Reformation of Suture Following Surgery for Isolated Sagittal
Craniosynostosis
Deepak Agrawal, Paul Steinbok, D CochraneDivision of Pediatric Neurosurgery, UBC and BC Children’s
Hospital, Vancouver, BC
ISOLATED SAGITTAL CRANIOSYNOSTOSIS
BASIS FOR MANAGEMENT
• Isolated entity in a normal child
• Operative Intervention-Improve cosmesis
ETIOLOGY
Moss’s Hypothesis
• Abnormality at cranial baseMoss, M. L. (1959). "The pathogenesis of premature cranial synostosis in man." Acta Anat (Basel) 37: 351-70.
• Proven for syndromic craniosynostosis
ETIOLOGY
Babler’s Hypothesis
• Abnormality is in the affected calvarial sutures Babler, W. J., J. A. Persing, et al. (1982). "Compensatory growth following premature closure of the coronal suture in rabbits." J Neurosurg 57(4): 535-42.
• Support from animal experimentsMabbutt, L. W. and V. G. Kokich (1979). "Calvarial and sutural re-development following craniectomy in the neonatal rabbit." J Anat 129(2): 413-22.
Reformation of sagittal suture should similarly be expected in children with isolated sagittal synostosis
OBJECTIVE
• To determine the incidence of reformation of the sagittal suture following surgical procedures for sagittal synostosis that involved a minimum of sagittal strip craniectomy
MATERIALS AND METHODS
• Retrospective study 1987-2000
• Children with isolated sagittal craniosynostosis
Operative Procedure
Minimum of vertex and parietal craniectomies(removal of the sagittal suture + 1.5 - 2.5 cm piece of adjacent parietal bone with the attached pericranium)
Children who had the bone flap replaced were excluded from the study
Assessment of resynostosis
POST-OP SKULL RADIOGRAPHS
• Suture morphology
• Patency of coronal and lambdoid sutures
RESULTS
• 114 children operated for isolated sagittal craniosynostosis in the above period.
• 42 children composed the study group.
RESULTS
• Median age at surgery- 3.9 months
(1.9 to 7.6 months)
• Mean follow up - 32.2 months
(6 to 144 months)
RESULTS
• Only 7/42 (16.7%) reformed the suture
• 35/42 (83.3%) had resynostosis of the sagittal suture
These findings are contrary to the results from animal experiments
WHY THE DISCREPANCY?
DISCUSSION
• Both dura mater and pericranium have osteogenic properties
• Dura-source of central new bone
• Pericranium- enhances peripheral new bone formation
Gosain AK, Santoro TD, Song LS, et al: Osteogenesis in calvarial defects: contribution of the dura, the pericranium, and the surrounding bone in adult versus infant animals. Plast Reconstr Surg 112:515-527, 2003
DISCUSSION
• In Sag synostosis surgery-central strip of bone with the attached pericranium removed
• Removal of this pericranium could potentially impair bony regeneration as well as suture reformation
DISCUSSION
• Common practice to coagulate the bleeding points on the dura
• This again could impair the osteogenic capacity of the dura
DISCUSSION
• Primary aim of surgery is cosmetic
• Persistence of bony defects and uneven contour of the bony regrowth may result in patient dissatisfaction, rarely culminating in repeat surgery
OUR HYPOTHESIS
Limiting coagulation on the dura & replacing pericranium could potentially result in consistent bone regeneration with smooth contour and reformation of a normal suture.
Further prospective studies would be required to prove this hypothesis
OTHER POTENTIAL FACTORS
GENETIC BASIS
• Inclusion of undiagnosed syndromic patients
• Genetic predisposition to synostosis
CONCLUSIONS
• We found a very high incidence of resynostosis following surgery for sagittal craniosynostosis
• The variability in reformation of the suture after surgery suggests a heterogeneous etiology and pathogenesis of isolated sagittal synostosis.
THANK YOU
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