity of complications relates to the surgical procedure and is higher among patients going for re-operation. Mean time of hospitalization is also modified by these issues.

PLAGIOCEPHALY, BRACHYCEPHALY AND CRANIAL ORTHOTIC DEVICES: MISSHAPEN HEADS AND HELMETS

The apparent prevalence of plagiocephaly has increased in recent years as indicated by referrals to paediatricians, neurosurgeons and craniofacial surgeons for advice and management.1 For the purposes of this article,...

Surgical treatment of isolated and syndromic craniosynostosis. Results and complications in 283 consecutive cases

To review the results and complications of the surgical treatment of craniosynostosis in 283 consecutive patients treated between 1999 and 2007. Our series consisted of 330 procedures performed in 283 patients diagnosed with scaphocephaly (n=155), trigonocephaly (n=50), anterior plagiocephaly (n=28), occipital plagiocephaly (n=1), non-syndromic multi-suture synostosis (n=20), and with diverse craniofacial syndromes (n=32; 11 Crouzon, 11 Apert, 7 Pfeiffer, 2 Saethre-Chotzen, and 2 clover-leaf skull). We used the classification of Whitaker et al. to evaluate the surgical results. Complications of each technique and time of patients' hospitalization were also recorded. The surgeries were classified in 12 different types according to the techniques used. Type I comprised endoscopic assisted osteotomies for sagittal synostosis (42 cases). Type II included sagittal suturectomy and expanding osteotomies (46 cases). Type III encompassed procedures similar to type II but that included frontal dismantling or frontal osteotomies in scaphocephaly (59 cases). Type IV referred to complete cranial vault remodelling (holocranial dismantling) in scaphocephaly (13 cases). Type V belonged to fronto-orbital remodelling without fronto-orbital bandeau in trigonocephaly (50 cases). Type VI included fronto-orbital remodelling without fronto-orbital bandeau in plagiocephaly (14 cases). In Type VII cases of plagiocephaly with frontoorbital remodelling and fronto-orbital bandeau were comprised (14 cases). Type VIII consisted of occipital advancement in posterior plagiocephaly (1 case). Type IX included standard bilateral fronto-orbital advancement with expanding osteotomies (30 cases). Type X was used in multi-suture craniosynostosis (15 cases) and consisted of holocranial dismantling (complete cranial vault remodelling). Type XI included occipital and suboccipital craniectomies in multiple suture craniosynostosis (10 cases) and Type XII instances of fronto-orbital distraction (26 cases). The mortality rate of the series was 2 out of 283 cases (0.7%). These 2 patients died one year after surgery. All complications were resolved without permanent deficit. Mean age at surgery was 6.75 months. According to Whitaker et al's classification, 191 patients were classified into Category I (67.49%), 51 into Category II (18.02%), 30 into Category III (10.6%) and 14 into Category IV (4.90%). Regarding to craniofacial conformation, 85.5 % of patients were considered as a good result and 15.5% of patients as a poor result. Of the patients with poor results, 6.36% were craniofacial syndromes, 2.12% had anterior plagiocephaly and 1.76% belonged to non-syndromic craniosynostosis. The most frequent complication was postoperative hyperthermia of undetermined origin (13.43% of the cases), followed by infection (7.5%), subcutaneous haematoma (5.3%), dural tears (5%), and CSF leakage (2.5%). The number of complications was higher in the group of re-operated patients (12.8% of all). In this subset of reoperations, infection accounted for 62.5%, dural tears for 93% and CSF leaks for 75% of the total. In regard to the surgical procedures, endoscopic assisted osteotomies presented the lowest rate of complications, followed by standard fronto-orbital advancement in multiple synostosis, trigonocephaly and plagiocephaly. The highest number of complications occurred in complete cranial vault remodelling (holocranial dismantling) in scaphocephaly and multiple synostoses and after the use of internal osteogenic distractors. Of note, are two cases of iatrogenic basal encephalocele that occurred after combined fronto-facial distraction. The best results were obtained in patients with isolated craniosynostosis and the worst in cases with syndromic and multi-suture craniosynostosis. The rate and severity of complications were related to the type of surgical procedure and was higher among patients undergoing re-operations. The mean time of hospitalization was also modified by these factors. Finally, we report our considerations for the management of craniosynostosis taking into account each specific technique and the age at surgery, complication rates and the results of the whole series.

Post-operative use of remoulding orthoses following cranial vault remodelling

The use of external orthoses following surgical cranial vault remodelling in infants with craniosynostosis was first described in the 1980s. While a few preliminary reports have been published on its use, there are no reports outlining specific orthotic considerations. The purpose of this paper is to present the orthotic community with an introduction to the various craniosynostoses, the resultant cranial morphologies, and specific orthotic considerations associated with these morphologies, including trigocephaly, frontal plagiocephly, brachycephaly, scapholocephaly, and occipital plagiocephaly. For each presentation, guidelines are presented as to where the cranial remoulding orthosis should maintain contact, thereby discouraging cranial growth, and where the voids should be established and maintained to allow for corrective cranial growth. Principles are supported by photographs of representative cases.