Posterior Vault Research Articles

Three-Dimensional Volumetric Changes in Posterior Vault Distraction With Distraction Osteogenesis.

Distraction osteogenesis (DO) may allow for maximal volumetric expansion in the posterior vault (PV) by overcoming viscoelastic forces of overlying soft tissues. Little evidence exists regarding surgical planning and anticipated 3D volumetric changes pre- and post-operatively. We aim to study the volumetric changes occurring in PV distraction in lambdoid craniosynostosis. From 2007 to 2019, a single institution retrospective review revealed 232 craniosynostosis patients. Fourteen demonstrated lambdoid synostosis (6%), and of those, 11 patients were included in the study due to treatment with PVDO or representative sample. Six patients had unilateral synostosis and 5 had bilateral synostosis. Imaging protocol for PVDO patients included preoperative head CT within 1 month of surgery and 8 weeks following distraction cessation with weekly skull plain films. 3D volumetric analyses were performed on pre and postoperative head CT using 3D Slicer software. Posterior fossa volume (PFV) increased by 38.7% and foramen magnum area increased by 26.9% postoperatively. Unilateral lambdoid craniosynostosis patients had greater increases in PFV versus bilateral lambdoid craniosynostosis patients (63.5% versus 8.9%, P = 0.007). Osteotomy to the asterion was more effective in increasing PFV versus osteotomy to foramen magnum (P = 0.050). Placement of distractor in the inferior third of the lambdoid suture is more effective in increasing PFV versus placement in the middle or top third of the suture (P = 0.041). Highest volumetric increases are seen in unilateral lambdoid synostosis. Extending osteotomy beyond the asterion is not necessary for maximal PV volumetric gain. Placement of distractor in the inferior third of the suture leads to maximal PV volumetric gains.

Staphylococcus aureus carriage state in healthy adult population and phenotypic and genotypic properties of isolated strains.

IntroductionAt present, infections induced by staphylococci, especially methicillin-resistant Staphylococcus aureus (MRSA) are one of key therapeutic and epidemiological problems.AimThe assessment of Staphylococcus aureus carrier state occurrence among a healthy adult population as well as determination of phenotypic and genotypic properties of the isolated strains.Material and methodsThe study included 100 healthy individuals. Material for bacteriological evaluation was collected from the posterior pharyngeal wall and tonsils, nasal vestibule and the skin of anterior nares using a sterile swab. The isolates identified as Staphylococcus aureus were analysed further, towards slime-forming capacity and the presence of genes mecA and nuc.ResultsThe analysis included 300 samples obtained from the posterior vault of the pharynx and tonsils, nasal vestibule and the skin of nares. Pharyngeal and vestibular S. aureus carriage was determined in 20% of the examined adults, whereas in 11 people with recognized positive throat colonization, the concurrent presence of golden staph was detected in the vestibule of the nose and on the skin, in the nose region. Identification process indicated the occurrence of strains defective in clumping factor synthesis (5% of isolates) and lack of the coa gene (11% of examined isolates). The PCR technique used to screen for the presence of the mec gene, did not confirm it in any of the strains under study. All the isolates had the gene encoding the thermostable nuclease nuc.ConclusionsS. aureus is a pervasive pathogen in community settings with constantly changing trends.

Ventricular shunt complications in patients undergoing posterior vault distraction osteogenesis.

The primary objective of this study is to investigate post-operative morbidity and shunt revision rates of patients with shunt-dependent hydrocephalus (SDH) undergoing posterior vault distraction osteogenesis (PVDO) compared to patients undergoing conventional posterior vault reconstruction (PVR). A retrospective case-controlled cohort analysis of all patients with SDH undergoing PVDO and PVR for syndromic or complex craniosynostosis was performed. Demographic information, perioperative variables, distraction protocols, and shunt-related complications-infection, surgical revision of shunt, increased length of stay (LOS), and readmission within 90 days of surgery-were compared using the appropriate statistical tests. Fourteen patients with ventricular shunts who underwent PVDO and eight patients with shunts who underwent PVR were identified. Shunt-related complication rates were significantly higher with PVDO (n = 5) compared to PVR (n = 0), p = 0.0093. Among the five patients who suffered complications, the most common were shunt infection (n = 4), shunt malfunction (n = 4), and wound infections (n = 3). All patients with complications required additional operations for shunt revision and/or replacement; four patients required multiple takebacks for such procedures, with an average of three additional procedures per patient. In complex or syndromic craniosynostosis patients who have previously undergone ventricular shunting, PVDO is associated with higher shunt-related complications and need for additional procedures when compared to traditional PVR. While the benefits of PVDO in the treatment of syndromic craniosynostosis are well documented, the risks of PVDO in the face of a VP shunt must be considered. Further investigation into patient-specific risk factors and risk reduction strategies is warranted.

