Craniosynostosis |
In the group of nonsyndromic multiple suture synostoses, a variety of types can be included, not all of which have been clearly defined. The most common is bilateral coronal synostosis, which is characterized by brachycephaly. Oxycephaly is a variation of complex, multiple-suture, nonsyndromic form and usually results from a combination of bilateral coronal, sagittal, and, possibly, lambdoid synostosis, resulting in the characteristic head shape. Cloverleaf skull deformity is a separate entity that is characterized by a typical head shape due to bilateral constrictions at the sylvian fissures. Under the term complex multiple suture synostosis, often referred to as pansynostosis, a variety of deformities are included, involving multiple sutures in patterns not conforming to any of the other types. Complex multiple suture synostosis is a mixture of otherwise unclassifiable combinations of affected sutures.
Craniosynostosis also is seen in the context of a variety of syndromes (more than 70). The most common syndromes encountered in clinical practice are Crouzon, Apert, Saethre-Chotzen, and Pfeiffer. These syndromes are all characterized by bilateral coronal synostosis of varying severity, often combined with some degree of sagittal synostosis. The typically observed brachycephaly is due to a shortened anteroposterior diameter of the skull and corresponding enlargement of the bitemporal and biparietal diameter. Other suture involvement can result in oxycephaly, scaphocephaly, and turricephaly. Combinations of all these deformities can be seen in complex cases.
A flat forehead and characteristically low-set ears commonly are seen. Patients, particularly those with Apert syndrome, tend to develop turricephaly, a feature not commonly seen in other syndromic forms. Other extracranial abnormalities commonly are observed as part of the syndromes. In both Crouzon and Apert syndromes, maxillary hypoplasia is present in varying degrees. Syndactyly of hands and feet (acrocephalosyndactyly) is a prominent feature of Apert syndrome. Bilateral ptosis commonly is seen in the context of Saethre-Chotzen syndrome and usually requires surgical treatment. Down slanting of the palpebral fissures is characteristic of Pfeiffer syndrome. In most forms of coronal synostosis, a variable degree of exophthalmos is present
Frequency: The overall incidence of craniosynostosis is estimated as 1:2,000 live births. Crouzon syndrome has an incidence of 1:60,000 live births, Apert syndrome has an incidence of 1:10,0000 live births. Saethre-Chotzen and Pfeiffer syndromes are much less common.
Etiology: The etiology of craniosynostosis is not clear at present, but genetic defects are becoming increasingly recognized. In 1912, Crouzon was the first to recognize an inheritance pattern in the syndrome that he described first as craniofacial dysostosis. He described a family in which the syndrome had been passed on vertically with a pattern similar to autosomal dominance. For several decades little further progress was made. Renewed interest and considerable advances in techniques employed in genetics in the last few years have contributed considerably in breaking new ground on important genetic aspects of craniosynostosis.
In syndromic forms of craniosynostosis, autosomal dominant inheritance clearly has been identified, though a number of patients have spontaneous new mutations. Familial cases are frequent, constituting from 25-46% of the total number of cases, variable for the different syndromes. A complete penetrance has been observed in all inherited cases. In nonsyndromic forms of craniosynostosis, no inheritance pattern has been identified, though familial occurrence has been observed in 4-10% of the patients, variable for the different types of syndrome. In familial cases, variable vertical and horizontal penetrance has been observed.
A major breakthrough in understanding the genetic background of craniosynostosis has been the identification of genetic defects in several syndromes, including the 3 most common ones (ie, Crouzon, Apert, Pfeiffer). The fact that mutations of the group of genes coding for fibroblast growth factor receptor (FGFR) are present in patients with Apert, Crouzon, and Pfeiffer syndromes is now clearly established. These genes, currently 4 are identified, are coding for receptors on the cell surface, which mediate the effects of fibroblast growth factors (FGF). The effects of FGFs are not fully understood, but they are already clearly implicated in important cellular processes such as cell growth, differentiation, migration, and survival. Although the 4 different genes are located in different chromosomes, the receptor proteins they encode for are very similar structurally.
Almost all cases of Apert syndrome are due to 1 of the 2 described mutations of the FGFR2 gene, located on chromosome 7. For Crouzon and Pfeiffer syndromes, the situation is less clear. Additional abnormalities of chromosome 10 have been identified. Currently, 25 mutations have been identified on the FGFR2 gene and implicated in the pathogenesis of Crouzon syndrome. Mutations of both FGFR1 and FGFR2 genes have been described in Pfeiffer syndrome, each corresponding to phenotypes of different clinical severity. No genetic defects have been identified in nonsyndromic forms of craniosynostosis. In the next few years, substantial progress is anticipated in this field, throwing new light on the underlying operative pathophysiological mechanisms in different forms of craniosynostosis. The effector link between the chromosomal defect and the actual premature fusion of the sutures has not been identified so far.
