Treatment Of Craniosynostosis Research Articles

Notre expérience de l’utilisation des plaques résorbables dans le traitement des craniosténoses

The use of resorbable plates increases for craniosynostosis surgery. This material, based on polymere (PLA, PGA) can replace steel wire and non resorbable plates. A few studies present surgical results about the use of this material with a long follow-up. We present our ten years experience of using resorbable material for craniosynostosis treatment in children. Between 2002 and 2012, we operated 283 craniosynostosis (98 scaphocephalies,55 trigonocephalies,79 plagiocephalies et 51 craniofaciostenoses). Among these surgeries, 211 were realized with resorbable material (plates and screws). Different criteria were observed: the esthetic result, the infection rate, the re-intervention, the bone defects and the inflammatory granuloma. Among the 211 craniosynostosis, we found 62 plagiocephalies, 66 scaphocephalies, 50 trigonocephalies, 33 craniofaciostenoses. All the reconstructions were realized with the same resorbable material (Macropore by Medtronic). The rate of complications was low: one scar infection without participation of material for two patients (0.9%), a pseudo-meningocele for two patients (0.9%), epilepsy for four children (1.8%) and bone defect for 15 (7%). We observed no granuloma for these patients. Our experience of ten years using resorbable material is very satisfactory. This material permits to realize solid and esthetic reconstructions with a low rate of infection without dangerous reaction for children in young age.

Development and testing of an absorbable spring for cranial expansion in rabbits

ObjectiveUse of metal springs for treatment of craniosynostosis is gaining ground in the surgical armamentarium, as these springs simplify operative technique, help to avoid extended approaches, and thus minimize morbidity. Nevertheless, these devices have to be removed eventually. The purpose of this study was to perform cranial expansion with a fully integrated, biodegradable polymer spring in an animal model and to assess the efficacy of and histological reaction to this device. Material and methodsThis was an experimental, unblinded, prospective study. Twelve female New Zealand rabbits (Oryctolagus cuniculus) aged 6 weeks were randomly allocated to two groups. Control animals underwent linear craniectomy alone. Intervention animals underwent craniectomy with placement of a poly(lactic-co-glycolic acid)/polyisoprene (PLGA/PI) copolymer blend spring for cranial expansion transverse to the ostectomy. Expansion was measured radiographically over 12 weeks with amalgam markers. At the end of the experiment period, histological analysis was performed to quantify inflammatory reaction. ResultsThe copolymer blend springs had a mean strength of 4.2N. In the intervention group, cranial expansion at the frontal markers was 9.6–11.67 mm (significantly greater than in controls). Histological analysis showed minor inflammatory reactions. ConclusionIn this animal model, cranial expansion by linear craniectomy followed by bioabsorbable spring placement was feasible and well tolerated by adjacent tissues.

Automatical Cranial Suture Detection based on Thresholding Method

Purpose The head of infants under 24 months old who has Craniosynostosis grows extraordinarily that makes head shape unusual. To diagnose the Craniosynostosis, surgeon has to inspect computed tomography(CT) images of the patient in person. It's very time consuming process. Moreover, without a surgeon, it's difficult to diagnose the Craniosynostosis. Therefore, we developed technique which detects Craniosynostosis automatically from the CT volume. Materials and Methods At first, rotation correction is performed to the 3D CT volume for detection of the Craniosynostosis. Then, cranial area is extracted using the iterative thresholding method we proposed. Lastly, we diagnose Craniosynostosis by analyzing centroid relationships of clusters of cranial bone which was divided by cranial suture. Results Using this automatical cranial detection technique, we can diagnose Craniosynostosis correctly. The proposed method resulted in 100% sensitivity and 90% specificity. The method perfectly diagnosed abnormal patients. Conclusion By plugging-in the software on CT machine, it will be able to warn the possibility of Craniosynostosis. It is expected that early treatment of Craniosynostosis would be possible with our proposed algorithm.

Insights into the development of molecular therapies for craniosynostosis.