Discussion: Onset and Resolution of Chiari Malformations and Hydrocephalus in Syndromic Craniosynostosis following Posterior Vault Distraction.

Discussion: Onset and Resolution of Chiari Malformations and Hydrocephalus in Syndromic Craniosynostosis following Posterior Vault Distraction.

Chirurgie secondaire des craniosténoses et faciocraniosténoses

Secondary surgeries for single craniosynostosis surgeries are mainly esthetic refinements rather than functional indications. However, cranioplasties for bone defects correction or insufficient corrections may be undertaken. Management of syndromic craniosynostoses usually requires multiple surgical interventions, the sequence of which might vary per the genetic mutation. It is commonplace to start with posterior vault expansion before age 6 months, then treat cerebellar tonsillar herniation by the age of twelve months, and delay fronto-facial monobloc advancement until at least 18-24 months of age. Ventricular shunting is preferably avoided or delayed. Failure to respect these guidelines can significantly complicate the subsequent management. Primary fronto-orbital advancement or early facial osteotomy type Le Fort3, may compromise the subsequent fronto-facial monobloc advancement. However, this salvage secondary monobloc may be undertaken in some instances despite previous anterior osteotomies with a higher morbidity.

A Craniometric Analysis of the Posterior Cranial Base After Posterior Vault Distraction.

Posterior vault distraction osteogenesis (PVDO) has been demonstrated to effectively increase intracranial volume, treat increased intracranial pressure, and improve head shape in syndromic patients. The purpose of this study is to compare changes along the posterior cranial base before and after distraction. A retrospective review was completed of subjects who underwent PVDO with computed tomography scans at 2 time-points: within 3 months preoperatively and 1 to 6 months postoperatively. Using Mimics software, craniometric landmarks were identified and surface area of the foramen magnum was calculated. A comparison of pre- to postoperative measurements was completed using Wilcoxon matched-paired signed rank tests and linear regression. A total of 65 PVDO subjects were identified, 12 subjects met inclusion criteria. Mean operative age was 3.0 ± 4.0 years. The cranial vault was distracted on average 25.0 ± 6.0 mm, with those < 12 months of age distracted 29.5 ± 4.9 mm and >12 months of age distracted 22.0 ± 4.9 mm (P = 0.0543). There was a significant increase in pre- to postoperative foramen magnum surface area (52.1 ± 63.2 mm, P = 0.002), length (0.9 ± 1.4 mm, P = 0.050), and width (0.6 ± 1.0 mm, P = 0.050). Similarly, linear distances between nasion and posterior cranial base landmarks such as foramen magnum (3.4 ± 4.2 mm, P = 0.010), and occipital protuberance (9.1 ± 9.6 mm, P = 0.003) were increased. Subjects under 12 months had a greater percentage increases in posterior vault length than those over 12 months. Posterior vault distraction osteogenesis is associated with an increase in size of the foramen magnum, and lengthening of the posterior cranial base, both of which may be beneficial in patients with turribrachycephaly.

S4A-01SESSION 4A: GENERALITIES IN CRANIOSYNOSTOSIS – PART I CLINICAL AND GENETIC CHARACTERIZATION OF CRANIOSYNOSTOSIS; A RETROSPECTIVE COHORT STUDY AT KING SAUD UNIVERSITY MEDICAL CITY

