2015 HSC Section 1 Book of Articles

predictable desired head shape not possible with

simple suturectomy.

Cranial vault remodeling and frontoorbital

advancement remains the standard operative treat-

ment for craniosynostosis, today. The benefit of

cranial vault remodeling is that the desired contour

is achieved without relying on expansion from the

growing brain. Thus, it can be employed successfully

on older children who have matured past the age

of rapid brain expansion. The pi procedure, one

method for treating sagittal craniosynostosis, is

named after the shape of the bone removed. Sagittal,

coronal and lambdoid sutures are removed and

parietal bones are outfractured. The frontal bone

is then secured more posteriorly, thus restoring a

shorter anterior–posterior cranial dimension [21].

There are many described variations of cranial

vault remodeling for each fused suture, but the

mainstays of treatment are frontoorbital advance-

ment for metopic and coronal synostosis and the

judicious use of osteotomies such as barrel-stave

techniques to normalize the cranial index and vault

height. Surgeons perform remodeling procedures

between 4 and 13 months of age and stable results

have been demonstrated at 1 year postoperatively

[16].

Cranial vault remodeling, while efficacious, is

limited by its significant morbidity, including blood

loss and prolonged time under anesthesia. In the

1990s Jimenez and Barone [22,23] introduced endo-

scopic suturectomy for the treatment of sagittal

synostosis, an alternative with minimal blood loss

and shorter hospital stay. Their approach was early

intervention to capitalize on brain growth and

expansion of the skull. They combined suturectomy

with orthotic helmet therapy, a passive splinting of

the growing calvarium introduced by Persing

et al.

the 1980s [24]. Properly designed helmets limit

growth in one dimension while allowing room for

compensatory expansion in another.

In a study comparing extended strip craniecto-

mies without orthotic helmets versus traditional

cranial vault remodeling for sagittal craniosynosto-

sis, Panchal

et al.

[25] showed no improvement in

cranial index for the strip craniectomy group,

whether or not they were operated on before 4

months of age. The cranial vault remodeling group

demonstrated age-appropriate cranial index values

at 1 year postoperatively. These results imply that

simple suture release procedures alone are ineffec-

tive and must be coupled with helmet therapy

[22,25].

Spring-assisted distraction is a more recent

development introduced by Lauritzen

et al.

[26].

In his follow-up study of 100 consecutive cases,

omega-shaped springs designed to either expand

or compress were applied across suture osteotomies

for sagittal, metopic, bicoronal, and multiple suture

synostoses [27]. Average time until spring removal

was 7 months for the sagittal synostosis group.

Complications included spring dislodgement (5%)

in his earlier cases and one case of overcorrection for

metopic synostosis. Cranial index in the first 20

patients with sagittal synostosis was normalized

from a mean of 67 preoperatively to 74 at 6 months

postoperatively, with stable results 3 years later.

Hypotelorism was also corrected during the

spring-mediated expansion for metopic synostosis.

The authors felt that this method had comparable

results to other methods of correction, justifying

the inherent need for repeat surgery to remove

the springs.

Distraction osteogenesis has an established role

in treating secondary midface hypoplasia in patients

FIGURE 5.

Computed tomography scan of a 6-month-old male with right lambdoid synostosis.

Management of nonsyndromic craniosynostosis

Okada and Gosain

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