For the past 2 decades, clinical and basic science researchers have gained significant insights into the molecular and genetic pathways associated with common forms of craniosynostosis. This has led to invaluable information for families and physicians in their attempts to understand the heterogeneity of craniosynostosis. Genetic mutations have been identified in the fibroblast growth factor receptors (FGFRs) as well as in other targets, including TWIST1, BMP, and RUNX2. Greater understanding of these and other pathways has led to the development of innovative approaches for applying medical therapies to the treatment of craniosynostosis, in particular by maintaining suture patency. In this article, the authors discuss the molecular pathophysiological mechanisms underlying various forms of craniosynostosis. They also highlight recent developments in the field of molecular craniosynostosis research with the hope of identifying targets for medical therapies that might augment the results of surgical intervention.

Spring-mediated sagittal craniosynostosis treatment at the Children's Hospital of Philadelphia: technical notes and literature review.

OBJECT Sagittal craniosynostosis has been treated using both cranial remodeling techniques and modification of the sagittal strip craniectomy. A more recent technique is to implant springs in conjunction with a suturectomy to transversely expand the parietal bones to accommodate the growing brain. In this paper the authors describe and evaluate several modifications to the spring-mediated cranioplasty (SMC) technique, most notably use of an ultrasonic scalpel to limit dural dissection and maximize opening of the stenosed suture by placement of multiple spring devices. In addition, the literature is reviewed comparing SMC to other surgical treatments of sagittal synostosis. METHODS The authors retrospectively reviewed patients who presented to the Children's Hospital of Philadelphia with a diagnosis of sagittal synostosis from August 2011 to November 2014. A pooled data set was created to compare our institutional data to previously published work. A comprehensive literature review was performed of all previous studies describing the SMC technique, as well as other techniques for sagittal synostosis correction. RESULTS Twenty-two patients underwent SMC at our institution during the study period. Patients were 4.2 months of age on average, had a mean blood loss of 56.3 ml, and average intensive care unit and total hospital stays of 29.5 hours and 2.2 days, respectively. The cranial index was corrected to an average of 73.7 (SD 5.2) for patients who received long-term radiological follow-up. When comparing the authors' institutional data to pooled SMC data, blood loss and length of stay were both significantly less (p = 0.005 and p < 0.001, respectively), but the preoperative cranial index was significantly larger (p = 0.01). A review of the SMC technique compared with other techniques to actively expand the skull of patients with sagittal synostosis demonstrated that SMC can be performed at a significantly earlier age compared with cranial vault reconstruction (CVR). CONCLUSIONS The authors found that their institutional modifications of the SMC technique were safe and effective in correcting the cranial index. In addition, this technique can be performed at a younger age than CVRs. SMC, therefore, has the potential to maximize the cognitive benefits of early intervention, with lower morbidity than the traditional CVR.

Posterior Cranial Vault Distraction Osteogenesis with Barrel Stave Osteotomy in the Treatment of Craniosynostosis.

Twenty years have passed since distraction osteogenesis was introduced into the field of craniomaxillofacial surgery, with distraction osteogenesis gradually consolidating its position for midface advancement in syndromic craniosynostosis. On the other hand, no consensus has been reached regarding its adaptation to calvarial bone. We reported that distraction osteogenesis was useful in posterior cranial vault expansion, and subsequently, similar reports have been successively observed worldwide. In posterior cranial vault distraction, intracranial capacity could be greatly expanded due to its simultaneous expansion with the scalp, with little risk of relapse because new bone is regenerated in the distraction gap. The possibility was suggested that the standard of first carrying out fronto-orbital advancement (FOA) for brachycephaly observed in syndromic craniosynostosis will greatly change posterior cranial vault distraction.