Introduction: Craniosynostosis (CS) is defined as premature fusion of one or more of the cranial sutures and is classified to either simple or complex.CS can present as a part of a syndrome or as isolated finding.The aim of this study was to evaluate the clinical and genetic pattern of CS among Saudi population. Methods: A retrospective cohort study has been conducted from February 2015 till February 2019 at King Saud University Medical City among patients diagnosed with CS. Results: A total of 31 patients with CS has been identified in our center, of which 26 patients were operated, 4 patients refused surgery, and 1 was operated outside. 58 % (18 cases) of patients were male and 42% (13 cases) were female. Mean age at surgery among the 26 patients was 16 months. Simple CS was observed in 19 cases and complex CS in 12 cases. In our population, the most common simple skull suture fusion was unilateral coronal (plageocephaly) followed by metopic (trigonocephaly). Raised intracranial pressure was detected in 35.4% of the patients especially among syndromic cases and the most common grade of Papilledema were grade I and grade II preoperatively. The Most common procedure done was cranial vault reconstruction with fronto-orbital advancement, followed by posterior vault distraction. Post-operatively, Papilledema resolved in all but one patient who had improvement and is still being followed up. Furthermore, we found that 77.4% of patients had normal development and 22.6% presented with developmental delay. Developmental delay was observed commonly among complex suture fusion patients followed by metopic suture fusion. Genetics etiology was identified either by whole exome sequencing, single gene testing or microarray. Testing revealed; FGFR2 (5 cases), TWIST1 (4 cases), ALPL (2 cases), FREM1 (1 case), TGFBR2 (1 case), TCF12 (1 case), MAN2B1 (1 case), SETD2 (1 case), Interstitial deletion of the short arm of chromosome 7 in one case, and dual genetic diagnoses in one patient with ALDOB and ADAT3 gene mutations. Genetic testing for the remaining 9 cases is still not finalized. Parental consanguinity presented in 25.8% of the patients. Conclusion: Worldwide, Sagittal suture is the most commonly affected suture in simple craniosynostosis, but in our population coronal suture fusion was observed to be affected the most. This is the first study conducted about this topic in Saudi Arabia and further studies needed to investigate the characteristics of CS in our population.

PAN 1.3 Chiari malformation in complex craniosynostosis and syringomyelia: epidemiology, management and surgical attitude

Introduction: Chiari malformation (CM) secondary to complex craniosynostosis is one of the most debated subjects in the discussion about surgical management in the facio- craniosynostotic patients. Premature fusion of cranial vault and cranial base sutures, congenital anomalies of the cerebellum, venous hypertension and hydrocephalus responsible of raised intracranial pressure are all the parameters to consider. The impact of foramen magnum decompression and posterior expansion/distraction is analyzed. Methods: This is a monocentric retrospective study including 182 patients with complex craniosynostosis treated between 2001 and 2016. Crouzon (88 patients, 52M/36F), Aperts (33 patients,18M/15F) and Pfeiffer (30 patients 16M/14F), 31 non-syndromic with combined bilambdoid and sagittal synostosis were included. 30/182 were submitted to foramen magnum decompression as first or second procedure, in 14/30 associated to posterior expansion; in 41/180 patients a posterior expansion/distraction has been realised without Chiari decompression. The impact of genetic anomalies, syringomyelia, sleep study results, control of raised ICP has been evaluated. Results: 42 patients presented Chiari type I malformation (19 patients with Crouzon, 23 with Pfeiffer, none in Aperts). Among them, syringomyelia was present in 25 children with Crouzon or Pfeiffer but none in Aperts. The mean age of syringomyelia diagnosis was 5.5 years (range, 10 months to 16 years). FM decompression decreased the number of central and obstructive sleep apnea. Neurological symptoms were relieved but syringomyelia images stayed unchanged. In the group of patients submitted to a simple posterior expansion, in 3% of cases a FM decompression became necessary for a CM aggravation with SOAS apparition Conclusions: FM decompression should be considered the main treatment for Chiari malformation to prevent late syringomyelia and central sleep apneas, in Crouzon and Pfeiffer. It can be associated with posterior vault expansion in the same time if intracranial pressure is present, but this study suggests that insufficient treatment of Chiari will lead to syringomyelia.

SYM9.9E Necker Experience of Frontofacial Monobloc Advancement with Distraction (FFMBA): 145 cases in faciocraniosynostotic children