Pathophysiology: Using immunocytochemistry techniques, abnormal osteoblastic activity has been observed in cultures of synostotic bone in which decreased growth rate; decreased alkaline phosphatase production; and increased levels of osteocalcin, platelet-derived growth factor (PDGF), and epidermal growth factor (EGF) have been observed. Histopathological examination of resected sutures has shown new bone formation across the area of the suture in various stages. These stages range from trabecular interdigitation across the fibrous tissue of the suture to frank bony fusion and overproduction, resulting in ridge formation on the site of the affected suture, which is palpable on clinical examination and observed at operation and prominent on the inner table of the skull.
Clinical: Apart from the obvious clinical deformity affecting the face and head, children can have airway problems, especially children with the syndromic form of craniosynostosis. Because of the hypoplastic maxilla, these children have difficulty breathing through their nose and end up breathing through their mouth. At night, these children can have sleep apnea. This affects not only their growth pattern, but also their behavior and speech. Children with raised intracranial pressure (ICP) can complain of chronic headaches, declining school performance, and gradual visual failure. As children grow, abnormal facial appearance has a negative effect on their social integration, with a corresponding effect on personality development.
A small minority of children present late. These children have mild deformity that is unnoticed in the first few months and years of life, and they present aged 4-8 years with symptoms of raised ICP.
One should clearly distinguish children who have a flattened posterior part
of the head on one or both sides without having premature fusion of the lambdoid
sutures. This condition often is called moulding or positional posterior
plagiocephaly and rarely requires surgical treatment. This condition manifests
with skull flattening, which usually is not progressive and is considered to be
due to the position that the head takes during sleep. No medical
treatment for craniosynostosis exists. Indications for surgical treatment in the
form of cranial expansion in the first few months of life include progressive
facial and cranial deformity, intracranial hypertension, and progressive
exophthalmos threatening the eyes.
Later on, children aged 5-10 years may develop recurrent craniostenosis and
require repeat operations.
In children with the syndromic form of craniosynostosis, progressive
maxillary hypoplasia causes breathing problems and difficulties because of poor
dentition apposition. Surgical treatment, in the form of midface advancement, is
common in children aged 10-15 years.
INDICATIONS
TREATMENT
Medical therapy: Positional posterior plagiocephaly, when severe, is treated at some units with plastic caps, which are fitted externally on the head and gradually can manipulate the shape of the skull. No clear benefit has been identified from their use, and they are not always tolerated well. Most cases are mild forms and do not require any treatment at all.
Surgical therapy: Early surgical treatment of craniosynostosis at the end of the 19th century included mostly linear craniectomies and excision of the affected sutures (suturectomies). At the turn of the century, Cushing observed that the complexity of the disorders in patients with craniosynostosis was such that linear craniectomies hardly were addressing the underlying cause. The results of such procedures were unsatisfactory for most types of craniosynostosis, particularly when involving the coronal suture complex. Head shape and exophthalmos did not improve, and further operative treatment was commonly required. For sagittal synostosis, linear craniectomy and excision of the affected suture is still effective when carried out in the first few months of life. In older children presenting late with untreated sagittal synostosis, complex cranial vault reconstruction is performed if the severity of the deformity merits treatment.
For other forms of craniosynostosis, involving coronal or metopic sutures, linear craniectomies have been abandoned in favor of more complex cranial expansion and remodeling. The techniques of frontoorbital advancement were pioneered in Paris in the late 1960s by Tessier and later modified by Marchac. In earlier years, a tendency for monobloc facial advancement existed, including forehead and midface in one osseous block. Monobloc facial advancement procedures have now gone out of fashion because they constitute extensive surgery with considerable morbidity and less than superior results.
Most cranial expansion procedures performed in children with craniosynostosis constitute variations of frontal-orbital advancement. The general principle of these procedures is the independent mobilization of the supraorbital bar with a series of facial osteotomies in the appropriate sites of the medial, superior, and lateral orbital walls and the frontal bone. Subsequent advancement and stabilization of the supraorbital bar in a new more anterior position results in expansion of the floor of the anterior fossa and the roof of the orbits. A new forehead is reconstructed with frontal bone flaps designed appropriately. With this technique, the connection of the coronal suture complex with the skull base is disrupted. This standard technique is used for most types of bilateral coronal synostosis, both isolated and syndromic.
Several variations of this technique have been described, differing mainly on the alternative possibilities of fixation of the lateral ends of the supraorbital bar on the adjacent temporal or zygomatic bones. The 2 most frequently used techniques are the "floating forehead" and the "tongue-in-groove"
. The former completely disconnects the supraorbital bar and forehead from the temporal bones, aiming to allow complete freedom of growth of the forehead from the skull base. The latter purposely attaches the supraorbital bars on to the adjacent temporal bones with internal fixation, aiming to maintain synchrony of growth between the realigned forehead and skull base. Although great claims have been made from proponents of both techniques, the clinical results are very comparable.For different types of craniosynostosis, appropriate modifications on the main technique of frontoorbital advancement are made. In metopic synostosis, the ridge of the prematurely fused suture is excised and the forehead is reconstructed with suitably designed frontal flaps and supraorbital bars. In unilateral coronal synostosis, earlier views favored unilateral frontal advancement. Although only one coronal suture is prematurely fused, in fact the deformity is bilateral because the normal side is attempting to compensate, and bilateral forehead correction usually is necessary.