Experimental comparative study of the histotoxicity of poly(lactic-co-glycolic acid) copolymer and poly(lactic-co-glycolic acid)-poly(isoprene) blend

Current treatments of craniosynostosis rely on the application of metal springs for cranial bone deviation. However, those metal springs demand a second surgical procedure for their removal. An attractive alternative would be the substitution of metal for bioresorbable polymers in the composition of the springs. The addition of poly(isoprene), PI, to poly(lactic-co-glycolic acid), PLGA, produces a polymeric blend with partial miscibility and distinct mechanical behavior that may benefit the patient recover. It is necessary to compare the histotoxicity of PLGA/PI to that presented by PLGA. In order to verify the histological behavior of the blend, 46 male Wistar rats (Rattus norvegicus, albino strain) underwent implantation of PLGA or PLGA/PI in the skull and were allocated into subgroups by timing of euthanasia (15, 30, 60, or 90 days). After euthanasia, the skull was removed and the histotoxicity was assessed histopathologically. The PLGA/PI blend showed greater histotoxicity in animals euthanized at 60 days, although in this period the histotoxicity of the PLGA/PI blend was similar to that of the PLGA copolymer at 15 days. Despite the instability of histological response, presented in different periods of observation, the results obtained in long-term show that the material has high potential for studies in craniosynostosis treatment.

Latest trends in minimally invasive synostosis surgery: a review.

To present the current surgical options for minimally invasive surgery for treatment of craniosynostosis. Minimally invasive procedures are well tolerated treatment options for patients with craniosynostosis. Suturectomy and helmet therapy is a treatment option for scaphocephaly with minimal blood loss and length of hospital stay. Spring-mediated cranioplasty is, in addition, a well tolerated and effective treatment option for scaphocephaly. In patients with multiple suture craniosynostosis, surgical techniques that utilize spring-assisted surgery can provide decreased morbidity with better bone formation made available for a second operation. Continued basic science research and clinical studies will expand the use and provide further minimally invasive procedures to infants with craniosynostosis.

Endoscopic craniosynostosis repair.

Craniosynostosis is a rare condition that affects approximately one child in every 2,000 live births, and involves pathological fusion of two or more skull bones. Consequences of craniosynostosis include possible limitation of brain growth and cosmetic effects on the appearance of the child. Traditional repairs for these conditions over the past 3-4 decades have involved an open operation with a large skin incision and major manipulations of the skull bones. More recently, minimally invasive endoscopic techniques have been developed to release the skull bones, followed by postoperative treatment with either an external orthosis or internal springs and distractors to achieve the desired correction. In this review minimally invasive endoscopic repair will be reviewed. A general overview of the condition and techniques for correction will be discussed, followed by specific application of these surgeries for different craniosynostosis diagnoses. Attention to the subtleties of each specific condition will be highlighted. Over the past two decades clinical experience and a large number of publications have substantiated the benefits of minimally invasive endoscopic techniques for the treatment of craniosynostosis. These techniques have clear benefits for selected patients, and should be part of the standard of care for this condition at craniofacial centers.

Management of Sagittal Synostosis

In the craniofacial surgery literature, there is a wide disparity of opinions regarding the appropriate treatment of nonsyndromic sagittal synostosis. With the lack of level 1 evidence to support a particular regimen, our study aims to elucidate the current state of practice among craniofacial surgeons with the hope of establishing a standard of care. An internet-based survey was sent to 102 craniofacial surgeons in 14 countries on 4 continents. Data were collected regarding the following parameters: primary indication for surgery, preference of timing, and choice of operative intervention for patients presenting with nonsyndromic isolated sagittal synostosis with normative intracranial pressure values. Surgeons were also queried regarding preoperative, intraoperative, and postoperative protocols. After 2 mailings, the response rate was 58% (59/102). For 63% of respondents, skull deformity was the primary indication for treatment of craniosynostosis. Open surgical management of sagittal craniosynostosis was most commonly performed at 6 months (35%) of age. Total cranial vault remodeling was the most commonly performed procedure (37%). Thirty-five percent of craniofacial surgeons chose an endoscopic surgical approach for patients presenting at younger than 4 months. Only 10% of craniofacial surgeons selected spring-assisted strip craniectomy. Seventy-one percent of polled surgeons performed computed tomographic scans of the skull in all cases, irrespective of presentation. Our survey demonstrates that there exists a wide disparity of opinion regarding diagnosis and treatment of nonsyndromic sagittal synostosis. When current practice is compared to findings in the literature, significant discrepancies exist.