Introduction: in faciocraniosynostotic children, simultaneous correction of raised intracranial pressure, frontal retrusion, exorbitism, and facial retrusion causing sleep apnea syndrome can be achieved by frontofacial monobloc advancement. Methods: Since year 2000, 145 children aged between 9 months and 17 years were operated on by the same surgeon (EA) of a frontofacial Monobloc osteotomy. Frontal bone elevation was performed in all cases. Main group of 138 patients underwent insertion of 4 internal distractors (KLS Martin, Arnaud and Marchac distractors). A subgroup of 7 patients aged under 15 months underwent postoperative external traction (3kg) applied to a zygomatic transfacial pin (K-wire 2mm in diameter). In the subgroup of young patients, a prolongated sedation was necessary during one week. In all primary patients (never operated of a frontoorbital advancement before), transposition periosteal flaps were used to seal the anterior fossa.A systematic simple protocol of lumbar puncture during 3 days was used in case of suspicion of postoperative CSF leak. In a subgroup of 109 patients who were prospectively evaluated for respiratory outcome, 44% had a systematical removal of adenoids and tonsils prior to Monobloc. Results: in 95% of patients exorbitism was corrected. Class I occlusion was obtained only in 75% of the cases at the end of distraction. The mean OSAS measured on AHI was reduced from 19.1 (+/-17.2) to a mean 12.5 (+/-13.6). But, only the patients in whom adenoids and tonsils were removed preoperatively benefited frankly from the Monobloc.The rate of major infections was 2% (3 out of 145) mostly in secondary patients. The rate of mortality was 1,3 % (2 patients out of 145): one was due to an untreated preoperative Chiari, the other to very severe venous malformations (both these complications occurred at the beginning of our experience). Minor complications included frequently contaminations of internal distractors (30%), and CSF leaks requiring temporary treatment in 8%. The use of transfacial pin was detrimental to tooth buds but helped correction of airways obstruction in severe patients around one year of age. Postoperative OSAS was significantly lower when premonobloc ENT surgery was performed (tonsils and adenoids) Conclusions: Recommendations for surgical management of FFMBA include the following: - Preoperative screening including CT scan, MRI with venous analysis, polysomnography and ophthalmologic examination. - Preliminary systematic ENT removal of tonsils and adenoids (if significally present). - Preliminary management of Chiari by posterior vault distraction associated to foramen magnum decompression if necessary - Prefer primary cases for FFMBA allowing systematic closure of anterior cranial fossa by bilateral anteriorly based pericranial flaps (those flaps rarely available in previously operated patients)- This step necessitates frontal bone elevation - Use 4 internal distractors with consolidation time of 4–6 months. - Sedation of 2–4 days useful in the immediate post-operative period. - Slow distraction rate to 0,5mm/day starting at day 3 until completion (20–25 mm). - Obtain overcorrection at orbital level, and at dental level if possible. - In the very young and very severe, a very early FFMBA could be performed with adjunction of transfacial pin and external traction during one week. - Postoperatively, reeducate mouth opening to prevent trismus

Onset and Resolution of Chiari Malformations and Hydrocephalus in Syndromic Craniosynostosis following Posterior Vault Distraction.

Patients with syndromic craniosynostosis have an increased incidence of progressive hydrocephalus and Chiari malformations, with few data on the relative benefit of various surgical interventions. The authors compare the incidence and resolution of Chiari malformations and hydrocephalus between patients undergoing posterior vault distraction osteogenesis (PVDO) and patients undergoing conventional cranial vault remodeling. Patients with syndromic craniosynostosis who underwent cranial vault surgery from 2004 to 2016 at a single academic hospital, with adequate radiographic assessments, were reviewed. Demographics, interventions, the presence of a Chiari malformation on radiographic studies and hydrocephalus requiring shunt placement were recorded. Mann-Whitney U and Fisher's exact tests were used as appropriate. Forty-nine patients underwent PVDO, and 23 patients underwent cranial vault remodeling during the study period. Median age at surgery (p = 0.880), sex (p = 0.123), and types of syndrome (p = 0.583) were well matched. Patients who underwent PVDO had a decreased incidence of developing Chiari malformations postoperatively compared with the cranial vault remodeling cohort (2.0 percent versus 17.4 percent; p = 0.033). Not surprisingly, no significant difference was found between the groups with regard to the incidence of postoperative hydrocephalus requiring shunt placement (PVDO, 4.1 percent; cranial vault remodeling, 4.3 percent; p = 0.999). As expected, PVDO did not significantly affect intracranial hydrodynamics to the extent that hydrocephalus shunting rates were different for patients with syndromic craniosynostosis. However, PVDO was associated with a reduced risk of developing a Chiari malformation; however, prospective evaluation is needed to determine causality. Therapeutic, III.

Posterior Vault Distraction in Multisuture Synostosis.

Posterior Vault Distraction in Multisuture Synostosis.

National 30-Day Outcomes for Posterior Cranial Vault Distraction.