All variations of frontoorbital advancement usually achieve satisfactory cosmetic results, with good forehead appearance and satisfactory cover of the orbits . A problem often encountered and difficult to correct is persistent narrowing in the temporal regions, observed after any type of frontoorbital advancement. In addition, abnormalities relating to abnormal skull growth, such as turricephaly, brachycephaly, low-set ears, and orbital dystopia, usually persist after successful surgery.
While frontoorbital advancement provides satisfactory correction of exorbitism and cosmetic improvement of forehead appearance, the principle of frontoorbital advancement does not seem to have any scientific basis. Many studies have indicated that this surgical technique is overcorrecting head volume, producing supranormal head volumes. This explains observations of a high incidence of frontal extradural collections at the site of the advancement after a successful surgery. Similarly, following successful correction of unilateral coronal synostosis, the previously compressed brain does not reexpand, and CSF occupies the newly created space instead. In the absence of another better alternative, frontoorbital advancement will continue to prevail, but it appears to have a cosmetic nature in most cases, excluding children with threatening exorbitism.
In a small selected group of patients for whom, despite classic syndromic appearances, the predominant problem found on careful appraisal of radiologic images is constriction of the posterior aspect of the skull. Recent attention to the posterior skull has demonstrated that posterior skull release can produce satisfactory results, often obviating the need for frontal advancement.
Syndromic patients with midface hypoplasia may require midface advancement. Midface advancement can be achieved either by a Le Fort III osteotomy and advancement in 1 operation or by midface distraction. The latter is gaining popularity because, even though it confines the patient to wear an external frame for several weeks, it appears to achieve a better long-lasting result.
Whenever the issue of possible intracranial hypertension arises, ICP monitoring usually is performed over 24 hours using an invasive bolt. Using an invasive bolt requires a small operation. In some units, routine measurement of ICP is performed in all syndromic cases, though this is not a universal policy.
Preoperative details: Children with significant midface deformity should be assessed by an anesthetist well before surgery because intubation may be a problem, and in extreme cases, tracheostomy may be required postoperatively.
Postoperative details: Postoperative imaging is used to demonstrate the new arrangement of the bony architecture of the cranial and facial skeleton. Radiographs obtained early in the postoperative period can be used as reference for further assessment. The rate of reossification can be assessed in the regions were dura was left uncovered by calvarium as a result of the advancement.
Evolution of radiological appearances can be particularly useful if the issue of recurrent deformity arises. While some loss of the advancement is expected in the first few years after operation, other features are seen as well in cases of recurrent craniostenosis, such as localized or generalized copper beating and sclerotic hyperdense bands of bone in the calvarium, representing recurrent synostosis.
Recently, the issue of the migration of fixation screws, plates, and wires has gained increasing attention. As the child grows, the skull bones continuously remodel according to natural forces. As a result, the screws used to stabilize the mobilized segment end up buried in the skull or even in the intracranial cavity. Postoperative CT scan is particularly helpful in monitoring that situation. Although the clinical significance is not known, identification and follow-up of the problem provides an opportunity for appropriate action to be taken. The recent development of bioabsorbable plates and screws may well eradicate the problem of migration.
Follow-up care: Typically, each patient has early postoperative plain radiographs, a CT scan in the first few months after operation, and in syndromic cases, MRI scans at yearly intervals to exclude development of hindbrain hernia. In patients with maxillary hypoplasia, yearly plain radiographs may be needed to assess the progress of the deformity when the issue of possible midface advancement is considered.
COMPLICATIONS
Complications
after craniofacial surgery are rare. Hypovolemic shock can occur if significant
intraoperative blood loss has not been replaced timely. Intraoperative dural
tears, which remain unrecognized, can cause postoperative CSF leaks and
resultant infection. Epidural or subdural hematoma can occur due to surgical
trauma. Almost all patients develop facial swelling postoperatively, more
prominent around the eyes, which rarely causes problems. Wound infections
generally are rare, even after midface procedures, which, by necessity, involve
operating in the oral cavity. The frequency of these complications is less than
10%.
ICP bolt insertion has a recognized small complication rate (2%), including
intracranial hemorrhage and infection.
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Constructed by Dr N.A. Nematallah Consultant in perioperative medicine and intensive therapy, Al Razi Orthopedic Hospital , State of Kuwait, email : razianesth@freeservers.com