Odilon Marc Lannelongue (1840–1911) and strip craniectomy for craniosynostosis

In the 19th century, Dr. Odilon Marc Lannelongue was a pioneering French surgeon who introduced a surgical technique for the treatment of craniosynostosis. In 1890, Dr. Lannelongue performed correction of sagittal synostosis by strip craniectomy. From his procedure, multiple techniques have been developed and endorsed for this condition, ranging from simple suturectomies to extensive calvarial vault remodeling. In addition, even today, endoscopically aided strip craniectomy is performed as a surgical treatment of craniosynostosis. This article describes the life and works of the surgeon who revolutionized the management of craniosynostosis.

Laser-Assisted Indocyanine Green Imaging to Assess Perfusion of Scalp Closure in an Infant

The current treatment of craniosynostosis is open surgical excision of the prematurely fused suture and cranial vault remodeling. Due to the change in skull morphology and the increase in volume, some tension on the skin flaps is noted with closure. Although complete wound breakdown is rare, it can be a devastating complication. We present our experience with the use of the SPY imaging system (Lifecell Corporation, Branchburg, NJ, USA) to visualize and record blood flow within the flaps of a 1-year-old patient with anterior plagiocephaly. Intraoperative indocyanine green angiography has the potential to be a significant advantage in such cases, providing a safe and objective method to assess intraoperative scalp perfusion, allowing the surgeon to take additional measures to ameliorate any ischemic problems.

Endoscopic-Assisted Management of Sagittal Synostosis

INTRODUCTION: Endoscopic-assisted technique for the treatment of craniosynostosis is gaining in popularity. The benefits in regards to operating room time, blood transfusion rates, hospital stay and reduced cost of treatment have been reported with equivalent improvement in cephalic index compared to open calvarial vault reconstruction.1–3 This study investigates two methods for endoscopic-assisted correction of sagittal synostosis: wide vertex suturectomy and barrel stave osteotomies versus narrow vertex suturectomy. METHODS: The authors prospectively observed patients with nonsyndromic sagittal synostosis treated with the endoscopic-assisted technique and molding helmet therapy. Wide vertex suturectomy (5cm) and barrel stave osteotomies was used exclusively between 2006 and 2010. Narrow vertex suturectomy (2.5 cm) was used between 2011 and 2012. All patients received 3 dimensional photographs for standardized assessment of head shape preoperatively and at subsequent postoperative evaluations. Patients were also measured by direct caliper measures to determine cranial index. The data collected included age at operation, blood loss, postoperative hemoglobin, transfusion rates, operating room times, and cephalic index. RESULTS: Twenty patients (10 wide vertex and barrel stave osteotomies (WV+BSO) and 10 narrow vertex (NV)) with isolated sagittal synostosis were treated by the endoscopic-assisted technique and moulding helmet therapy. Mean age at operation and follow-up time was 3.8 and 10 months for NV and 3.6 and 13 months for WV+BSO. Mean operating room time was 66 minutes for the NV group and 88 minutes for the WV+BSO group. The mean blood loss was 29ml for NV with 0% (0 of 10 patients) transfusion rate versus 49 ml and 0% (0 of 10 patients) transfusion rate for WV+BSO. Postoperative hemoglobin was 8.4g/dL and 7.3g/dL for the NV and WV+BSO groups. The pre- and postoperative cephalic index for the NV technique was 69% and 79% versus 72% and 80% for WV+BSO. CONCLUSION: Narrow-vertex suturectomy and moulding helmet therapy is effective in the treatment of sagittal synostosis. Avoiding additional barrel stave osteotomies can decrease operating room time and risk of transfusion.

Craniosynostosis: Caring for Infants and Their Families

Craniosynostosis is a developmental anomaly with premature closure of the cranial sutures causing an abnormally shaped skull in an infant. Recommended surgical treatment involves cranial vault reconstruction to open the closed suture, increase intracranial volume, and allow the brain to grow normally. Parents work with a multidisciplinary team during the evaluation process and face various preoperative and postoperative stressors. Critical care nurses can improve the care of the infants and their families by being knowledgeable about the anatomy, assessment, and surgical and nursing management of infants with this anomaly and its impact on the patients' families. This article discusses the definitions, diagnosis, and treatment of craniosynostosis and support for parents of infants with this malformation.