Posterior vault distraction (PVD) can rapidly expand calvarial volume in infancy. Limited data exist regarding its perioperative and postoperative safety profile. This study sought to investigate the patient profile, outcomes, and safety of PVD using a national pediatric database. Posterior vault distraction patients between 2012 and 2016 were isolated from the National Surgical Quality Improvement Program Pediatric database. Patient background, perioperative outcomes, and risk factors were analyzed using chi-squared, t test analysis, and multivariate regression. Ninety-four patients who underwent PVD were isolated with 67 ultimately meeting inclusion criteria for the study. The majority of patients undergoing PVD had limited other documented comorbidities. No patients required reoperation or 30-day readmission. There were no incidences of stroke, surgical site infection, or death. Subdividing outcomes by specialty, plastic surgeons performed PVD on significantly older patients than neurosurgeons (188 days vs 138 days, P = 0.008). Increasing age was associated with increasing operative time (P < 0.001). Furthermore, increasing age is associated with greater absolute transfusion requirements (P = 0.018) and higher, but not significant, risk of requiring any volume of blood transfusion (P = 0.105). Posterior vault distraction is a safe procedure to rapidly expand calvarial volume in the setting of craniosynostosis. Increasing patient age is the strongest predictor for prolonged operative time and higher blood transfusion volumes.

Management of craniosynostosis in Australia and New Zealand

Introduction: The management of syndromic and non-syndromic craniosynostosis is controversial with different units performing various procedures at different points in time and for different reasons. This study was performed to compare protocols of assessment and surgery in craniofacial units in Australasia.&#x0D; Methods: All paediatric craniofacial surgery centres in Australia and New Zealand were surveyed with respect to their current protocols for the preoperative assessment, intraoperative management and postoperative follow-up of syndromic and non-syndromic craniosynostosis patients.&#x0D; Results: All eight centres completed the survey with 100 per cent response rate. There was considerable homogeneity in the management of the various synostoses. Differences in management were notable in the preoperative assessments that were offered and the management of midface retrusion in syndromic craniosynostoses.&#x0D; Conclusion: Single-suture management among surveyed centres was relatively homogenous. Developmental assessment is not routinely performed for single-suture disease but is desired by the majority of surveyed centres. Postoperative CT scans are not commonly used but a number of centres desired routine use of 3D photometry for outcome assessment. In multi-suture cases, expansion of the posterior vault was performed in all cases but management of midface retrusion was variable.

Anterior Cranial Vault Reconstruction With Distraction for Primary and Secondary Craniosynostosis Repair.

Traditional fronto-orbital advancement continues to be a useful operation for correction of craniosynostosis involving the coronal or metopic sutures. Recently, distraction osteogenesis has been used to correct a variety of cranial deformities. Studies have mostly focused on posterior vault distraction due to its simplicity and greater volume gain when compared with anterior vault distraction. However, certain patients are not candidates for posterior distraction due to anterior deformity and need for expansion of the frontal skull. The authors have developed a technique that allows for both reshaping as well as distraction of the anterior cranial vault.This was a retrospective chart review performed between March 2012 and October 2016 at a single institution by a single plastic surgeon. Thirty-nine (39) patients were included in this study. The indications for surgical intervention were signs of increased intracranial pressure or severe anterior skull deformity in the setting of craniosynostosis. The authors reviewed patient characteristics, length of follow-up, number of previous and subsequent surgeries, complications, and rate of relapse.The average age of patients undergoing the procedure was 5.2 years (range 6 months-15 years). Twenty-four (24) patients had 1 previous surgery, 3 had 2 previous surgeries, 1 had 3 previous surgeries, and 11 had no previous surgeries. The average follow-up was 2.5 years (range 6 months-4 years). One patient had a broken activation wire requiring return to the operating room. Three (3) patients (2 Apert and 1 Crouzon) underwent subsequent posterior vault distraction surgery. All patients demonstrated significant improvement in forehead cosmesis.Anterior cranial vault reconstruction with distraction is a safe alternative to traditional cranial vault reconstruction. It can improve forehead shape and position in older children who have had previous surgery as well as patients with severe anterior skull deformity associated with craniosynostosis.

