Tag: craniosynostosis

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The cranial orbital buttress technique for nonsyndromic unicoronal and metopic craniosynostosis

The cranial orbital buttress technique for nonsyndromic unicoronal and metopic craniosynostosis

Neurosurg Focus 38 (5):E4, 2015

Current craniosynostosis procedures can result in complications due to absorbable plates and screws or other specialized expensive hardware. The authors propose the cranial orbital buttress (COB) technique of frontoorbital remodeling for metopic and unicoronal synostoses, wherein no plates or screws are used. They hypothesize that, with this technique, aesthetically acceptable outcomes for unicoronal and metopic synostosis can be achieved. In this article, they present this technique and compare the results with current frontoorbital remodeling practices.

METHODS The authors conducted a retrospective chart review of cases in which patients with nonsyndromic unicoronal or metopic synostosis underwent cranio-orbital surgery at their institution from 1985 through 2009. Operative parameters, surgical variations, and complications were analyzed. The COB technique uses a 1-piece switch, hemiforeheads, or multiple pieces for forehead remodeling. The supraorbital bar is reconstructed in patients with metopic synostosis using a double wedge or greenstick fracture technique, and in patients with unicoronal synostosis a hinge procedure based on a 1.5-orbital osteotomy is used. The supraorbital bar is advanced and supported in place by bone graft(s) inserted at the lateral aspect(s) of the orbit(s) to form a buttress, with fixation done using absorbable sutures.

RESULTS A total of 79 cases met the criteria for inclusion in the study. Twenty-nine patients had metopic synostosis, 3 had combined metopic and sagittal synostoses, and 47 had unicoronal synostosis. The patients’ mean age at surgery was 11.4 ± 10.1 months and the mean operative time was 183.4 ± 41.0 minutes. The mean length of hospital stay was 3.7 ± 1.2 days. The mean blood loss was 150.0 ± 125.6 ml, and 33% of patients required a blood transfusion (mean volume 206.9 ± 102.3 ml). In metopic synostosis, hemiforeheads were used most often (24/29, 83%), and the supraorbital bar was remodeled using a bilateral intracranial orbital osteotomy followed by a double wedge modification (23/29,79%) or a greenstick fracture (4/29 14%) for milder cases. Forehead remodeling for unicoronal synostosis was by a forehead switch (39/47, 83%) and the supraorbital bar was remodeled using a 1.5-orbital intracranial orbital osteotomy (34/47, 72%) such that the bar was advanced on the abnormal side and hinged at the midline of the normal orbit. Perioperative complications occurred in 19% of cases and included dural tears (16%), inconsequential subdural hematoma (1.3%), and nasal greenstick fracture (1.3%). The total reoperation rate was 7.6% (cranioplasties for irregular contours, 6.3%; scar revision, 1.3%).

CONCLUSIONS The COB remodeling technique is simple and efficient, gives acceptable outcomes, and is less resource intensive than previous techniques reported in the literature.

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Cranial vault remodeling for sagittal craniosynostosis in older children

Neurosurg Focus 31 (2):E3, 2011,DOI: 10.3171/2011.5.FOCUS1196

Sagittal craniosynostosis is the most common form of craniosynostosis and is commonly treated within the first year of life. Optimal treatment of patients older than 1 year of age is not well characterized. The authors reviewed cases of sagittal craniosynostosis involving patients who were treated surgically at their institution when they were older than 1 year in order to determine the rate of intracranial hypertension (ICH), potential to develop nonhealing cranial defects, and the need for various surgical procedures to treat the more mature phenotype.

Methods. A retrospective chart review was conducted of all cases in the Children’s Hospital of Pittsburgh Neurosurgery Database involving patients who underwent cranial vault remodeling for scaphocephaly after 1 year of age between October 2000 and December 2010.

Results. Ten patients were identified who met the inclusion criteria. Five patients underwent anterior two-thirds cranial vault remodeling procedures, 3 patients underwent posterior vault remodeling, and 2 patients underwent 2-staged total vault remodeling. All patients had improved head shapes, and mean cephalic indices improved from 65.4 to 69.1 (p = 0.05). Six patients exhibited signs of ICH. No patients with more than 3 months of follow-up exhibited palpable calvarial defects.

Conclusions. Patients with sagittal synostosis treated after 1 year of age demonstrate increased rates of ICH, warranting diligent evaluations and surveillance to detect it; rarely develop clinically significant cranial defects if appropriate bone grafting is performed at the time of surgery; and achieve acceptable improvements in head shape.

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Sinus pericranii in children: report of 16 patients and preoperative evaluation of surgical risk

J Neurosurg Pediatrics 4:050360–500420, 2009.(DOI: 10.3171/2009.7.PEDS0994)

Sinus pericranii (SP) is a rare venous varix in an extracranial location connected to the intracranial venous system. The aim of this retrospective study was to report on 16 pediatric cases of SP with consideration of the preoperative evaluation of surgical risk.

Methods. The study population consisted of 10 patients who had undergone surgery for SP and 6 patients with concomitant craniosynostosis and SP. The mean age of the patients at presentation was 3.7 years. To identify characteristics of SP with high operative risk, 8 cases in this report and 11 previously reported cases of SP with sufficient information were categorized on the basis of the number and size of SP, the number and size of transcranial channels, the venous drainage type, and the amount of blood loss. Hemorrhage amounts were classified into 3 grades based on the description of intraoperative blood loss.

Results. Sinus pericranii not associated with craniosynostosis were resected without any postoperative morbidity. Sinus pericranii associated with craniosynostosis were preserved. After craniofacial reconstruction, 2 cases of SP with craniosynostosis regressed, completely in one patient and partially in another. These 2 patients with SP were confirmed to have compromised intracranial sinus before craniofacial reconstruction. Among a total of 19 patients, multiplicity or size (> 6 cm) of SP (p = 0.036) and multiplicity (> 3) or size (> 3 mm) of transcranial channels (p = 0.004) was associated with more severe hemorrhage grade. Sinus pericranii with peripheral venous drainage (drainer type) was not associated with hemorrhage grade after classification into 3 grades (p = 0.192). However, all 3 cases of SP with massive Grade 3 hemorrhage were the drainer type. Hemorrhage grade was correlated with the number of risk factors for SP (r = 0.793, p < 0.001).

Conclusions. Three risk factors of SP and the presence of compromised intracranial sinus are markers for high-risk SP. “Squeezed-out sinus syndrome” is suggested as a concept for SP associated with compromised intracranial sinus, mainly caused by craniosynostosis. Sinus pericranii in squeezed-out sinus syndrome probably serves as a crucial alternative to venous drainage of the brain with intracranial venous compromise. Conservative treatment for such patients with SP is recommended.


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