Posterior cranial distraction in the treatment of craniosynostosis—effects on intracranial volume

Posterior cranial distraction in the treatment of craniosynostosis : effects on intracranial volume

OS0714 乳幼児期に拘束された脳の応力解析のための境界条件の検討

In this study, we aimed to develop a method of brain stress analysis to support the treatment of craniosynostosis. Currently, craniosynostosis has been fixed up by surgeiy. It is necessary to develop to predict the effect of surgery during the growth of patients. Previously, we developed a simple head model, where the growth of brain is expressed by thermal expansion of brain elements. Here, we analyzed the effect of meninges on stress distribution of brain constrained by skull under growing. In addition, the boundary condition considering the existence of brain stem was discussed.

Posterior cranial vault expansion in the treatment of craniosynostosis. Comparison of current techniques

Surgical procedures which aim at expanding the posterior cranial vault have come to play an increasingly important role in the treatment of syndromic craniosynostosis. The posterior cranial vault may be expanded by formal cranioplasty or by less invasive methods based on gradual posterior cranial vault expansion or distraction. These procedures share the common goals to prevent intracranial hypertension and progression toward turricephaly by effectively increasing the intracranial volume. They also reduce any local brain compression within the posterior cranial fossa. This review describes the various techniques available for less invasive and gradual posterior cranial vault expansion and their rationale based on our experience on the last 40 cases. Volumetric data for three different surgical techniques have been compared (two cases of posterior cranial vault expansion by free-floating parieto-occipital bone flap, two with springs, and two with internal distractors). The volumetric analysis showed an expansion of 13 and 24 % for the free posterior flap, 18 and 25 % for the translambdoid springs, and 22 and 29 % for the distractors. Although these figures are not strictly comparable, our data suggest that these three techniques offer a potential for a significant increase in skull volume. The indications for such procedures must, however, be tailored according to the age and condition of the single patient.

Current approaches to management of nonsyndromic craniosynostosis

Surgical alternatives to traditional cranial vault remodeling for the treatment of craniosynostosis are being discussed in recent plastic and neurosurgical literature. This review highlights recent developments and discusses the risks as well as benefits of each. Surgical treatment of craniosynostosis has evolved from simple suturectomy, to extensive cranial vault remodeling, and now back to the minimally invasive. Options today include endoscopic suturectomies, spring-mediated cranioplasties, and distraction osteogenesis as well as cranial vault remodeling. There are disagreements among centers on the most optimal timing and best operative procedure. Clinicians should be aware that different surgical treatments are rapidly being developed for nonsyndromic craniosynostosis.

Endoscopic Cranial Suture Release for the Treatment of Craniosynostosis—Is It the Future?

There has been a circle of treatment in craniofacial surgery, with an original era of strip craniectomy surgeries that transformed into an era of major craniofacial reconstructions. The reason for this transition was the concern that release operations failed to correct the deformity in a substantial percentage of patients and that the larger operations yielded more reliable outcomes. During the past decade, we have seen a return to smaller strip operations, now enhanced with postoperative adjuvant therapy using helmets, springs, and distracters. In this article, the author discusses why this is not simply a return to failed techniques of the past and reviews the status of endoscopic surgery at Children's Hospital Boston.

Simultaneous Fronto-Orbital Advancement and Dynamic Posterior Cranial Vault Expansion in Apert Syndrome

Craniosynostosis in Apert syndrome is routinely treated by wide frontal and bilateral supraorbital reshaping and posterior cranial decompression. Dynamic cranial vault expansion has proved to be useful in craniofacial surgery, and its use has extended to syndromic patients. Although a controversy remains between conventional osteotomy and application of the spring-mediated technique in surgical treatment of craniosynostosis, there have been several positive clinical reports on expansion techniques for nonsyndromic and syndromic craniosynostosis. Simultaneous fronto-orbital advancement and posterior cranial vault expansion have been applied successfully to 2 patients of Apert syndrome, without intraoperative complications or postoperative morbidity and improving final cranial shape.