WPI-13 Lack of association of cranial lacunae with intracranial hypertension in children with crouzon syndrome and apert syndrome: a 3D morphometric quantitative analysis

ObjectivesCranial lacunae on CT is equivalent to the plain X-ray ‘copper beating’ seen in craniosynostosis. Copper beating has not been shown to correlate to intracranial hypertension (IH). However it is a purely quantitative assessment – can qualitative measurement of CT cranial lacunae more accurately predict IH in children with craniosynostosis?DesignRetrospective cohort study.Subjects18 consecutive children with Crouzon and 17 with Apert syndrome were identified.MethodsPatients were divided into IH and non-IH groups defined on an intention to treat basis. 3D software was used to analyse% of calvarial lacunae.ResultsMean age at CT scan was 380 days (range 6–1778). Of the 35 children, 21 required surgery for raised ICP (17 posterior vault expansion 2 ventriculo-peritoneal shunts (VPS), 1 spring-assisted cranioplasty and 1 fronto-orbital advancement) at mean age of 512 days (range 38–1710). Of the 21 children with raised ICP, 15 had lacunae with mean lacuna/calvarium percentage of 3% (0%–28%). Of the 14 non-raised ICP children, 8 had lacunae with mean lacuna/calvarium percentage of 2% (0%–8%). T-test demonstrated no significant difference between the 2 groups. For both groups, parietal bones were most likely to show lacunae (IH 14/21, non-IH 9/14), followed by occipital (IH 8/21, non-IH 3/14), followed by frontal (IH 6/21, non-IH 2/14).ConclusionsResults suggest that cranial lacunae, measured using quantitative 3D methods, do not predict IH, in agreement with evidence from qualitative plain skull radiograph studies.

Intraoperative intracranial pressure monitoring in the pediatric craniosynostosis population.

OBJECTIVEEvaluation of increased intracranial pressure (ICP) in the pediatric craniosynostosis population based solely on ophthalmological, clinical, and radiographic data is subjective, insensitive, and inconsistent. The aim of this study was to examine the intraoperative ICP before and after craniectomy in this patient population.METHODSThe authors measured the ICP before and after craniectomy using a subdural ICP monitor in 45 children. They regulated end-tidal carbon dioxide and the monitoring site under general anesthesia to record consistent ICP readings.RESULTSThe average age of the patient population was 29 months (range 3.8-180.5 months). Thirty-seven patients (82.2%) were undergoing initial craniosynostosis procedures. All craniosynostosis procedures were categorized as one of the following: frontoorbital advancement (n = 24), frontoorbital advancement with distraction osteogenesis (n = 1), posterior vault distraction osteogenesis (n = 10), and posterior vault reconstruction (n = 10). Nineteen of 45 patients (42.2%) had syndromic or multisuture craniosynostosis. The mean postcraniectomy ICP (8.8 mm Hg, range 2-18 mm Hg) was significantly lower than the precraniectomy ICP (16.5 mm Hg, range 6-35 mm Hg) (p < 0.001). Twenty-four patients (53%) had elevated ICP prior to craniectomy, defined as ≥ 15 mm Hg. Only 4 (8.9%) children had papilledema on preoperative funduscopic examination (sensitivity 17%, specificity 100%, negative predictive value 51%, and positive predictive value 100%). There were no significant differences in elevated precraniectomy ICP based on type of craniosynostosis (syndromic/multisuture or nonsyndromic) or age at the time of surgery. Patients undergoing initial surgery in the first 12 months of life were significantly less likely to have elevated precraniectomy ICP compared with patients older than 12 months (26.3% vs 73.1%, p = 0.005).CONCLUSIONSIn this study, the authors report the largest cohort of syndromic and nonsyndromic craniosynostosis patients (n = 45) who underwent precraniectomy and postcraniectomy ICP evaluation. A craniectomy or completed craniotomy cuts for distractors effectively reduced ICP in 43/45 patients. The authors' findings support the notion that papilledema on funduscopy is a highly specific, however poorly sensitive, indicator of increased ICP, and thus is not a reliable screening method. These findings indicate that even nonsyndromic patients with craniosynostosis are at risk for increased ICP. Furthermore, patients who present prior to 12 months of age appear less likely to have elevated ICP on presentation. Further studies with other noninvasive imaging of the retina may be useful as an adjunct tool for determining elevated ICP.

Infectious aspects of tissues of leiomyomatous nodules removed in women of reproductive age, patients with uterine leiomyoma

The state of the microbial ecology of genital organs in women of reproductive age deserves special attention of the doctor-clinician. Infections of the genital tract are recognized as one of the triggers of uterine myoma. Leiomyoma of the uterus can arise as a result of lesions of the myometrium by inflammatory processes. The goal is to examine the tissues of distant leiomyomatous nodules for the presence of an associated microbial flora in women of reproductive age who suffer from asymptomatic and symptomatic clinical course of the uterine leiomyoma. The presence of infectious flora in the vaginal contents and cervical channel of 216 women of reproductive age, patients with uterine leiomyoma, and in 30 distant leiomyomatous nodules of the uterus was investigated. In the vaginal content of Virus herpes simplex was 30.6% in the IIA group and 32.4% in the group IIB, Cytomegalovirus, respectively — in 27.8% and 28.7%. The result to Chlamidia trachomatis was positive in 25.0% of women in the IIA group and 26.9% — in group IIB, Mycoplasma hominis — in 12.96% and 15.7%, Ureaplasma urealyticum — in 4.6% and 8.3 %, Virus papilloma hominis oncogenic type — in 3,7% and 5,6%. The dominant infections of the cervical canal of women of reproductive age, patients with uterine leiomyoma, were Virus herpes simplex in the IIA group — 34.3% and in group IIB — 38.0%, Chlamidia trachomatis — 32.4% and 37.0%, Cytomegalovirus — 33.3% and 32,4%, Mycoplasma hominis — 13.9% and 17.6%, Ureaplasma urealyticum — 6.5% and 10.2%, Virus papilloma hominis — 3.7% and 6.5% respectively. In the tissues of the leiomyomatous nodules, Mycoplasma hominis DNA was detected in 43.3%, Chlamidia trachomatis — in 40.0%, Ureaplasma urealyticum — in 36.7%, Cytomegalovirus and Mycoplasma hominis by 30.0%, Virus papilloma homynis — in 23.3%, Candida albicans — in 6.7% of cases of observations. Titres Enterococcus fec., St. epidermidis in the tissues of the leiomyomatous nodules were 108 CFU/ml. These pathogens in vaginal content were sown in titres 1010 and 105 CFU/ml, respectively. The viral flora in the tissues of the leiomyomatous nodules was determined 1.8 times more often, and the amount of CFU / ml was 1.7 times greater than in the vaginal contents. Streptococcus B, D, Staphylococcus aureus, Bacteroides sp., Mycoplasma hominis, Ureaplasma urealyticum, Chlamydia trachomatis in the tissues of the leiomyomatous nodules were determined on average with a frequency of 32.8%, and in the vaginal content — 15.7%, which is 2.1 times was more. The frequency of Mycoplasma hominis in the tissues of the leiomyomatous nodules was in 3 and 2.8 times, or 28.9% and 27.6% greater than the posterior vaginal vault and cervical canal, Ureaplasma urealyticum — in 5.6 and 4.4 times, or 30.2% and 28.4%, Virus papilloma homynis oncogenic type 16 of 18 — in 5.1 and 4.6 times, or 18.8% and 18.2% respectively. The results obtained indicate that infections in the tissues of the leiomyomatous nodules could have been given by intracanalicular, hematogenous, lymphogenous pathways. It is possible that these infections were in the body of a woman in an active form in the past. In the algorithm for monitoring patients with uterine leiomyoma at reproductive age, it is advisable to include bacteriological, PCR studies of the vaginal microbiocenosis, cervical canal, urethra in observation dynamics, tissues of remote leiomyomatous nodules by identifying microflora in order to prevent the occurrence of concomitant diseases of the urogenital tract and correction of organ biocenosis, which can to prevent the etiopathogenetic mechanisms, such as the occurrence of uterine fibroids and the transition of tumor growth from simple type in the proliferative and is one of the stages of pathogenetically substantiated prevention of uterine leiomyoma.

Craniometric Analysis of Frontal Cranial Morphology Following Posterior Vault Distraction.

Posterior vault distraction osteogenesis (PVDO) is believed to improve frontal contour in infants with syndromic craniosynostosis and turribrachycephaly. This study provides an objective craniometric analysis to determine how PVDO affects anterior cranial morphology. A retrospective chart review of patients who underwent PVDO was performed. Inclusion criteria included pre- and postoperative computed tomography (CT) scans within 3 months before surgery and another 1 to 6 months after device removal. Volumetric and craniometric data were derived using Mimics software and compared using paired t-test and Wilcoxon rank-sum test. About 65 patients underwent PVDO, and 13 patients met inclusion criteria. Mean age at intervention was 3.4 ± 4.2 years. Total cranial volume increased 249 ± 159 cm in all patients (P = 0.0001) and 380 ± 128 cm in patients younger than 1 year of age (n = 6, P =0 .0008). Supraorbital retrusion decreased from 5.44 ± 3.89 to 4.54 ± 3.91 mm postoperatively (P = 0.0004), decreasing significantly in patients without previous frontal surgery and not in those with previous frontal surgery (P = 0.2115; comparison P = 0.0047). Basofrontal angle decreased by 2.92 ± 2.16 degrees (P = 0.0004) with a greater decrease of 3.33±2.68 degrees in those younger than 12 months (P = 0.0289) and 2.58±1.74 degrees in those older (P = 0.0079). No change was found in anterior cranial height and anterofrontal angle (P > 0.05). PVDO improves frontal contour by decreasing supraorbital retrusion and reducing frontal bossing in syndromic craniosynostosis patients with turribrachycephaly. When combined with its demonstrated efficacy for cranial expansion, these frontal changes likely reinforce PVDO's ability to influence the timing of, and to a degree, the need for frontal surgery in this group.

Posterior Vault Distraction Osteogenesis in Nonsyndromic Patients: An Evaluation of Indications and Safety.

The purpose of this study was to evaluate the indications, safety, and short-term outcomes of posterior vault distraction osteogenesis (PVDO) in patients with no identified acrocephalosyndactyly syndrome (study) and to compare those to a syndromic cohort (controls). Demographic and perioperative data were recorded and compared across the study and control groups for those who underwent PVDO between January 2009 and December 2016. Univariate analysis was conducted using χ and Fisher exact tests for categorical variables, and Mann-Whitney U test for continuous variables. Sixty-three subjects were included: 19 in the nonsyndromic cohort, 44 in the syndromic cohort. The cohorts had similar proportion of subjects exhibiting pansynostosis (42.1% of nonsyndromic versus 36.4% of syndromic, P = 0.667). The nonsyndromic cohort was significantly older (4.04 ± 3.66 years versus 2.55 ± 3.34 years, P = 0.046) and had higher rate of signs of raised intracranial pressure (68.4% versus 25.0%, P = 0.001) than the syndromic cohort. There was no significant difference in perioperative variables or rate of complications (P > 0.05). The mean total advancement distance achieved was similar, 27 ± 6 mm in the nonsyndromic versus 28 ± 8 mm in the syndromic cohort (P = 0.964). All nonsyndromic subjects with signs of raised intracranial pressure demonstrated improvement at an average follow-up of 22 months. As in the syndromic patient, PVDO is a safe and, in the short-term, effective modality for cranial vault expansion in the nonsyndromic patient. The benefits and favorable perioperative profile of PVDO may therefore be extended to patient populations other than those with syndromic craniosynostosis.

Power-Assisted Particulate Bone Grafting Effectively Prevents Osseous Defects After Cranial Vault Reconstruction

Cranial vault reconstruction (CVR) is the gold standard in the operative treatment of craniosynostosis. Full thickness osseous defects (FTOD) of the calvaria have been observed in 5% to 15% patients after CVR, with higher rates cited in the fronto-orbital advancement (FOA) subset. Particulate bone graft (PBG) harvested manually has been shown to decrease FTOD after FOA from 24% to 5.5%. The authors used a modified technique using a powered craniotome, with the hypothesis that the technique would also improve outcomes. A retrospective review was performed of patients who underwent CVR for craniosynostosis between 2004 and 2014. Patient demographics, diagnosis, age, operative details, and postoperative care were reviewed in detail. Categorical, nonparametric variables were compared by Fisher exact tests. A total of 135 patients met inclusion criteria. The most common diagnoses were metopic (n = 41), sagittal (n = 33), and unilateral coronal craniosynostosis (n = 31); 65% (n = 88) underwent FOA, 29% (n = 39) underwent single-stage total vault reconstruction, and 6% (n = 8) had a posterior vault reconstruction. CVR was performed without PBG in 95 patients and with PBG in 40 patients. Without PBG, FTOD were discovered on clinical examination in 18% of patients (n=17): 11 presented with subcentimeter defects, while 6 had larger defects requiring revision cranioplasty (6% operative revision rate). Among those receiving PBG, 1 patient presented a subcentimeter FTOD (2.5% FTOD incidence and 0% operative revision rate). Particulate bone graft harvested with a powered device decreases the rate of FTOD and reoperation rate after CVR for craniosynostosis.